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Complications after surgical treatment of pelvic fractures: a five-year follow-up of 194 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:877-882. [PMID: 35142922 PMCID: PMC10125928 DOI: 10.1007/s00590-022-03215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Surgical treatment of pelvic fractures is an advanced intervention associated with multiple complications. The primary aim of this study was to investigate the rate of unplanned reoperations after pelvic fracture surgery. Secondary aims included occurrence of other adverse events and mortality. METHODS All adult patients ≥ 18 years with surgically treated pelvic fracture operated at the Karolinska University Hospital in Sweden between 2010 and 2019 were identified and retrospectively included. Data were 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 194 patients were included with mean age (± SD, range) 45.4 (16, 18-83) years. 62% were males (n = 121) and the median (IQR) follow-up time was 1890 (1791) days (4.9 years). Forty-eight patients (25%) had an unplanned reoperation, with infection being the most common cause of reoperation (n = 18, 9.3%). Seventy-eight (40%) patients had an adverse event not requiring reoperation and the most common event was nerve injury (n = 34, 18%). Concomitant abdominal injury was identified as a risk factor for an adverse event (OR 2.5, 95% CI 1.3-4.9, p < 0.01). 30-day mortality was 1.5% and 1-year mortality 6.2%. CONCLUSION The rate of unplanned reoperation after pelvic fracture surgery was high, as was the rate of other adverse events not requiring surgery. No identified risk factor was found to predict further surgery, but concomitant abdominal injury was a risk factor for other adverse events. Mortality was low at both 30 days and 1 year.
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Marchand LS, Sepehri A, Hannan ZD, Zaidi R, DuBose JJ, Morrison JJ, O'Toole RV, Slobogean GM. Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries. J Orthop Trauma 2022; 36:74. [PMID: 34050079 DOI: 10.1097/bot.0000000000002191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA). DESIGN Retrospective case series. SETTING Academic, Level 1 trauma center in North America. PATIENTS Twenty-five patients with disruption of the pelvic ring and hemodynamic instability. INTERVENTION Placement of a REBOA device as an adjuvant treatment to trauma resuscitation. MAIN OUTCOME MEASURE Death and ischemic-related complications. RESULTS The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy. CONCLUSIONS REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Aresh Sepehri
- University of British Columbia, Vancouver, BC, Canada
| | - Zachary D Hannan
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Raza Zaidi
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Joseph J DuBose
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Jonathan J Morrison
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Gerard M Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
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The pelvic fracture - Indicator of injury severity or lethal fracture? Injury 2018; 49:1568-1571. [PMID: 29909925 DOI: 10.1016/j.injury.2018.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Presence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury. MATERIAL AND METHODS Karolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, "SweTrau". Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality. RESULTS Univariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3-3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2-0.9), while factors as Shock (OR 7.1, CI 4.6-10.9), GCS < 9 (OR 6.2, CI 3.9-9.8), ISS > 15 (OR 12.4, CI 8.1-18.9), Age >60 (OR 3.2, CI 2.1-4,9) and ASA 3-4 (OR 4.7, CI 3.1-7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar. CONCLUSION Presence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock.
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INFIX/EXFIX: Massive Open Pelvic Injuries and Review of the Literature. Case Rep Orthop 2016; 2016:9468285. [PMID: 27493818 PMCID: PMC4963555 DOI: 10.1155/2016/9468285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022] Open
Abstract
Introduction. Open pelvic fractures make up 2–5% of all pelvic ring injuries. Their mortality has been reported to be as high as 50%. During Operation Enduring Freedom protocols for massive open pelvic injuries lead to the survival of injuries once thought to be fatal. The INFIX is a subcutaneous anterior fixator for pelvic stabilization which is stronger than external fixation. The purpose of this paper is to describe the use of INFIX and modern algorithms for massive open pelvic injuries. Methods. An IRB approved retrospective review describes 4 cases in civilian practice with massive open pelvic injuries. We also review the modern literature on open pelvic injures. Discussion. Key components in the care of massive open pelvic injuries include hemorrhage control by clamping of the aorta or REBOA when necessary and fecal/urinary diversion. The INFIX can be used internally, as a partial INFIX partial EXFIX, or as an EXFIX. Its low profile allows for easy application of wound vacs and wound care and when subcutaneous avoids pin tract infections. Conclusion. Massive open pelvic injuries are a difficult problem. Following modern protocols can help prevent mortality.
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Vaidya R, Scott AN, Tonnos F, Hudson I, Martin AJ, Sethi A. Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? Am J Surg 2015; 211:495-500. [PMID: 26781723 DOI: 10.1016/j.amjsurg.2015.08.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mortality in patients sustaining pelvic fractures has been reported to be 4% to 15%. We sought to investigate the cause of death based on timing and evaluate if type of fracture and Injury Severity Score have an influence on the survival time. METHODS Sixty-nine patients of eight hundred sixty seven with a pelvic fracture who died during their hospital admission were included. Fractures were classified using the Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association system. Cause determined by autopsy in 48/69. RESULTS The leading cause of death within 6 hours was abdominal and pelvic hemorrhage; 6 to 24 hours head injury, and greater than 24 hours multiple organ dysfunction syndrome. Survival time did not correlate between fracture type (P < .12) or Injury Severity Score. Only 2 patients died of isolated pelvic hemorrhage. CONCLUSIONS Despite the advances made in acute management of the traumatized patient in the emergency department, mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.
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Affiliation(s)
- Rahul Vaidya
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA.
| | - Alesha N Scott
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA
| | - Fred Tonnos
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA
| | - Ian Hudson
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA
| | - Adam J Martin
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA
| | - Anil Sethi
- 4G University Health Centre, Detroit Receiving Hospital, 4201 St. Antoine Blvd, Detroit, MI 48201, USA
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Mauffrey C, Cuellar DO, Pieracci F, Hak DJ, Hammerberg EM, Stahel PF, Burlew CC, Moore EE. Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J 2014; 96-B:1143-54. [PMID: 25183582 DOI: 10.1302/0301-620x.96b9.33914] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.
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Affiliation(s)
- C Mauffrey
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D O Cuellar
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - F Pieracci
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D J Hak
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E M Hammerberg
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - P F Stahel
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - C C Burlew
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E E Moore
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
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Hasankhani EG, Omidi-Kashani F. Treatment outcomes of open pelvic fractures associated with extensive perineal injuries. Clin Orthop Surg 2013; 5:263-8. [PMID: 24340145 PMCID: PMC3858096 DOI: 10.4055/cios.2013.5.4.263] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 05/10/2013] [Indexed: 11/11/2022] Open
Abstract
Background The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries. Methods We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis. Results The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia. Conclusions Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.
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Affiliation(s)
- Ebrahim Ghayem Hasankhani
- Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Lindahl J, Handolin L, Söderlund T, Porras M, Hirvensalo E. Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors. Eur J Trauma Emerg Surg 2012; 39:57-63. [PMID: 23420138 PMCID: PMC3573185 DOI: 10.1007/s00068-012-0242-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 11/18/2012] [Indexed: 11/12/2022]
Abstract
Purpose The control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE). Methods Forty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated. Results All large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than −10 mmol/l) obtained on admission. Conclusions PRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<−10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.
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Affiliation(s)
- J Lindahl
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
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Bilateral Internal Iliac Artery Ligation as a Damage Control Approach in Massive Retroperitoneal Bleeding AfterPelvic Fracture. ACTA ACUST UNITED AC 2010; 69:1507-14. [DOI: 10.1097/ta.0b013e3181d74c2f] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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