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Lapow JM, Lobao A, Kreinces J, Feingold J, Carr A, Sullivan T, Wellman DS, Asprinio DE. Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis. J Orthop 2023; 45:48-53. [PMID: 37841903 PMCID: PMC10570961 DOI: 10.1016/j.jor.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
Background A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients. Methods The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI. Results 41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001). Conclusions Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.
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Affiliation(s)
- Justin M. Lapow
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Antonio Lobao
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Jason Kreinces
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Jacob Feingold
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Alexis Carr
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Tim Sullivan
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - David S. Wellman
- Department of Orthopaedic Surgery, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
| | - David E. Asprinio
- Department of Orthopaedic Surgery, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
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Jang H, Jeong ST, Park YC, Kang WS. Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1492. [PMID: 37629782 PMCID: PMC10456831 DOI: 10.3390/medicina59081492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Soon Tak Jeong
- Department of Physical Medicine and Rehabilitation, Ansanhyo Hospital, Ansan-si 15457, Republic of Korea;
| | - Yun Chul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Republic of Korea
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What are the risk factors for complications after combined injury of the pelvic ring and acetabulum? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:341-346. [PMID: 35079877 DOI: 10.1007/s00590-021-03189-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Combined acetabular and pelvic ring injuries represent a unique subset of pelvic trauma and little is known regarding their complications and outcomes. We sought to further evaluate these injury patterns and quantify their outcomes. METHODS A retrospective review at a single level 1 trauma center was performed on all patients with operatively treated combined ring and acetabulum injuries during a seven-year period. Main outcome measurements include all-cause complication including residual neurologic deficit, deep infection, conversion to total hip arthroplasty, deep venous thrombosis and mortality. RESULTS Seventy operatively treated combined ring and acetabulum patients with one-year follow-up were reviewed. The overall complication rate was 44%. Hip dislocation occurred in 40% of the cohort and was significantly associated with residual neurologic deficit and all-cause complication. Angiography with embolization was not associated with an increased rate of deep infection. Open acetabular approaches had a significantly higher complication rate compared to percutaneous procedures. Delay to definitive fixation greater than 36 h trended toward but did not reach association with all complications. CONCLUSION Combined injuries to the acetabulum and pelvic ring have high rates of complications. No individual fracture patterns were identified as risk factors, but hip dislocation was associated with an increased rate of complications. When possible, percutaneous reduction and fixation of acetabular fractures and early definitive fracture fixation lead to lower rates of complications. Use of angiography with embolization appears to be safe and does not increase the risk of infection or other complications.
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Risk Factors for Deep Infection and Conversion Total Hip Arthroplasty After Operative Combined Pelvic Ring and Acetabular Fractures. J Orthop Trauma 2022; 36:573-578. [PMID: 35605104 DOI: 10.1097/bot.0000000000002415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine risk factors for deep infection and conversion total hip arthroplasty (THA) after operative management of combined pelvic ring and acetabular injuries. DESIGN Retrospective case control study. SETTING Level 1 trauma center. PATIENTS AND INTERVENTION We reviewed 150 operative combined pelvic ring and acetabular injuries at our institution from 2010 to 2019, with an average follow-up of 690 (90-3282) days. MAIN OUTCOME MEASUREMENTS Deep infection and conversion THA. RESULTS Patients who developed deep infection (N = 17, 11.3%) had higher rates of hip dislocation ( P = 0.030), intraoperative transfusion ( P = 0.030), higher body mass index (BMI) ( P = 0.046), increased estimated blood loss ( P < 0.001), more intraoperative units transfused ( P = 0.004), and longer operative times ( P = 0.035). Of the 84 patients with 1-year follow-up, 24 (28.6%) required conversion to THA. Patients requiring conversion THA were older ( P = 0.022) and had higher rates of transverse posterior wall fracture pattern ( P = 0.034), posterior wall involvement ( P < 0.001), hip dislocation ( P = 0.031), wall comminution ( P = 0.002), and increased estimated blood loss ( P = 0.024). The order of the pelvic ring versus acetabular fixation did not affect rates of conversion to THA ( P = 0.109). Multiple logistic regression showed that an increased number of intraoperative units transfused [adjusted odds ratio (aOR) = 1.56, 95% confidence interval (CI) = 1.16-2.09, P = 0.003] and higher BMI (aOR = 1.10, 95% CI = 1.01-1.16, P = 0.024) were independently associated with an increased odds of deep infection. Posterior wall involvement was independently associated with an increased odds of conversion THA (aOR = 5.73, 95% CI = 1.17-27.04, P = 0.031). CONCLUSIONS Rates of deep infection and conversion THA after operative fixation of combined injuries were 11.3% and 28.6%, respectively. Higher average BMI and number of intraoperative units of blood transfused were independently associated with deep infection, whereas posterior wall involvement was independently associated with conversion to THA in these patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Zhang L, Michihata N, Matsui H, Fushimi K, Yasunaga H, Tsuda Y, Tanaka S, Kobayashi H. Preoperative arterial embolization and wound complications after resection of malignant bone tumor in the pelvis: a nationwide database study. Jpn J Clin Oncol 2022; 52:1176-1182. [PMID: 35818346 DOI: 10.1093/jjco/hyac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Massive intraoperative blood loss is common in pelvic malignant bone tumor surgery, and preoperative arterial embolization may be used in selected cases. Preoperative arterial embolization reportedly increases wound complications in pelvic fracture surgery, but little evidence is available regarding pelvic bone tumor surgery. METHODS Using a Japanese nationwide database (Diagnosis Procedure Combination database), we searched for patients who underwent pelvic malignant bone tumor surgery between July 2010 and March 2018. The primary endpoint was wound complications, defined as any wound requiring re-operation, negative pressure wound therapy or both. Univariate analyses (the chi-squared test for categorical variables, the unpaired t-test for continuous variables) and multivariate logistic regression analyses were performed to examine the association between preoperative arterial embolization and wound complications. RESULTS Among the 266 eligible patients, 43 (16%, 43/266) underwent embolization and 69 (26%, 69/266) developed wound complications. In the univariate analyses, preoperative arterial embolization (P < 0.001), duration of anesthesia (P < 0.001), the volume of blood transfusion (P < 0.001) and duration of indwelling drain tube (P < 0.001) were associated with wound complications. In the multivariate logistic regression analysis, preoperative arterial embolization was significantly associated with wound complications (odds ratio, 3.92; 95% confidence interval, 1.80-8.56; P = 0.001). CONCLUSIONS Preoperative arterial embolization may be associated with increased wound complications after pelvic malignant tumor surgery.
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Affiliation(s)
- Liuzhe Zhang
- Department of Orthopedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yusuke Tsuda
- Department of Orthopedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo, Tokyo, Japan
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Duchesne J, Taghavi S, Khan M, Perreira B, Cotton B, Brenner M, Ferrada P, Horer T, Kauvar D, Kirkpatrick A, Ordoñez C, Priouzram A, Roberts D. Circulatory Trauma: A Paradigm for Understanding the Role of Endovascular Therapy in Hemorrhage Control. Shock 2021; 56:22-29. [PMID: 34797785 DOI: 10.1097/shk.0000000000001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The pathophysiology of traumatic hemorrhage is a phenomenon of vascular disruption and the symptom of bleeding represents one or more vascular injuries. In the Circulatory Trauma paradigm traumatic hemorrhage is viewed as injury to the circulatory system and suggests the underlying basis for endovascular hemorrhage control techniques. The question "Where is the patient bleeding?" is replaced by "Which blood vessels are disrupted?" and stopping bleeding becomes a matter of selective vessel access and vascular flow control. Control of traumatic hemorrhage has traditionally been performed via external access to the end organ that is bleeding followed by the application of direct pressure, packing, or clamping and repair of directly affected blood vessels. In the circulatory trauma paradigm, bleeding is seen as disruption to vessels which may be accessed internally, from within the vascular system. A variety of endovascular treatments such as balloon occlusion, embolization, or stent grafting can be used to control hemorrhage throughout the body. This narrative review presents a brief overview of the current role of endovascular therapy in the management of circulatory trauma. The authors draw on their personal experience combined with the last decade of published experiences with the use of endovascular techniques in trauma and present general recommendations for their evolving use. The focus of the review is on the use of endovascular techniques as specific vascular treatments using the circulatory trauma paradigm.
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Affiliation(s)
- Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana, USA
| | - Sharven Taghavi
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana, USA
| | - Mansoor Khan
- Department of Digestive Diseases, Brighton and Sussex University Hospitals, Brighton, UK
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California, USA
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canadian Forces Health Services
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery. Fundación Valle del Lili. Universidad del Valle, Cali , Colombia
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
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Armbruster M, Seidensticker M. [Interventional radiology as emergency treatment for pelvic injuries]. Unfallchirurg 2021; 124:627-634. [PMID: 34283262 DOI: 10.1007/s00113-021-01045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
CLINICAL ISSUE Pelvic arterial bleeding constitutes a potentially life-threatening event, which can be difficult to control with surgical procedures alone, especially in the case of ligamentous ruptures and a subsequently increased pelvic volume. STANDARD RADIOLOGICAL PROCEDURES Using angiography and embolization (AE) with resorbable gelatine-based particles or permanent coils, plugs, liquid embolic systems or by vascular stenting, in most cases traumatic pelvic arterial bleeding can be stopped and can also be used to close pseudoaneurysms, arteriovenous fistulas or dissections. METHODOLOGICAL INNOVATION AND EVALUATION The AE has become established as a fast and effective minimally invasive procedure in the treatment of traumatic pelvic vascular injuries with an advantageous risk-benefit ratio. PRACTICAL RECOMMENDATIONS An interdisciplinary approach should be used in the indications for AE; which can be used as definitive treatment as well as in combination with surgical procedures. To improve the clinical outcome any delay between establishing the indications and the start of the intervention must be avoided.
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Affiliation(s)
- Marco Armbruster
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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Cheon SJ, Ahn TY, Jung SJ, Jang JH, Kim JH, Jeon CH. Does transarterial pelvic embolization have a negative effect on perioperative outcomes in pelvic ring injury and acetabular fracture? Asian J Surg 2021; 45:239-245. [PMID: 34078580 DOI: 10.1016/j.asjsur.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/17/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether TAE negatively impacted perioperative outcomes in patients who underwent open surgery for pelvic trauma. METHODS We retrospectively reviewed the medical records and radiographs of patients who had open surgery for an acute pelvic trauma between February 2014 and May 2017. The patients were classified into two groups: those who underwent TAE and those who did not. We evaluated preoperative demographics and perioperative outcomes between the two groups. Injury type-specific comparisons were also performed. RESULTS A total of 136 patients (50 TAE and 86 non-TAE) were included in this study. There were significant differences in preoperative demographics including the type of injury, injury severity score, revised trauma score, surgical approach, initial blood pressure, and the amount of transfusion within 24 h between the two groups. However, no differences in perioperative outcomes were identified except for the amount of total transfusion. There were significant differences between the two groups in the injury type-specific comparisons, specifically in the amount of transfusion within 24 h in patients with pelvic ring injury and in the injury severity score in patients with acetabular fracture. However, there was no difference in perioperative outcomes between the groups for either injury type. CONCLUSION In the present study, we were unable to identify negative effects of TAE on perioperative outcomes. Therefore, when considering open surgery subsequent to TAE, there is no evidence of increased risk for negative perioperative outcomes, especially with respect to bone healing and deep infection.
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Affiliation(s)
- Sang Jin Cheon
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Seok Jin Jung
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Trauma Center, Pusan National University Hospital, Republic of Korea.
| | - Jae Hun Kim
- Department of Trauma Surgery, Trauma Center, Pusan National University Hospital, Republic of Korea
| | - Chang Ho Jeon
- Department of Radiology, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Repubilic of Korea
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Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization. J Orthop Trauma 2021; 35:167-170. [PMID: 32931686 DOI: 10.1097/bot.0000000000001956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits. DESIGN Retrospective cohort study. SETTING Academic level 1 trauma center. PATIENTS Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization. INTERVENTION Percutaneous posterior pelvic fixation and pelvic arterial embolization. MAIN OUTCOME MEASUREMENTS Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients. RESULTS Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group. CONCLUSION Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Lai CY, Tseng IC, Su CY, Hsu YH, Chou YC, Chen HW, Yu YH. High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: a retrospective study. BMC Musculoskelet Disord 2020; 21:335. [PMID: 32473630 PMCID: PMC7260801 DOI: 10.1186/s12891-020-03372-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/27/2020] [Indexed: 11/19/2022] Open
Abstract
Background In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures. Methods We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted. Results During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03). Conclusion Performing AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.
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Affiliation(s)
- Chih-Yang Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - I-Chuan Tseng
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Chun-Yi Su
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, and Chang Gung University, Keelung City, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Huan-Wu Chen
- Department of Medical Imaging & Intervention, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan City, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan.
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