Open pelvic fracture: the killing fracture?

Emergency treatment of pelvic ring injuries: state of the art

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

Intelligent robot-assisted fracture reduction system for the treatment of unstable pelvic fractures

BACKGROUND

Precise and minimally invasive closed reduction is the premise of minimally invasive internal fixation. This paper aims to explore the safety and efficacy of a robot-assisted fracture reduction system (RAFR) in the treatment of pelvic fractures and to analyze its clinical advantages and existing problems.

METHODS

The RAFR system intelligently designed the optimal reduction path and target position based on a preoperative three-dimensional(3D) CT scan of the patient. The reduction robotic arm automatically reduced the affected hemipelvis according to the pre-planned reduction path.

RESULTS

The average residual displacement was the 6.65 ± 3.59 mm. According to Matta's criteria, there were 7 excellent, 10 good, and 3 fair, and the excellent and good rate was 85%. No postoperative complications occurred.

CONCLUSION

In our study, the RAFR system could complete accurate and minimally invasive closed reduction for most patients with unstable pelvic fractures, which could achieve good fracture reduction quality and short-term efficacy.

Management of Pelvic Trauma

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.

Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study

BACKGROUND

Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures.

METHODS

Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min.

RESULTS

Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures.

CONCLUSION

In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

Outcomes of open pelvic fractures: A case series

Introduction

Albeit rare, open pelvic fractures are life threatening injuries associated with significant morbidity and mortality. Due to their rarity, there is paucity of data and literature on best management practices. An open pelvic fracture is one where there is a connection between the fracture site and either the skin, rectum, vagina, or genitourinary system. They commonly affect young individuals involved in high energy injuries. During resuscitation, prompt recognition and control of sepsis and stabilization of unstable fractures should precede definitive management.

Materials and methods

We conducted a retrospective study of prospectively collected data between 2012 and 2022 for patients managed in two teaching hospitals in Kenya. All patients were followed up for at least 6 months. The Faringer classification was used to classify the soft tissue wounds and the Young and Burgess classification was used to classify the pelvic fractures. We investigated their functional outcomes using their ability to ambulate independently and the Merle d' Aubigne-Postel score.

Results

Eight patients with an average age of 31 years were included. All were referrals. Three (37.5 %) developed sepsis but resolved. Four (50 %) needed a diverting stoma, which included 2 of the 3 patients who had developed sepsis. 5(62.5 %) needed an external fixator as part of definitive management. There were no mortalities. All achieved full independent ambulation; and all our patients achieved an average Merle d' Aubigne-Postel score of 17.

Conclusion

Our study demonstrates that early sepsis control, appropriate fracture fixation and a multidisciplinary approach can yield satisfactory functional outcomes.

Trends in non-operative management of low-energy pelvic fracture: An analysis of the Nationwide Inpatient Sample

Introduction

Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends.

Methodology

Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends.

Findings

123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%).

Conclusion

The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries.

Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study

INTRODUCTION

Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures.

METHODS

We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality.

RESULTS

Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003).

CONCLUSION

A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.

Management of open pelvic ring injuries

Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.

TiRobot‑assisted versus conventional fluoroscopy-assisted percutaneous sacroiliac screw fixation for pelvic ring injuries: a meta‑analysis

BACKGROUND

The TiRobot is the only robot that has been reported in the literature for posterior pelvic injuries. We aim to compare TiRobot-assisted pelvic screw fixation with the conventional fluoroscopy-assisted percutaneous sacroiliac screw fixation.

METHODS

We conducted a meta-analysis to identify studies involving TiRobot‑assisted versus conventional percutaneous sacroiliac screw fixation for pelvic ring injuries in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and WanFang database, up to April 2022. The following keywords were used: "TiRobot," "robot," "robotic," "pelvic fracture," "screw fixation," "percutaneous," and "pelvic ring injury." Pooled effects of this meta-analysis were calculated using STATA SE version 15.0.

RESULTS

Compared with conventional fluoroscopy-assisted percutaneous sacroiliac screw fixation, TiRobot will result in less radiation exposure time of screw implantation (P = 0.000), less frequency of intraoperative fluoroscopy (P = 0.000), fewer guide wire attempts (P = 0.000), less intraoperative blood loss (P = 0.005), better screw accuracy (P = 0.011), better Majeed score (P = 0.031), and higher overall excellent and good rates of Majeed score (P = 0.018). However, there were no significant differences in terms of operative time (P = 0.055), fracture healing time (P = 0.365), and overall excellent and good rate of reduction accuracy (P = 0.426) between the two groups.

CONCLUSION

TiRobot-assisted fixation has less intraoperative fluoroscopy and intraoperative blood loss, superior screw accuracy, and Majeed score compared with conventional percutaneous sacroiliac screw fixation. TiRobot has no significant effect on operative time, fracture healing time, and reduction accuracy. Given the relevant possible biases in our meta-analysis, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.

A review of open pelvic fractures with concurrent genitourinary injuries

INTRODUCTION

Open pelvic fractures (OPFs) are uncommon but potentially lethal traumatic injuries. Often caused by high energy blunt trauma, they can cause severe injury to abdominal and pelvic structures. We sought to conduct a review of the literature in order to ascertain the rates of genitourinary injury and vaginal laceration after OPF and the rates of resulting infection and mortality.

METHODS

A review of PubMed was conducted to identify studies reporting the rates of genitourinary injury from OPF. Study characteristics, patient characteristics, and outcomes were collected. The data were pooled, and descriptive statistics were obtained.

RESULTS

Eight studies encompassing 343 patients were included. Average age was 35.1 years (10-85.9), 28% were female, and the average Injury Severity Score was 26.5 (4-75). 95.5% of patients had a blunt mechanism of injury. Motor vehicle collision (23.9%), motorcycle accident (19.7%), and pedestrian struck (19.3%) were the most common etiologies. Overall mortality and infection rates were 31.2% and 18.7%, respectively. 19.7% of patients suffered an injury to the genitourinary system, and 32.4% of females sustained a vaginal laceration.

DISCUSSION

OPFs have the potential for extremely high morbidity and mortality. While much research has been done to prevent early mortality from hemorrhage, there is comparatively little research into late mortality stemming from infection and sepsis. Intravenous antibiotics are the mainstay of treatment, and local antibiotics usage has been encouraged. In patients with a vaginal laceration, it is important to provide antibiotic coverage for vaginal flora.

Determination of risk factors associated with surgical site infection in patients undergoing preperitoneal pelvic packing for unstable pelvic fracture

Background

Several recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients.

Methods

We retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study.

Results

SSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis.

Conclusions

Repacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.

Design and evaluation of an intelligent reduction robot system for the minimally invasive reduction in pelvic fractures

Introduction

Pelvic fracture is a severe high-energy injury with the highest disability and mortality of all fractures. Traditional open surgery is associated with extensive soft tissue damages and many complications. Minimally invasive surgery potentially mitigates the risks of open surgical procedures and is becoming a new standard for pelvic fracture treatment. The accurate reduction has been recognized as the cornerstone of minimally invasive surgery for pelvic fracture. At present, the closed reduction in pelvic fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces of soft tissue involved in the fragment manipulation, which might result in fracture malreduction. To overcome these shortcomings and facilitate pelvic fracture reduction, we developed an intelligent robot-assisted fracture reduction (RAFR) system for pelvic fracture.

Methods

The presented method is divided into three parts. The first part is the preparation of 20 pelvic fracture models. In the second part, we offer an automatic reduction algorithm of our robotic reduction system, including Intraoperative real-time 3D navigation, reduction path planning, control and fixation, and robotic-assisted fracture reduction. In the third part, image registration accuracy and fracture reduction accuracy were calculated and analyzed.

Results

All 20 pelvic fracture bone models were reduced by the RAFR system; the mean registration error E1 of the 20 models was 1.29 ± 0.57 mm. The mean reduction error E2 of the 20 models was 2.72 ± 0.82 mm. The global error analysis of registration and reduction results showed that higher errors are mainly located at the edge of the pelvis, such as the iliac wing.

Conclusion

The accuracy of image registration error and fracture reduction error in our study was excellent, which could reach the requirements of the clinical environment. Our study demonstrated the precision and effectiveness of our RAFR system and its applicability and usability in clinical practice, thus paving the way toward robot minimally invasive pelvic fracture surgeries.

Association between 3D Printing-Assisted Pelvic or Acetabular Fracture Surgery and the Length of Hospital Stay in Nongeriatric Male Adults

Pelvic and acetabular fractures are challenging for orthopedic surgeons, but 3D printing has many benefits in treating these fractures and has been applied worldwide. This study aimed to determine whether 3D printing can shorten the length of hospital stay (LHS) in nongeriatric male adult patients with these fractures. This is a single-center retrospective study of 167 nongeriatric male adult participants from August 2009 to December 2021. Participants were divided into two groups based on whether they received 3D printing assistance. Subgroup analyses were performed. Pearson’s correlation and multivariable linear regression models were used to analyze the LHS and the parameters. Results showed that 3D printing-assisted surgery did not affect LHS in the analyzed patients. The LHS was positively correlated with the Injury Severity Score (ISS). Initial hemoglobin levels were negatively associated with LHS in patients aged 18−40 and non-major trauma (ISS < 16) patients. In 40−60-year-old and non-major trauma patients, the duration from fracture to admission was significantly associated with LHS. This study indicates that 3D-assisted technology for pelvic or acetabular fracture surgery for nongeriatric male adults does not influence the LHS. More importantly, the initial evaluation of patients in the hospital was the main predictor of the LHS.

Three-year functional outcome after open pelvic fracture treatment: a retrospective case series from a level I trauma center

PURPOSE

Open pelvic fractures have high mortality rates, and survivors may have ongoing functional deficits from severe trauma and invasive life-saving procedures. However, there are limited reports regarding the functional status evaluation following open pelvic fractures. We aimed to report the treatment experiences and short-term functional outcomes of patients with open pelvic fractures.

METHODS

We retrospectively reviewed the data of 19 consecutive patients with pelvic fractures who underwent treatment at a single institute between January 2014 and June 2018. The resuscitation protocol, osteosynthesis strategy, reduction quality of the pelvic ring, and functional outcomes were analyzed.

RESULTS

The incidence and mortality rates in patients with open pelvic fractures were 4.9 and 21.6%, respectively. Ten, one, and seven of the open wounds related to the pelvic fractures were located in Faringer zones I, II, and III, respectively. Fractures of four patients were categorized as classes 1 and 2, and those of 11 patients as class 3, according to the Jones-Powell classification. Eleven of 19 (57.9%) and 9 of 19 (47.5%) revealed excellent reduction quality by Matta/Torenetta and Lefaivre criteria, respectively. The Merle d'Aubigné score improved at each evaluation but stagnated after 24 months. The Majeed hip score also improved at the 12-month evaluation but the improvement stopped thereafter. At a 3-year follow-up, the patients with excellent reduction of the pelvic ring showed the highest functional performances.

CONCLUSION

Improvements in functional status of patients with open pelvic fractures can be anticipated based on the reduction quality of the pelvis ring.

Management and outcomes of open pelvic fractures: An update

BACKGROUND

Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.

PATIENTS AND METHODS

A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.

RESULTS

Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.

CONCLUSION

Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.

Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center

Purpose

Pelvic trauma has increased risk of mortality in the elderly. Our study aimed to analyze the impact of the additional burden of pelvic fractures in severely injured elderly.

Methods

This is a retrospective analysis of a prospectively maintained trauma registry from 2012 to 2018 at an American College of Surgeons (ACS) verified Level I Trauma Center. Trauma patients aged ≥ 65 years with ISS ≥ 16 and AIS severity score ≥ 3 in at least two body regions were divided in two groups: group I, consisted of elderly polytrauma patients without pelvic fractures, and group II elderly who had concomitant pelvic fractures. We used a double-adjustment method using propensity score matching (PSM) with subsequent covariate adjustment to minimize the effect of confounding factors, and give unbiased estimation of the impact of pelvic fractures. Balance assessment was conducted by computing absolute standardized mean differences (ASMDs) and ASMD < 0.10 reflects good balance between groups.

Results

Of 12,774 patients admitted during this time, 411 (3.2%) elderly with a mean age of 77.75 ± 8.32 years met the inclusion criteria. Of this cohort, only 92 patients (22.4%) had pelvic fractures. Females outnumbered males (55 vs. 45%). Comparing characteristics of group I and group II using ASMDs, pelvic trauma patients were more likely to have higher systolic blood pressure (SBP), head injuries, lower extremity injuries, anticoagulant therapy, and cirrhosis. Fewer variables differed significantly after matching. We observed few instances of worse outcomes associated with pelvic trauma using PSM with and without covariate adjustment. Crude PSM without covariate adjustment, showed a significantly higher rate of deep vein thrombosis (DVT) for pelvic trauma (p < 0.001). Crude PSM also showed a significantly higher rate of ventilator-associated pneumonia (VAP) in group II (p = 0.006). PSM with covariate adjustment did not confirm differences on these outcomes. PSM both without and with covariate adjustment found lower ventilator days and ICU length of stay among patients with pelvic trauma. No significant differences were seen on 12 outcomes: death, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest with cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pulmonary embolism (PE), unplanned intubation, unplanned admission to intensive care unit (ICU), catheter-associated urinary tract infection (CAUTI), and hospital length of stay.

Conclusions

At a Level I Trauma Center the additional burden of pelvic fractures in seriously injured elderly did not translate into higher mortality. PSM without covariate adjustment suggests worse rates among pelvic trauma patients for DVT and VAP but covariate adjustment removed statistical significance for both outcomes. Pelvic trauma patients had shorter time on ventilator and in the ICU. Whether similar analytic methods applied to patients from larger data sources would produce similar findings remains to be seen.

Clinical features and risk factors for mortality in patients with open pelvic fracture: A retrospective study of 46 cases

BACKGROUND

This study aimed to investigate the clinical features, current management strategies, and outcomes of open pelvic fracture patients.

METHODS

We performed a retrospective review of data on patients with blunt trauma and open pelvic fractures admitted to our trauma center over a 5-year period (January 2013 to December 2017). Demographic as well as clinical data including injury mechanism, injury severity score (ISS), fracture classifications, transfusion requirements, interventions, length of hospital and intensive care unit (ICU) stay, and prognosis were investigated. Univariate analysis and binary logistic regression were used to identify the risk variables of death. Finally, a brief literature review was performed to understand the current capacity of treatment and prognosis of this type of injury.

RESULTS

Forty-six patients (36 male and 10 female) were included in this study, mean age 43.2 ± 14.2 years. The overall mortality rate was 17.4%; 43.5% of the patients were hypotensive (systolic blood pressure (SBP) <90 mmHg) on arrival. The average ISS was 31.7 ± 6.7, and the average packed red blood cell (PRBC) transfusion during the first 24 h was 9.6 ± 7.4 units. Five patients (10.9%) underwent transcatheter arterial embolization in the early stage of management. The average hospital and ICU length of stay were 53.0 ± 37.6 days and 14.3 ± 15.3 days, respectively. Statistically significant differences were found in ISS, PRBC units received with the first 24 h, SBP, lactate and base excess on admission, and mechanism of injury when comparing between the death and the survival groups (p < 0.05). ISS and lactate on admission were found to be the independent risk factors for mortality.

CONCLUSION

The mortality rate of open pelvic fractures remains high. ISS and lactate on admission were the independent risk factors for mortality. Optimization of the trauma care algorithms for early identification and treatment of this injury could be the key to decreasing mortality.

Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors

Purpose

To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures.

Methods

Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status.

Results

Out of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70).

Conclusion

In this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication.

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.

Predictors of Acute Mortality After Open Pelvic Fracture: Experience From 37 Patients From A Level I Trauma Center

BACKGROUND

Open pelvic fractures are caused by high-energy traumas and are accompanied by organ injuries. Despite improvements in pre-hospital care, the acute mortality rate following open pelvic fractures remains high. This study aimed to report experiences in managing open pelvic fractures, identify potential independent predictors that contribute to acute mortality in such patients, and generate a scoring formula to predict mortality rate.

METHODS

Open pelvic fracture patients managed during a 42-month period were retrospectively studied. Logistic regression analysis was used to determine predictors of acute mortality. Using the Youden index, threshold values of predictors were selected. Significant predictors were weighted to create a scoring formula. The area under the curve (AUC) was tested in this specific group.

RESULTS

The incidence of open pelvic fractures in all pelvic fractures was 4.9% (37/772), and the overall mortality rate was 21.6% (8/37). All the successfully resuscitated patients entered the reconstruction stage survived and underwent the complete treatment course. Univariate and multivariate logistic regression analyses revealed that the revised trauma score (RTS) was the single independent predictor of acute mortality. A scoring formula was generated following the statistical analysis. The probability of mortality was 0% and 100% when the score was above and below -2, respectively. This model predicted mortality with an AUC of 0.948 (95% confidence interval 0.881-1.000, P < 0.01).

CONCLUSION

The RTS may be a potential predictor of acute mortality in open pelvic fracture patients. Further work would be required to validate the clinical efficacy of the generated scoring formula.

Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures

BACKGROUND

Open pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality.

METHODS

A query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher's exact test and chi-square test for categorical variables, and Welch's t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications.

RESULTS

A total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality.

CONCLUSION

We report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population.

LEVEL OF EVIDENCE

Level II, Retrospective study.

Regional Injury Classification and Treatment of Open Pelvic Fractures

OBJECTIVES

To propose the regional injury classification of open pelvic fracture and summarize the characteristics of its treatment.

METHODS

Clinical data for 67 open pelvic fractures treated from January 2001 to December 2017 were retrospectively analyzed. There were 48 male and 19 female patients. The patients were aged from 12 to 68 years old, and their pelvic fractures were categorized according to Tile classification (type A: 23 cases; type B: 19 cases; type C: 25 cases). Main injury distribution: pubic perineum, 29 cases; ilioinguinal, 20 cases; and sacroiliac, 7 cases. There were 5 cases of ilioinguinal-perineum and 6 cases of sacroiliac-perineum injury. Based on the region of the injury, the mortality and combined injury of each group were observed. The relationship between regional injury groups and death was examined.

RESULTS

Following active treatment, 28 patients died. The mortality rate was 41.8% (28/67), with 39 patients surviving. The average follow-up time was 6 months (3 months to 1 year after discharge). Majeed pelvic fracture score: the score was excellent in 12 cases, good in 14 cases, fair in 9 cases, and poor in 4 cases; there was an excellent and good rate of 66.7%. Open pelvic fracture regional injury classification includes: the perineal type (type I); the ilioinguinal type (type II); the sacroiliac type (type III); and the composite type (type IV). All types were independent of each other, and the mortality of open pelvic fractures was positively correlated with this classification, with a correlation coefficient of 0.620 (P = 0.001 < 0.05; the difference was statistically significant). In this study, cystourethral injury, anorectal injury, and infection were the main combined injuries of type I. The type II and III injuries were mainly iliac vascular injuries. The main combined injuries of type IV were infection, injury of ilium vessels and its branches. There was a statistical difference among the combined injuries of each subtype (P = 0.001 < 0.05).

CONCLUSIONS

The criteria for regional classification were clear, the mortality of the four subtypes increased gradually, and the incidence of combined injury of each subtype varied. Each subtype had different therapeutic characteristics.

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation

OBJECTIVE

To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).

DESIGN

Retrospective observational cohort study.

SETTING

Level I academic trauma center.

PATIENTS

Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.

INTERVENTION

Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).

MAIN OUTCOME MEASURE

Incidence of postoperative surgical site infections of the pelvic space.

RESULTS

Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.

CONCLUSIONS

These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.

LEVEL OF EVIDENCE

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

Influence of energy absorbers on Malgaigne fracture mechanism in lumbar-pelvic system under vertical impact load

Malgaigne fractures are the most common and widespread pelvic injuries resulting from the shear forces the action mechanism of which has not been explained in the literature yet. Military accidents with improvised explosive devices (IED) perfectly reflect this type of pelvic fracture. The finite element (FE) model of lumbar-pelvic complex (LPC) was developed based on computed tomography (CT) scans with the seat including steel frame, padding and soft tissue. The correlation coefficients of both low (100 N) and high (500 N) loads were greater than that currently obtained in the literature due to the presence of muscle force, pubic symphysis and joint cartilage. The dynamic analysis was performed to determine the influence of varying kinds of foam materials i.e. polyurethane, aluminium honeycomb structured and polyurethane auxetic foam on the stress/strain distribution in LPC under vertical impact load with the velocity of 7 m/s. Performed analysis showed the first fracture occurred in the L5 vertebrae resulting in the sacroiliac ligaments disruption and stress concentration in the pelvic ring causing further fractures of the wing of ilium, pubis and ischium bones. This results clearly explain the inconclusive findings about the second fracture that occurs in the pelvic area under a vertical impact load. The applied seat padding foam significantly reduced the stresses transmitted to the anatomical structures, thereby avoiding the risk of pelvic fracture. The analysis has proven that the auxetic polyurethane foam can be used as a good energy absorber.