Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option

Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients

BACKGROUND

Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality.

METHODS

All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events.

RESULTS

A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18-94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2).

CONCLUSIONS

Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality.

Management of pelvic ring fractures in limited resources country: a retrospective study

PURPOSE

Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country.

METHODS

We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score.

RESULTS

From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score.

CONCLUSION

The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Does Time to Pelvic Fixation Influence Outcomes in Trauma Patients?

BACKGROUND

Pelvic fractures cause significant morbidity in the trauma population. Many factors influence time to fracture fixation. No previous study has determined the optimal time window for pelvic fixation.

METHODS

A retrospective review of trauma patients with pelvic fractures from 2016 to 2020 was performed. Patients were stratified into EARLY and LATE groups, by time to fixation within 3 days or greater than 3 days whether from admission or from completion of a life-saving procedure. Unpaired Student's t-test and Fisher's exact test were performed with multiple linear regression for variables with P < .2 on univariate analysis.

RESULTS

287 patients were identified with a median fixation time of 3 days. There was no significant difference in demographics, incidence of preceding life-saving procedure, angioembolization, or mechanism of injury in the 2 groups (P > .05). Length of stay in the EARLY group was significantly reduced at 11.9 +/- .7 days compared to 18.0 +/-1.2 days in the LATE group (P < .001). There was no significant difference in rates of ventilator-associated pneumonia, deep vein thrombosis, pulmonary embolism (PE), acute kidney injury (AKI), pressure ulcer, or acute respiratory distress syndrome (ARDS) (P > .05). There were significantly more SSIs (surgical site infections) in the LATE group. After multiple linear regression adjusting for covariates of age and ISS, the difference in hospital LOS was 5.5 days (95% CI -8.0 to -3.1, P < .001).

DISCUSSION

Fixation of traumatic pelvic fractures within 3 days reduced LOS. Prospective multi-center studies will help identify additional factors to decrease time to surgery and improve patient outcomes.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery

OBJECTIVE

To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects.

RESULTS

Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = -0.55 at baseline, r = -0.78 at 6 months, and r = -0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%).

CONCLUSIONS

SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI.

LEVEL OF EVIDENCE

Prognostic Level II.

Salvaging Pull-Out Strength in a Previously Stripped Screw Site: A Comparison of Three Rescue Techniques

Screw stripping during bone fixation is a common occurrence during operations that results in decreased holding capacity and bone healing. We aimed to evaluate the rescue of the stripped screw site using screws of different dimensions. Five screw configurations were tested on cadaveric specimens for pull-out strength (POS). The configurations included a control screw tightened without stripping, a configuration voluntarily stripped and left in place, and three more configurations in which the stripped screws were replaced by a different screw with either increased overall length, diameter, or thread length. Each configuration was tested five times, with each screw tested once. The POS of the control screw, measured to be 153.6 ± 27 N, was higher than the POS measured after stripping and leaving the screw in place (57.1 ± 18 N, p = 0.001). The replacement of the stripped screw resulted in a POS of 158.4 ± 64 N for the screw of larger diameter, while the screws of the same diameter but increased length or those with extended thread length yielded POS values of 138.4 ± 42 and 185.7 ± 48 N, respectively. Screw stripping is a frequent intraoperative complication that, according to our findings, cannot be addressed by leaving the screw in place. The holding capacity of a stripped screw implanted in cancellous bone can successfully be restored with a different screw of either larger diameter, longer length, or extended thread length.

Experimental study of the strength characteristics of fixation of the symphysis pubis with an original plate for the reconstruction of the anterior pelvic semi-ring

The destabilization of bone fixators has led to repeated surgical interventions that increased the risk of migrations of metal fixators, infectious and inflammatory complications as well. The modern trends in hip bone injury surgery are related to developing and using of metal fixators, which are effective in acute injury; however, sometimes the condition of the patient and the technical support of hospitals don’t allow performing surgery in the acute period, and these metal fixators are ineffective for chronic damage. Consequently, until now, the problem of finding the optimal design of structures for fixing chronic damage of anterior pelvic semi-ring which will be able to exclude its destabilization, is still of current interest.

The purpose of the study: developing and experimental researching of durable features of original plate for reconstruction of the anterior pelvic semi-ring.

Materials and methods: In order to ensure stable fixation of chronic pelvic injuries, the original metal plates have been worked out. They are made individually in accordance with the anatomical and functional structures of the anterior pelvic semi-ring of the patient with using additive technologies. The study of the reliability of the different variants of ostiosynthesis of the anterior pelvic semi-ring with using well-known pelvic plates and a new original design was carried out. Stability tests for different plate fixing methods and mechanical strength of metallophyxators were carried out on a universal test machine of LFM-50kN series.

Results: one plate fixation in tensile test showed the lowest result – 0.341 kN, a low result of shear loads was received with the same object. The best result was shown by the polyaxial monolithic plate fixation in case of stretching – 0.51 kN at the shear loads – 0.591 kN. Necessary force applied to destabilizing of the metal structure while using a polyaxial monolithic plate was a half-higher than stretched, and a third higher than at shear loads, it demonstrates the benefits of using these metal fixators.

Conclusion: It is experimentally confirmed that the polyaxial monolithic plate provides the highest stability of fixing anterior pelvic semi-ring indicator in contrast with fixing of one or two plates.

Anatomic relationship between S2 sacroiliac screws' entry points and pelvic external branches of superior gluteal artery

OBJECTIVE

To study the relationship between the pelvic external branches of the superior gluteal artery and the entry area of the S2 sacroiliac screw to provide the anatomical basis and technical reference for avoiding the superior gluteal artery injury during the clinical screw placement.

METHODS

CTA imaging of superior gluteal artery of 74 healthy adults (37 males and 37 females) was randomly selected. The safe bony entry area ('safe area' for abbreviation) of S2 sacroiliac screw in the standard lateral view of the pelvis three-dimensional reconstruction CT image was determined by the CT auxiliary measurement software. The relationship between the pelvic external branches of the superior gluteal artery and the safe area of S2 sacroiliac screw was observed, and the cases in which the artery intersected the safe area were counted. The distance between the safe area and the superior gluteal artery branches closest to it was measured for the cases in which the artery and the safe area did not intersect.

RESULTS

21 of the 74 cases did not have a bone channel of horizontal S2 sacroiliac screw, so they were excluded from this study. In the remaining 53 cases, 12 cases had the deep superior branch of the superior gluteal artery through the safe area of S2 screw (22.6%), and 16 cases had the superficial branch of the superior gluteal artery through the safe area of S2 screw (30.2%). There was no obvious overlap feature and law between the safe area and the superficial and deep superior branches. In 20 cases of the 53 cases, the safe area of S2 screw was located between the deep superior branch and the superficial branch of superior gluteal artery (37.7%), and in 5 cases, the safe area of S2 screw was located behind the superficial branch of superior gluteal artery (9.4%). In the cases where the superior gluteal artery did not intersect the screw entry bony safe area, the part of superior gluteal artery closest to the safe area was located in front or back of the widest part of the safe area.

CONCLUSION

The risk of accidental injury of the deep superior branch and superficial branch of the superior gluteal artery is high during the process of S2 sacroiliac screw placement. Even if the screw entry point is located in the bony safe area, the absolute safety of screw placement cannot be guaranteed. We strongly suggest that a careful and thorough plan is needed before surgery.

Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates

Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.

Time to definitive fixation of pelvic and acetabular fractures

BACKGROUND

The timing of definitive surgical stabilization is a controversial topic of pelvic and acetabular fracture (PAF) management. Historically, staged care with delayed definitive fixation was recommended; however, more recently, some centers have shown early definitive fixation to be feasible in most patients. We hypothesized that time to definitive fixation of PAF decreased without adverse outcomes.

METHODS

A level 1 trauma center's prospective pelvic fracture database was retrospectively analyzed. A total of 341 of the 1,270 consecutive PAF patients had surgery between January 2009 and December 2018. Demographics, polytrauma status, hemodynamic stability, time to definitive operation, length of intensive care unit stay, hospital length of stay, mortality were recorded. Data is presented as mean ± SD, percentages. Statistical significance was determined at p < 0.05.

RESULTS

There were 34 ± 8 per year operatively treated PAF patients during the study period. The demographics (age, 44.1 ± 18 years; 74.5% males) and injury severity (Injury Severity Score, 20; interquartile range, 16-29) did not change. Time to definitive fixation on average was 85 ± 113 hours (range, 0.8-1286 hours). Linear regression analysis demonstrated a decrease in time to definitive fixation considering all patients (β = -0.186, p = 0.003). pelvic ring fractures with polytrauma (β = -1.404, p = 0.03). and hemodynamically unstable patients (β = -1.428, p = 0.037). There was no significant change in mortality, length of stay, or intensive care unit length of stay for the overall cohort or any subgroup.

CONCLUSION

Time to definitive fixation in PAF has decreased during the last decade, with the largest decrease in time to fixation occurring in the hemodynamically unstable and pelvic fracture with polytrauma cohorts. The timely definitive internal fixation is achievable without increased length of stay.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

Pelvic angioembolization: how urgently needed?

Purpose

Angioembolization (AE) has been questioned as first-line modality for hemorrhage control of pelvic fracture (PF)-associated bleeding due to its potential inconsistent timely availability. We aimed to describe the patterns of AE use with hemostatic resuscitation and hypothesized that time to AE improved during the study period.

Methods

A Level-1 trauma center’s prospective PF database was analyzed. All consecutive PFs referred to angiography between 01/01/2009 and 12/31/2018 were included. All suspected pelvic hemorrhage was managed with AE; pelvic packing was not performed. Demographics, injury/shock severity, 24-h transfusion data, time to AE and mortality were recorded. Data are presented as median (IQR).

Results

During the 10-year study period, 1270 PF patients were treated. Thirty-six (2.8%) [75% male, 49 (33;65) years, ISS 36 (24;43), base deficit 3.65 (5.9;0.6), transfusions 4(2;7)] had AE. The indication for AE was clinical suspicion (CS) of pelvic bleeding [CS 24(67%)] or arterial blush on CT [CT 12 (33%)]. Median time to AE was 141 min for CS, and 223 min for CT, with no change over the study period. Patients with CS had a higher ISS, worse base deficit, greater transfusion requirements and faster time to AE. Five patients (14%) died. There were no deaths attributed to exsanguination.

Conclusions

Time to AE did not improve. Patients referred from CT are physiologically different from CS and should be analyzed accordingly, with CS resulting in faster time to AE in sicker patients. Contemporary resuscitation challenges the need for hyperacute AE as no patients exsanguinated despite time to AE of more than 2 h.

The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures

Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

Fracture fixation in the polytrauma patient: Markers that matter

Timing and type of fracture fixation in the multiply-injured trauma patient have been important and controversial topics. Ideal care for these patients come from providers who communicate well with one another in a team fashion and view the whole person, rather than focusing on injury to individual systems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which may have profound impact upon outcomes. The concept of Early Total Care arose from the realization that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most patients. However, insufficient assessment and understanding of the physiological status of polytraumatized patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other procedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improvement of acidosis.

Strategies for the management of hemodynamically unstable pelvic fractures: From preperitoneal pelvic packing to definitive internal fixation

BACKGROUND/OBJECTIVE

Preperitoneal pelvic packing is useful, and favorable treatment outcomes have been reported. However, the timing of subsequent internal fixation of the pelvis is still debatable. We report the outcomes of a study on patients that underwent internal fixation after preperitoneal packing.

METHODS

A retrospective review was performed for patients with hemodynamically unstable pelvic fracture who underwent preperitoneal pelvic packing and internal fixation. Patients who underwent internal fixation with simultaneous packing removal were placed in Group 1. Patients who underwent definitive internal fixation later were placed in Group 2.

RESULTS

Of the 56 patients (mean age 44.7 years), 36 were male. The mean time from injury to internal fixation was 1.3 (1-2) days and 5.6 (3-10) days in Group 1 and 2, respectively. There was a significant difference in the mean duration of stay in the intensive care unit: 10.9 (3-54) days in Group 1 vs. 14.4 (5-43) days in Group 2 (p = 0.019). Thirty-one cases of complications occurred among 14 patients (25%), including six cases of surgical site infection. Among the six cases of infection, four were superficial and two were deep; five of these cases occurred in Group 2, including both cases of deep infection (p = 0.013).

CONCLUSION

Performing internal fixation with packing removal should aid the return of the patient to a stable state, as it is possible to utilize the same incision line used for the original packing procedure, while providing stability to the pelvis.

A novel hybrid fixation (percutaneous anterior pelvic bridge with K-wire) for the treatment of traumatic pelvic ring injury: A prospective study

BACKGROUND

The aim of the study was to introduce a novel percutaneous technique for the treatment of pelvic ring injuries using a percutaneous anterior pelvic bridge (PAPB) with K-wire.

METHODS

From December 2010 to November 2016, a prospective study of 86 patients with anterior pelvic ring fracture (42 utilizing PAPB with K-wire and 44 utilizing PAPB). Patient data was retrieved from electronic charts. Radiological results were assessed based on the Matta criteria system to evaluate the quality of the reduction and time to union. Functional outcomes were evaluated using the Majeed scoring system. Postoperative complications were also recorded.

RESULTS

Age, sex, cause of injury, type of fracture, functional recovery, American Society of Anesthesiologists classification, union time, Majeed scoring and complications did not differ significantly between the two groups. The quality of the reduction and pain scoring differed between groups (all p-values < 0.05). Group A got better reduction and less pain scoring.

CONCLUSIONS

The novel percutaneous technique with hybrid fixation using PAPB with K-wire is a successful alternative for the treatment of pelvic ring injuries, which results in better quality of reduction and less pain scoring outcomes comparing to PAPB. May the PAPB + K-wire could provide more stability.

Computational analysis on the feasibility of transverse iliosacral screw fixation for different sacral segments

PURPOSE

To evaluate the feasibility of transverse iliosacral (TIS) screw placement in different segments of the sacrum and measure the parameters of the unilateral iliosacral (IS) screw in the case that cannot be inserted the TIS screw.

METHODS

This study used 100 pelvic continuous computed tomography images. Mimics (Materialise Interactive Medical Image Control System) was used to reconstruct the three-dimensional pelvis model. All sacrums were divided into the normal group and dysmorphic group. Any difference in osseous fixation pathway (OFP) diameter in the first two segments between both groups was investigated. In dysmorphic sacrums, the optimal inserting angle and length of the unilateral S1 screw were measured. The number of foramen in every sacrum was recorded.

RESULTS

Thirty-two sacrums had sacral dysmorphism. The OFP diameter for the S2 TIS screw in the dysmorphic group was larger than that in the normal group (p = 0.02). Receiver operating characteristic curve analysis indicated the cutoff values as 20.55 mm and 15.18° for the S1 front edge height and S1S2 angle, respectively. In the dysmorphic case, the unilateral S1 IS screw should be inserted with a cephalad incline angle of 36.14 ± 5.97° and a ventrally incline angle of 37.33 ± 4.64°. S3 TIS screw placement rate was 53.1% in the dysmorphic group.

CONCLUSIONS

The most common cause of sacral dysmorphism is the fusion of the L5 to the true S1. In dysmorphic sacrums, the unilateral IS screw should be placed obliquely in the S1 segment, and the S2 segment usually has a sufficient OFP for the TIS screw. Using S3 TIS screw and two TIS screws in the first segment technique is not recommended because of a high risk.

Lactate as an Early Predictor for Early Massive Transfusion in Trauma Patients: A Retrospective Study

Objective

Transfusion is a key treatment for patients with hemorrhage. Early massive transfusion (EMT) is defined as transfusion of 10 or more units of red blood cells (RBC) within the first 6 hours. We attempted to determine whether metabolic markers can be used as predictors for EMT.

Method

We retrospectively reviewed outcomes in 71 patients who visited the emergency department within 12 hours after trauma and received at least 1 unit of RBC within 24 hours between January 2008 and June 2010.

Results

Of the 71 patients, 54 were male and 17 were female; their mean age was 50.3±17.7 years. Of these, 15 required EMT and 56 did not; these patients received 17.7±13.1 and 2.8±2.3 units of RBCs, respectively. There were significant differences between EMT and non-EMT groups in injury severity score (ISS; p=0.001), systolic blood pressure (SBP; p=0.010), base deficit (p=0.003), and lactate concentration (p=0.001). Logistic regression analysis showed that SBP <90 mmHg (odds ratio [OR] 11.71, 95% CI 1.83-74.77, p=0.009), ISS ≥25 (OR 23.39, 95% CI 1.87-293.23, p=0.015), and lactate ≥3.5 mmol/L (OR 6.99, 95% CI 1.10-44.33, p=0.039) were significant predictors of EMT. The area under the curve for ≥3.5 mmol/L lactate was 0.79 (p=0.001), with a sensitivity of 76.7% and a specificity of 67.8%. The 30-day mortality rate was significantly higher in patients with lactate ≥3.5 mmol/L than in those with lactate <3.5 mmol/L (p=0.002).

Conclusion

Lactate concentration is an important predictor of the need for EMT and should be considered in the initial phase of trauma resuscitation to prepare for massive transfusion.

Modified pedicle screw-rod fixation versus anterior pelvic external fixation for the management of anterior pelvic ring fractures: a comparative study

Background

Anterior pelvic ring fracture, as high-energy trauma, needs to be effectively treated. The purpose of the current study was to evaluate the clinical applications of modified pedicle screw-rod fixation and anterior pelvic external fixation for the treatment of anterior pelvic ring fracture.

Methods

Either modified pedicle screw-rod fixation (modified PSRF group, N = 21) or anterior pelvic external fixation (APEF group, N = 22) was performed to 43 patients, with or without fixation of posterior ring. Clinical outcomes were evaluated via Majeed scores. Relevant clinical evaluation indicators including operation time, intraoperative blood loss, hospitalization duration, and complications were compared between these two groups.

Results

The operation time in APEF group was significantly less than that in modified PSRF group (P < 0.0001). No significant difference with respect to intraoperative blood loss and hospitalization duration between the two groups was shown (P = 0.51 and P = 0.33, respectively). Six patients developed surgical site infection in APEF group. Three patients experienced loss of fixation, and two patients experienced loosening of fixator in APEF group. Temporary lateral femoral cutaneous nerve irritation occurred in three patients in modified PSRF group while two patients in APEF group. One patient experienced femoral nerve palsy in modified PSRF group. Fractures of all patients healed well eventually. No statistical difference regarding Majeed evaluation scores was found between two groups.

Conclusions

Application of both modified PSRF and APEF could provide similar satisfactory clinical outcomes for anterior pelvic ring fracture. Modified PSRF, a minimally invasive technique with the advantages of internal fixation, could be performed as an alternative method for instable pelvic fractures.

Trial registration

Research Registry UIN: researchregistry2776.

Biomechanical characteristics of fixation methods for floating pubic symphysis

Background

Floating pubic symphysis (FPS) is a relatively rare injury caused by high-energy mechanisms. There are several fixation methods used to treat FPS, including external fixation, subcutaneous fixation, internal fixation, and percutaneous cannulated screw fixation. To choose the appropriate fixation, it is necessary to study the biomechanical performance of these different methods. The goal of this study was to compare the biomechanical characteristics of six methods by finite element analysis.

Methods

A three-dimensional finite element model of FPS was simulated. Six methods were used in the FPS model, including external fixation (Ext), subcutaneous rod fixation (Sub-rod), subcutaneous plate fixation (Sub-plate), superior pectineal plate fixation (Int-sup), infrapectineal plate fixation (Int-ifa), and cannulated screw fixation (Int-scr). Compressive and rotational loads were then applied in all models. Biomechanical characteristics that were recorded and analyzed included construct stiffness, micromotion of the fracture gaps, von Mises stress, and stress distribution.

Results

The construct stiffness of the anterior pelvic ring was decreased dramatically when FPS occurred. Compressive stiffness was restored by the three internal fixation and Sub-rod methods. Unfortunately, rotational stiffness was not restored satisfactorily by the six methods. For micromotion of the fracture gaps, the displacement was reduced significantly by the Int-sup and Int-ifa methods under compression. The internal fixation methods and Sub-plate method performed well under rotation. The maximum von Mises stress of the implants was not large. For the plate-screw system, the maximum von Mises stress occurred over the region of the fracture and plate-screw joints. The maximum von Mises stress appeared on the rod-screw and screw-bone interfaces for the rod-screw system.

Conclusions

The present study showed the biomechanical advantages of internal fixation methods for FPS from a finite element view. Superior stabilization of the anterior pelvic ring and fracture gaps was obtained by internal fixation. Subcutaneous fixation had satisfactory outcomes as well. Sub-rod fixation offered good anti-compression, while the Sub-plate fixation provided favorable anti-rotational capacity.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Multiple Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

OBJECTIVES

To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures.

DESIGN

Prospective, cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Fractures included femur (n = 167), pelvis (n = 74), acetabulum (n = 54), and spine (n = 107).

MAIN OUTCOME MEASUREMENTS

Complications, including pneumonia, acute respiratory distress syndrome, infections, deep venous thrombosis, pulmonary embolism, sepsis, multiple organ failure, and death, and length of stay.

RESULTS

Definitive fixation was performed concurrently with another procedure in 147 patients. They had greater ISS (29.4 vs. 24.6, P < 0.01), more transfusions (8.9 U vs. 3.6 U, P < 0.01), and longer surgery (4:22 vs. 2:41, P < 0.01) than patients with fracture fixation only, but no differences in complications. When patients who had definitive fixation in the same setting as another procedure were compared only with other patients who required more than 1 procedure performed in a staged manner on different days (n = 71), complications were fewer (33% vs. 54%, P = 0.004), and ventilation time (4.00 vs. 6.83 days), intensive care unit (ICU) stay (6.38 vs. 10.6 days), and length of stay (12.4 vs. 16.0 days) were shorter (all P ≤ 0.03) for the nonstaged patients.

CONCLUSIONS

In resuscitated patients, definitive fixation in the same setting as another procedure did not increase the frequency of complications despite greater ISS, transfusions, and surgical duration in the multiple procedure group. Multiple procedures in the same setting may reduce complications and hospital stay versus additional surgeries on other days.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of non invasive external pelvic compression: a systematic review of the literature

Introduction

Pelvic fractures might carry a significant risk of bleeding. A wide variety of pelvic binders together with pelvic sheets are available and offer an adjunct to the initial management of poly-trauma patients with pelvic injuries. These devices are collectively referred to as pelvic circumferential compression devices (PCCDs). The aim of this study was to review the literature for evidence pertinent to the efficacy and safety of PCCDs.

Methods

Using the PRISMA guidelines a systematic search on PubMed, Web of Science, CINAHL, Embase and Scopus was carried out. Articles included were in English language and published between 1999 and 2015. Studies included were appraised with narrative data synthesis.

Results

Seven articles addressed mechanical properties of non-invasive external mechanical devices, six articles focused on physiological aspects, and three studies evaluated the pressure characteristics of these devices. We found 4 case reports regarding adverse effects. None of the studies identified addressed the cost effectiveness or pain relief issues related to the use of PCCDs.

Conclusions

Based on available literature, PCCDs are widely used in the initial management of patients with suspected pelvic bleeding. There is evidence to suggest that external compression reduces disrupted pelvic rings. There are some complications reported following application of PCCDs. Hemorrhagic source and physiological effectiveness of PCCDs needs to be addressed in future studies. In the meantime judicious application of PCCDs will continue to be recommended.

A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality

BACKGROUND

Previous studies evaluating the epidemiology of pelvic ring fractures and predictors of mortality are largely based upon non-US populations, potentially limiting their generalizability. This study sought to analyze trends of pelvic ring fractures and associated complications in the United States using the largest and most recent national data set available. The specific aims of this study were to determine whether the incidence of pelvic ring fractures changed over time, whether in-hospital mortality following pelvic ring fracture changed over time, whether hospital length of stay following pelvic ring fracture changed over time, and whether there are independent predictors of in-hospital mortality, adverse events, or nonroutine discharge following pelvic fracture.

METHODS

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with pelvic ring fractures between 1990 and 2007. A cohort representative of 1 464 458 patients was identified, and multivariable logistic regression was used to find independent predictors of mortality, adverse events, and nonroutine discharge to another inpatient facility.

RESULTS

Between 1990 and 2007, the population-adjusted incidence of pelvic ring fractures increased from 27.24 to 34.30 per 100 000 capita (P < .001). Mortality declined from 4.2% to 2.8% (P < .001) paralleling an increase in the proportion of patients treated with surgical fixation (7.22%-10.36%). All forms of internal fixation were associated with decreased odds of mortality, while external fixation was associated with increased odds of mortality. Internal fixation was also associated with lower odds of adverse events and nonroutine discharge to inpatient facilities. The average in-hospital length of stay decreased from 11.2 days to 6.5 days (P < .001).

CONCLUSION

This study provides the largest and most comprehensive epidemiologic analysis of pelvic ring fractures in the United States. Knowledge of the increasing incidence of pelvic fractures and prognostic factors associated with poor outcomes may improve outcomes.

Pelvic ring injuries: Surgical management and long-term outcomes

Pelvic ring injuries present a therapeutic challenge to the orthopedic surgeon. Management is based on the patient's physiological status, fracture classification, and associated injuries. Surgical stabilization is indicated in unstable injury patterns and those that fail nonsurgical management. The optimal timing for definitive fixation is not clearly defined, but early stabilization is recommended. Surgical techniques include external fixation, open reduction and internal fixation, and minimally invasive percutaneous osteosynthesis. Special considerations are required for concomitant acetabular fractures, sacral fractures, and those occurring in skeletally immature patients. Long-term outcomes are limited by lack of pelvis-specific outcome measures and burden of associated injuries.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BACKGROUND

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

METHODS

Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.

RESULTS

All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).

CONCLUSIONS

Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Internal versus external fixation of the anterior component in unstable fractures of the pelvic ring: pooled results from a systematic review

PURPOSE

Improving reduction of the pelvic ring improves long-term functional outcomes for patients. It has been demonstrated that posterior internal fixation is necessary to adequately control fractures to the posterior ring and there is evidence that supplementing this with fixation of the anterior ring improves stability. It is accepted that internal fixation provides greater stability than external fixation of the anterior ring but long-term differences in radiographic and functional outcomes have not yet been quantified.

METHODS

A search of electronic databases, reference lists and review articles from 1989 to 2015 yielded 18 studies (n = 884) that met our inclusion criteria. We included studies that discussed pelvic ring injuries in adults, reported functional or radiological outcomes or complications by anterior ring intervention and exceeded 14 patients. We excluded biomechanical and cadaver studies.

RESULTS

Internal fixation of the anterior pelvic ring had better functional and radiographic outcomes. Residual displacement of >10 mm was less common with internal fixation (ER 0.12, 95 % CI 0.06-0.24) than external fixation (ER 0.31, 95 % CI 0.11-0.62). Unsatisfactory outcomes also occurred at a lower rate (ER 0.09, 95 % CI 0.03-0.22) compared to external fixation (ER 0.32, 95 % CI 0.18-0.50). Losses of reduction (ER 0.02, 95 % CI 0.01-0.04 versus ER 0.07, 95 % CI 0.02-0.21), malunions (ER 0.03, 95 % CI 0.01-0.08 versus ER 0.07, 95 % CI 0.02-0.21) and delayed/non-unions (ER 0.02, 95 % CI 0.01-0.05 versus ER 0.04, 95 % CI 0.02-0.07).

CONCLUSIONS

Internal fixation of the anterior pelvic ring as supplementary fixation for unstable injuries to the pelvic ring appears to result in better radiographic and functional outcomes as well as fewer complications. However, data that separated outcomes and complications in relation to interventions of the anterior pelvic ring were limited. More studies looking specifically at outcomes in relation to the type of anterior ring intervention are needed.

The Effect of Body Mass Index on Posttraumatic Transfusion after Pelvic Trauma

The impact of body mass index (BMI) on posttraumatic blood transfusion after pelvic trauma is not well known. We conducted a retrospective review of trauma registry data over a 5-year period. Patients were stratified by BMI as normal: less than 25 kg/m2, overweight: 25 to 29.9 kg/m2, obese: 30 to 39.9 kg/m2, and morbidly obese: 40 kg/m2 or greater. Fractures were identified as “likely to receive transfusion” based on literature. Multivariable logistic regression modeling evaluated the relationship between BMI and initial posttraumatic transfusion. A second regression model was created to test the effect of BMI after adjusting for fractures “less likely to receive transfusion.” Sixty-six of 244 patients (27.3%) received transfusion (mean: 1.1 ± 2.3 units). Morbid obesity was associated with transfusion (less than 55.6 vs 24.8%; P < 0.05) and units of total blood transfused (2.2 ± 2.9 vs 1.0 ± 2.2 mL; P < 0.05). The average age of patients who received a blood transfusion was significantly older compared with patients who did not receive a transfusion (45.4 ± 18.8 vs 36.1 ± 16.1 years; P < 0.05). After adjusting for potential confounders, morbid obesity was a significant risk factor for transfusion (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.4 to 12.0). Adjusting by age and fracture patterns “less likely to receive transfusion,” morbid obesity remained a risk factor for transfusion (OR, 4.5; 95% CI, 1.5 to 12.9). Morbid obesity represented a significant risk factor for posttraumatic transfusion in isolated pelvic trauma, even for fracture patterns “less likely to receive transfusion.”

Damage-control orthopedics versus early total care in the treatment of borderline high-energy pelvic fractures

The purpose of this study was to compare the effectiveness of damage-control orthopedics (DCO) vs early total care (ETC) in the treatment of borderline high-energy pelvic fractures. Seventy-two patients with borderline high-energy pelvic fractures were retrospectively reviewed; 39 received DCO and 33 received ETC. Demographic data and initial injury severities were comparable between groups, except for Abbreviated Injury Scale (AIS) head scores and Glasgow Coma Scale (GCS) scores. Regarding postoperative complications, the incidence rates of acute lung injury and acute respiratory distress syndrome and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score were significantly lower in the DCO group compared with the ETC group. Similar results were also observed in subgroups stratified by age (younger than 40 years and 40 years and older). Regarding patients with Tile B fractures, there was no significant difference between groups in incidence rates of overall postoperative complications. However, in patients with Tile C fractures, especially in those 40 years and older, the DCO group had a lower incidence rate of ALI and had lower APACHE II scores than did the ETC group. This study's findings indicate that DCO is the most suitable therapeutic option for patients with Tile C fractures, especially for those 40 years and older, whereas ETC is preferred for patients with Tile B fractures, provided that it is possible to avoid a second operation as well as any delays in patient mobilization.

Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement

BACKGROUND

Upper sacral segment dysplasia increases the risk of cortical perforation during iliosacral screw insertion. Dysmorphic sacra have narrow and angled upper osseous corridors. However, there is no validated definition of this anatomic variation. We hypothesized that pelves could be quantitatively grouped by anatomic measurements.

METHODS

One hundred and four computed tomography (CT) scans and virtual outlet views of uninjured pelves were analyzed for the presence of the five qualitative characteristics of upper sacral segment dysplasia. CT scans were reformatted to measure the cross-sectional area, angulation, and length of the osseous corridor. Principal components analysis was used to identify multivariable explanations of anatomic variability, and discriminant analysis was used to assess how well such combinations can classify dysmorphic pelves.

RESULTS

The prevalences of the five radiographic qualitative characteristics of upper sacral segment dysplasia, as determined by two reviewers, ranged from 28% to 53% in the cohort. The rates of agreement between the two reviewers ranged from 70% to 81%, and kappa coefficients ranged from 0.26 to 0.59. Cluster analysis revealed three pelvic phenotypes based on the maximal length of the osseous corridor in the upper two sacral segments. Forty-one percent of the pelves fell into the dysmorphic cluster. The five radiographic qualitative characteristics of dysmorphism were significantly more frequent (p < 0.007) in this cluster. A combination of upper sacral coronal and axial angulation effectively explained the variance in the data, and an inverse linear relationship between these angles and a long upper sacral segment corridor was identified. A sacral dysmorphism score was derived with the equation: (first sacral coronal angle) + 2(first sacral axial angle). An increase in the sacral dysmorphism score correlated with a lower likelihood of a safe transsacral first sacral corridor. No subjects with a sacral dysmorphism score >70 had a safe transsacral first sacral corridor.

CONCLUSIONS

Sacral dysmorphism was found in 41% of the pelves. The major determinants of sacral dysmorphism are upper sacral segment coronal and axial angulation. The sacral dysmorphism score quantifies dysmorphism and can be used in preoperative planning of iliosacral screw placement.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]

BACKGROUND

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

METHODS

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

RESULTS

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

CONCLUSIONS

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.

Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Management of pelvic fractures

PURPOSE OF REVIEW

The management of patients with pelvic fractures can be demanding. Severe pelvic fractures pose a great challenge for physicians and can greatly contribute to significant patient morbidity and mortality. The purpose of this review is to highlight recent, positive changes in the management of patients with pelvic fractures.

RECENT FINDINGS

The current status of pelvic fracture management is presented, including a recently proposed algorithm for management, an evaluation of roles of angioembolization and preperitoneal packing. Additionally, the approach of bilateral internal iliac artery ligation as a salvage procedure is reviewed, and the outcome of acute (<24 h) pelvic fracture operative fixation. Regardless of the strategy adopted, a multidisciplinary approach is required for the proper management of hemodynamically unstable patients with pelvic fractures.

SUMMARY

The key elements in managing patients with pelvic fractures are swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage to facilitate survival of these patients. Multimodality therapies including external pelvic stabilization, angioembolization and preperitoneal pelvic packing are useful adjuncts that require appropriately trained and immediately available personnel. A multidisciplinary approach has been shown to be beneficial for patient outcomes.

The long-term clinical outcome after pelvic ring injuries

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries.

We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed.

In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44).

At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury.

Cite this article: Bone Joint J 2013;95-B:548–53.

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.

Individual and team training with first time users of the Pelvic C-Clamp: do they remember or will we need refresher trainings?

BACKGROUND

Pelvic ring injuries with associated hemorrhage from the presacral venous plexus are major contributors to morbidity and mortality in trauma patients. The Pelvic C-Clamp is an often discussed, yet seldom used device for both skeletal and hemodynamic stabilization. In a recent study we have addressed this issue and have stressed the importance of regular training sessions with the device. This study is aimed as an extended follow up with a special focus on how trained skills are retained over time.

MATERIALS AND METHODS

32 participants with various levels of training were taught to use the clamp. Thirty-six hours later, a hands-on session was performed where the time needed for placement and accuracy of placement were evaluated on a model in individual and team settings. 12 months later a re-evaluation was performed.

RESULTS

Evaluation showed that during the first session, 57/64 pins (89.15 %) were placed inside the safe area. The team training results showed reduced times for assembly and more exact pin placement. In the re-evaluation 1 year later, 75 % of all pins were safely placed and the time needed for assembly was significantly longer.

CONCLUSIONS

The majority of 57 pins were placed in the safe area within 6 min after one single training session. This reproduces the Australian data and supports the theory that adequately educated and skilled physicians should be able to handle the device properly. The data from the re-evaluation suggest that repeating the training session with the device improves performance.

Advances and future directions for management of trauma patients with musculoskeletal injuries

Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.

A comparison of percutaneous reduction and screw fixation versus open reduction and plate fixation of traumatic symphysis pubis diastasis

PURPOSE

Plate fixation, the conventional treatment for traumatic symphysis pubis diastasis, carries the risk of extensive exposure, blood loss and postoperative infections. Percutaneous screw fixation is a minimally invasive treatment. The goal of the present study was to compare the outcome of plate fixation and percutaneous screw technique in the treatment of traumatic pubic symphysis diastasis.

METHODS

Ninety patients with traumatic symphysis pubis diastasis were treated from January 2003 to December 2009 at two level 1 regional trauma centers. The mean time of follow-up was 21 months (18 to 26). Forty-five patients were treated by percutaneous screw fixation. Forty-five patients were treated by plate and screws fixation. The demographic, distribution of fracture patterns, blood loss, incision length, fixation failure, malunion, revision surgery and functional scores were compared.

RESULTS

Seven cases were lost during follow-up. Demographics (age and gender), fracture classification and Injury Severity Score were comparable in the two groups (P > 0.05). Blood loss and extensive exposure were much less in screw group (P < 0.01). Patients in screw group achieved better functional performance (P = 0.01). There were no significant differences favoring plate fixation in reduction quality (P = 0.32), implant failure (P = 0.39), malunion (P = 0.15), revision surgery rates (P = 0.27), percentage of impotence in the male patients (P = 0.2) and implant removal time (P = 0.12) between the two groups.

CONCLUSIONS

Our results indicate that besides lower rate of iatrogenic injuries and better functional outcome, percutaneous screw fixation of the pubic symphysis is as strong as plate fixation.

Intramedullary nailing of femoral shaft fractures in polytraumatized patients. a longitudinal, prospective and observational study of the procedure-related impact on cardiopulmonary- and inflammatory responses

BACKGROUND

Early intramedullary nailing (IMN) of long bone fractures in severely injured patients has been evaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and morbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients.

METHODS

Twelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples were collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed pulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded peri- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily.

RESULTS

Mean Injury Severity Score (ISS) was 31 ± 2.6. No procedure-related effect of the primary IMN on coagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-α) increased significantly from 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the first to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related transient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post procedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute lung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection.

CONCLUSION

In the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. We could not demonstrate any major additional IMN-related impact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be interpreted carefully due to the relatively few patients included.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00981877.

Percutaneous limited internal fixation combined with external fixation to treat open pelvic fractures concomitant with perineal lacerations

External fixation combined with colostomy is a traditional management of the pelvic fractures associated with perineal lacerations. However, malunion and dysfunction caused by malreduction and loss of reduction are common. One-stage definitive fixation without soft tissue harassment is requisite for the treatment. The purpose of this study was to assess the outcome of 1-stage definitive fixation by combining percutaneous limited internal fixation and external fixation in the treatment of pelvic fractures with perineal lacerations. Eighteen adults with high-energy unstable pelvic ring fractures associated with perineal lacerations were admitted between June 2003 and December 2010. Mean follow-up was 28 months. After wound closure and colostomy, 10 patients received external fixation and percutaneous screw fixation, and 8 patients underwent external fixation. Demographics, wound and fracture classification, and Injury Severity Score were comparable between the groups (P>.05). Initial reduction quality was comparable between the groups (P=.14), but the loss of reduction during follow-up was more significant in the external fixation group (P=.004). Combined fixation achieved better functional results than external fixation (P=.02). There were 2 cases of superficial wound infection in each group (P=1.0). By combining debridement, wound closure, colostomy, percutaneous limited internal fixation, and external fixation, we improved pelvic fracture recovery while reducing the risk of infection. One-stage definitive fixation is a better choice than external fixation in the treatment of open pelvic fracture concomitant with perineal wound.

Second hit phenomenon: existing evidence of clinical implications

The last two decades extensive research evidence has been accumulated regarding the pathophysiology of trauma and the sequelae of interventions that follow. Aim of this analysis has been to collect and categorise the existing data on the so-called "second hit" phenomenon that includes the biochemical and physiologic alterations occurring in patients having surgery after major trauma. Articles were extracted from the PubMed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was utilised for quality assessment of the outcomes. Twenty-six articles were eligible for the final analysis, referring to a total of 8262 patients that underwent surgery after major trauma. Sixteen retrospective clinical studies including 7322 patients and 10 prospective ones, including 940 patients were evaluated. Several variables able to reproduce a post-operative second hit were identified; mostly related to pulmonary dysfunction, coagulopathy, fat or pulmonary embolism, and the inflammatory immune system. Indicative conclusions were extracted, as well as the need for further prospective randomised trials. Suggestions on the content and the rationale of future studies are provided.