Pelvic Fracture Patients Research Articles

Isolated Severe Pelvic Fractures Treated With or Without Resuscitative Endovascular Balloon Occlusion of the Aorta: A Matched Cohort Study

INTRODUCTION: Previous studies have revealed resuscitative endovascular balloon occlusion of the aorta (REBOA) may be correlated with higher mortality and acute kidney injury rates in severely injured patients. This study investigated outcomes in severe pelvic fracture patients with or without REBOA. METHODS: This was a retrospective study of patients with severe pelvic fracture (pelvis AIS 3 or greater) in the TQIP database (2013 to 2018). Patients were excluded if transferred from another hospital, without sign of life in the emergency department, died in the emergency department, there was a penetrating mechanism, or other than lower extremity region AIS greater than 3. Propensity score matching was performed with age, vital signs, Injury Severity Score, comorbidities, each AIS region scores, and hollow viscus injuries. Outcomes were mortality and complications, including acute kidney injury, ARDS, venous thromboembolism, deep venous thrombosis, severe sepsis, and ventilator-associated pneumonia or pneumonia. RESULTS: A total of 376 patients were matched: 94 patients with REBOA and 282 patients without. REBOA patients were more likely to undergo laparotomy (62.8% vs 42.9%, p < 0.001) and had higher transfusion rates (12 vs 5 units PRBC, p < 0.001). The REBOA group had worse 24-hour mortality (23.1% vs 13.2%; p = 0.024), worse in-hospital mortality (31.9% vs 21.3%, p = 0.036), higher venous thromboembolism rate (13.8% vs 6.7%, p = 0.033) and higher deep venous thrombosis rate (11.7% vs 6.3%, p = 0.009; Table). Table. - Postmatched Outcome Variable Total, N = 376 No REBOA, n = 282 (75%) REBOA, n = 94 (25%) p Value HLOS, days * 15.0 (6.0–28.0) 15.0 (7.0–27.0) 18.0 (2.0–28.0) 0.947 ICU LOS, days* 7.0 (3.0–15.0) 7.0 (3.0–15.0) 7.5 (3.0–14.0) 0.676 AKI 30 (8%) 19 (6.7%) 11 (11.7%) 0.124 ARDS 12 (3.2%) 10 (3.5%) 2 (2.2%) 0.738 VTE 32 (8.5%) 19 (6.7%) 13 (13.8%) 0.033 DVT 23 (6.1%) 12 (4.3%) 11 (11.7%) 0.009 VAP or pneumonia 19 (5.1%) 15 (5.3%) 4 (4.3%) 0.792 24-h mortality* 58 (15.6%) 37 (13.2%) 21 (23.1%) 0.024 In-hospital mortality 90 (23.9%) 60 (21.3%) 30 (31.9%) 0.036 AKI, acute kidney injury; DVT, deep venous thrombosis; HLOS, hospital length of stay; LOS, length of stay; REBOA, resuscitative endovascular balloon occlusion of the aorta; VAP, ventilator-associated pneumonia; VTE, venous thromboembolism. CONCLUSION: REBOA use in severe pelvic trauma patients is correlated with higher rates of mortality, venous thromboembolism, and deep venous thrombosis compared with no REBOA. Further randomized controlled studies should be designed to verify the benefits of REBOA use in severe trauma patients.

Impact of Pelvic Fracture Sites on Fibrinogen Depletion in Patients with Blunt Trauma: A Single-Center Cohort Study.

Background: We aimed to examine the association of pelvic fracture sites with the minimum fibrinogen level within 24 h after hospital arrival. Methods: We conducted a single-center cohort study using health records review. We included patients with pelvic fractures transported by ambulance to a tertiary-care hospital from January 2012 to December 2018 and excluded those transported from other hospitals or aged younger than 16 years. The pelvic fracture was diagnosed and confirmed by trauma surgeons and/or radiologists. We classified the fracture sites of the pelvis as ilium, pubis, ischium, acetabulum, sacrum, sacroiliac joint diastasis, and pubic symphysis diastasis, and each side was counted separately except for pubic symphysis diastasis. We performed linear regression analysis to evaluate the association between pelvic fracture sites and the minimum fibrinogen level within 24 h of arrival. Results: We analyzed 120 pelvic fracture patients. Their mean age was 47.3 years, and 69 (57.5%) patients were men. The median Injury Severity Score was 24, and in-hospital mortality was 10.8%. The mean minimum fibrinogen level within 24 h of arrival was 171.4 mg/dL. Among pelvic fracture sites, only sacrum fracture was statistically significantly associated with the minimum fibrinogen level within 24 h of arrival (estimate, −34.5; 95% CI, −58.6 to −10.4; p = 0.005). Conclusions: Fracture of the sacrum in patients with pelvic fracture was associated with lower minimum fibrinogen levels within 24 h of hospital arrival and the requirement of blood transfusion.

Surgery scheduling of pelvic fracture patients with stochastic recovery time

Surgery scheduling of pelvic fracture patients with stochastic recovery time

Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. MethodsRetrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). ResultsDuring the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. ConclusionPPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients.

ObjectiveTo analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.MethodsThis retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.ResultsA total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.ConclusionPatients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

Early Outcome Analysis of Management of Closed Pelvic Ring Fractures in Emergency: Conservative Versus Surgical at Level III Trauma Center in India.

Introduction: Pelvic bone fracture is often observed in high-speed road traffic accidents, and forms a medical emergency as it is often complicated with associated internal exsanguination, shock, and mortality. Managing such cases cost-effectively in a developing country with limited assets, without compromising on patient outcomes still remains an obstacle.Objective: To compare and contrast the clinical aftermath of urgent non-surgical and surgical treatment of closed pelvic ring fracture patients and to analyze the types and severity of complications and final functional outcome.Material and methods: Twenty-five patients with pelvic fractures received at the casualty of IMS and SUM Hospital, Bhubaneswar, between January 2017 and January 2018 were included in the study. Marvin Tile classification was used to classify the fractures. Analysis and assessment of patients were done preoperatively and at six-month follow-up after management, with radiology and functional score using D’Aubinge-Postel Scale. The mode of injury, various management protocols for each type of fracture pattern, and associated complications were also noted. And finally, an outcome comparison was drawn between surgical and non-surgical options for various fractures. A Chi-square test was used to compare the outcomes.Results: The functional outcome as per the D'Aubigne-Postel Scale, on average six months, was excellent in nine patients (36%), good in seven (28%), fair in four (16%), and poor in four (16%). The outcome comparison was insignificant statistically in both radiological assessment (p 0.614) and functional scores (p 0.26) between the conservative and surgical outcomes. The average duration of hospital stay, duration to ambulation, duration to full recovery, and complications were significantly more in patients managed conservatively. While the cost of treatment was more in the surgical group. One death was observed in the study group due to septicemia which might have been directly related to the severity of pelvic injury and choice of treatment.Conclusion: Tile’s Type B and C fractures, managed surgically allow faster mobilization of the patient and a shorter recovery period while the cost of treatment is significantly more. Tiles type A is best managed conservatively.

Comparison of mortality among hemorrhage-control methods performed for hemodynamically unstable patients with traumatic pelvic fractures: A multi-center study

/Objective: We aimed to analyze the effects of hemorrhage control methods on the mortality of patients with hemodynamic instability due to pelvic fracture and investigate independent mortality risk factors in these patients. Ninety-seven pelvic bone fracture patients with hemodynamic instability who visited the emergency departments of two university hospitals over 5 years were enrolled. These patients were categorized based on 28-day mortality (survival group) and acute hemorrhage mortality (non-survival group). Forty-seven patients (48.5%) underwent pelvic angiography; 45 (46.4%), pre-peritoneal pelvic packing; and 19 (19.6%), external fixation. Differences in hemorrhage control methods did not significantly affect mortality. However, there was a significant difference in mortality between the groups with and without hemorrhage control methods. Multivariate logistic regression analysis revealed that patient age, trauma and injury severity score (probability of survival), and blood transfusion amount within 24h were independent risk factors for 28-day mortality. Meanwhile, patient age, Glasgow coma scale (GCS) score, systolic blood pressure (SBP), and blood transfusion amount within 24h were independent risk factors for mortality due to acute hemorrhage. Rapid and appropriate application of hemorrhage control methods can reduce acute hemorrhage-related mortality in hemodynamically unstable patients with pelvic fractures. Moreover, none of the hemorrhage control methods were superior for the decreasing mortality rate in these patients.

The application of the WSES classification system for open pelvic fractures—validation and supplement from a nationwide data bank

BackgroundOpen pelvic fractures are rare but complex injuries. Concomitant external and internal hemorrhage and wound infection-related sepsis result in a high mortality rate and treatment challenges. Here, we validated the World Society Emergency Society (WSES) classification system for pelvic injuries in open pelvic fractures, which are quite different from closed fractures, using the National Trauma Data Bank (NTDB).MethodsOpen pelvic fracture patients in the NTDB 2015 dataset were retrospectively queried. The mortality rates associated with WSES minor, moderate and severe injuries were compared. A multivariate logistic regression model (MLR) was used to evaluate independent factors of mortality. Patients with and without sepsis were compared. The performance of the WSES classification in the prediction of mortality was evaluated by determining the discrimination and calibration.ResultsA total of 830 open pelvic fracture patients were studied. The mortality rates of the mild, moderate and severe WSES classes were 3.5%, 11.2% and 23.8%, respectively (p < 0.001). The MLR analysis showed that the presence of sepsis was an independent factor of mortality (odds of mortality 9.740, p < 0.001). Compared with patients without sepsis, those with sepsis had significantly higher mortality rates in all WSES classes (minor: 40.0% vs. 3.1%, p < 0.001; moderate: 50.0% vs. 9.1%, p < 0.001; severe: 66.7% vs. 22.2%, p < 0.001). The receiver operating characteristic (ROC) curve showed an acceptable discrimination of the WSES classification alone for evaluating the mortality of open pelvic fracture patients [area under curve (AUC) = 0.717]. Improved discrimination with an increased AUC was observed using the WSES classification plus sepsis (AUC = 0.767).ConclusionsThe WSES guidelines can be applied to evaluate patients with open pelvic fracture with accurate evaluation of outcomes. The presence of sepsis is recommended as a supplement to the WSES classification for open pelvic fractures.

Pelvic Fractures-An Underestimated Problem? Incidence and Mortality Risk after Pelvic Fracture in Austria, 2010-2018.

(1) Background: Pelvic fractures (PFs) are related to osteoporosis, and represent a serious individual and socioeconomic burden. (2) Methods: We examined age- and sex-standardised incidence rates (SIRs) of PF, along with rates of all-cause overall and one-year mortality among patients with PF. We compared the mortality rates between PF patients and a matched fracture-free cohort. Patients ≥50 years old in Austria hospitalised with PF in 2010–2018, along with their dates of death, were recorded. (3) Results: We identified 54,975 patients with PF, of whom 70.9% were women. Between 2010 and 2018 the SIR of PF increased in men by 10.0%—from 125.3 (95% Confidence Interval 118.9–132.0) to 137.8 (95% CI 131.8–144.0) per 100,000—and in women by 2.7%—from 218.7 (95% CI 212.0–225.6) to 224.7 (95% CI 218.3–231.3) per 100,000. The one-year post-PF mortality rate was higher in men than in women (13.0% and 11.1%, respectively; p < 0.001). Pelvic fracture patients aged ≥65 had an elevated mortality risk (Hazard Ratio 1.75, 95% CI 1.71–1.79, p < 0.001) compared to controls. (4) Conclusions: There is a clear increase in the incidence of PF in the elderly population, with a greater increase in men over time. Pelvic fracture itself contributes to increased mortality in individuals aged 65 and above.

Frailty Is Associated With Worse Outcomes In Geriatric Pelvic Fractures.

Frail, geriatric patients with pelvic fractures can present differently than non-frail patients. Using the Clinical Frailty Scale(CFS), a retrospective analysis was conducted to determine the relationship between patients' CFS and outcomes after pelvic fractures. We hypothesized that frail, geriatric trauma patients defined as a CFS>4 with pelvic fractures have worse outcomes than non-frail patients with a CFS≤4 despite similar injuries. All geriatric patients with pelvic fractures and documented CFS were included. Seventy patients were included, with 59% (n = 41) frail. The groups were compared with no difference in mortality. The frail group was older and were most likely discharged to a skilled nursing facility (65.8%). Non-frail were most likely discharged to acute rehab (52%). Frail had lower functional status at discharge (median: 14.5v.16, P = .015). Frail patients had worse overall outcomes in this analysis of geriatric pelvic fracture patients. Special attention should focus on this vulnerable population to ensure optimal treatment and outcomes.

Open technique for supra-acetabular pin placement in pelvic external fixation: a cadaveric study

BackgroundStandard supra-acetabular pin placement still needs fluoroscopic guidance, which is technically demanding for an untrained surgeon due to the unfamiliar fluoroscopic view and the risk of damaging some structures. The risks associated with the open technique without fluoroscopy have not yet been investigated, despite the palpable entry point and large bony corridor for rapid insertion in the limited time available for the management of unstable pelvic fracture patients. The aim of this study was to compare the open technique without fluoroscopy to the fluoroscopically assisted percutaneous technique for the positioning of supra-acetabular screws in cadavers without pelvic instability.Materials and methodsThe open technique for half-pin placement was compared to standard fluoroscopic guidance in 16 hemipelves (8 cadavers). The open technique was first performed on one side in each cadaver after simple randomization, followed by standard fluoroscopic guidance on the other side. In the open technique group, a Schanz pin 5 mm in diameter and 200 mm in length was inserted in the area just above the anteroinferior iliac spine (AIIS) and aimed with a medial inclination of 20° and a cephalad inclination of 10–20° after a 2 cm pilot drill hole had been established. Standard fluoroscopically guided pin placement was performed on the other side. Fluoroscopic assessment was conducted after final pin placement on both sides. The lateral femoral cutaneous nerve of the thigh (LFCN) and the hip capsule were identified via the Smith–Peterson approach. After complete dissection of soft tissue, it was clearly apparent that pin penetration was conducted outside the bony corridor.ResultsThe LFCN was found to be in a risk zone near the pin (mean distance, 15 mm; range, 0–30 mm). One LFCN may have been injured in the fluoroscopic guidance group. The mean medial inclination of the pin was 19.8° (range, 5–40°) and the mean cephalad inclination was 11.5° (range 0–20°) in the open technique group. The mean medial inclination of the pin was 30.4° (range, 20–45°) and the mean cephalad inclination was 19.3° (range, 2–35°) in the fluoroscopic guidance group. The mean distance of the pin entry point from the AIIS was 11.1 mm (range, 0–35 mm) in the open technique group. The mean distance of the entry point of the pin from the AIIS was 15.1 mm (range, 0–25 mm) in the fluoroscopic guidance group. The mean hip joint capsule distance was 12 mm (range, 8–25 mm). No joint penetration was observed in the open technique group, compared to one joint penetration in the fluoroscopic guidance group. No sciatic notch penetration was found in either group, but pin penetration outside the external cortex of the ilium was found only in the open technique group, in 4 hemipelves.ConclusionsThis study shows that the freehand technique performed by experienced trauma surgeons may be as acceptable as controlled pin insertion under image intensification for selecting the proper entry point and stabilizing the anterior pelvic ring.

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures

Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092–3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Benefits of early application of pelvic circumferential compression device to reduce bleeding in pelvic fractures

BackgroundTo study of efficacy of early pelvic circumferential compression device using in patients with suspected pelvic trauma, compared with conventional stepwise approach.MethodsTraumatic injury and at least one of the following criteria are required for inclusion: loss of consciousness or a Glasgow coma score (GCS) of less than 13; systolic blood pressure less than 90 mmHg; falling from more than 6 m; injury to several important organs; and a positive pelvic compression test. Patients who satisfied the inclusion criteria for the experimental group were given an early application of a commercial pelvic sling beginning in July 2019. The control group consisted of cases who got the device after clinical or radiological confirmation of a pelvic fracture in the previous year. Gender, age, mechanism of injury, GCS, hospital stay, amount of packed red blood cell transfusion, hematocrit in emergency room, and hematocrit 24 h after application of pelvic binder were all assessed and compared.ResultsThe study had a total of 30 participants, with 15 in each group. The number of packed red blood cell transfusions in the early pelvic binder group (0.80 ± 1.42) is considerably lower than in the control group (2.4 ± 2.32) (P = 0.008), although the hematocrit change is not statistically different between the groups (2.1 VS 0.7) (P = 0.191). The time it took to install a pelvic binder was considerably shorter in the early pelvic binder group (16.40 ± 5.45) than in the control group (40.40 ± 13.64) (P = 0.001). There were no problems associated to soft tissue and skin necrosis in either group of patients.ConclusionsThe use of the PCCD for 24 h prior to clinical and radiographic confirmation has significantly reduced the rate of packed red blood cell transfusion in any pelvic fracture patient without device-related complications.Trial registrationThe study was entered into the Thai Clinical Trials Registry (TCTR20210809007).

Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis.

Hemodynamically unstable pelvic fracture patients are challenging to manage. Preperitoneal packing (PPP) and angioembolization (AE) are two interventions commonly used to help gain hemorrhage control. Recently, there has been a tendency to support PPP in hemodynamically unstable pelvic fracture seemingly in direct comparison with AE. However, it seems that key differences between published cohorts exist that limits a comparison between these two modalities. A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only manuscripts printed in English eligible (PROSPERO CRD42021236219). Included studies were retrospective and prospective cohort studies and a quasirandomized control trial. Studies reported demographic and outcome data on hemodynamically unstable patients with pelvis fractures that had either PPP or AE as their initial hemorrhage control intervention. The primary outcome was in-hospital mortality rate. Eighteen studies were included totaling 579 patients, of which 402 were treated with PPP and 177 with AE. Significant differences were found between AE and PPP in regard to age, presence of arterial hemorrhage, Injury Severity Score, and time to intervention. The crude mortality rate for PPP was 23%, and for AE, it was 32% (p = 0.001). Analysis of dual-arm studies showed no significant difference in mortality. Interestingly, 27% of patients treated with PPP did not get adequate hemorrhage control and required subsequent AE. Because of bias, heterogeneity, and inadequate reporting of physiological data, a conclusive comparison between modalities is impossible. In addition, in more than a quarter of the cases treated with PPP, the patients did not achieve hemorrhage control until subsequent AE was performed. This systematic review highlights the need for standardized reporting in this high-risk group of trauma patients. Systematic review and meta-analysis, level III.

Optimized Backprojection Filtration Algorithm for Postoperative Reduction and Analysis of Respiratory Infection-Related Factors of Pelvic Fractures by CT Imaging

To explore the computed tomography (CT) imaging characteristics and BPF algorithm fine lung CT image efficiency for the diagnosis of pelvic fracture patients and assist clinicians to carry out the disease care and treatment, CT images based on optimized back-projection filtering (BPF) algorithm were utilized to diagnose postoperative reduction of pelvic fractures and penetrating lung infection caused by long-term bed rest. A total of 100 patients with pelvic fracture were selected and all of them underwent pelvic fracture surgery and were rolled into conventional CT diagnosis group (conventional group) and BPF algorithm optimized CT image diagnosis group (BPF group). One group used conventional CT images to guide pelvic reduction and detect lung infections, and the other used BPF algorithm to optimize the images. The results showed that the BPF group was superior to the conventional CT group in both image clarity and shadow area, and the peak signal-to-noise ratio (PSNR) was significantly better than that of the conventional group ( P &lt; 0.05 ). Nine more cases were detected in the algorithm group than in the conventional group, and the incidence of complications was 48% in the conventional group and 28% in the BPF group, with a statistical difference of 20% between the two groups ( P &lt; 0.05 ). In addition, the satisfaction of returning patients was 96% in the BPF group and 77% in the conventional group ( P &lt; 0.05 ). The diagnosis of pulmonary infection was more obvious in the BPF group, indicating that BPF optimization of the CT image was suitable for clinical diagnosis and had a practical application value.

In-Hospital Clinical Outcomes in Patients with Fragility Fractures of the Lumbar Spine, Thoracic Spine, and Pelvic Ring: A Comparison of Data before and after Certification as a DGU® Geriatric Trauma Centre.

Background and Objectives: The implementation of orthogeriatric co-management (OGCM) reflects the demand for interdisciplinary collaborations due to the increasing comorbidities of geriatric trauma patients. This study aimed to assess clinical in-hospital outcomes in lumbar spine, thoracic spine, and pelvic ring fragility fracture patients before and after the implementation of a Geriatric Trauma Centre (GTC) certified by the German Trauma Society (DGU®). Materials and Methods: In this observational, retrospective cohort study, geriatric trauma patients (>70 years of age) were stratified into either a pre-GTC group (hospital admission between 1 January 2012 and 31 December 2013) or a post-GTC group (hospital admission between 1 January 2017 and 31 December 2018). Patients’ pre-injury medical complexity was measured by ASA class (American Society of Anaesthesiologists classification), the use of anticoagulant medication, and the ACCI (Age-adjusted Charlson Comorbidity Index). Outcome parameters were patients’ in-hospital length of stay (LOS) and mortality rates, as well as new in-hospital findings and diagnoses. Further, the necessity of deviation from initial management plans due to complications was assessed using the Adapted Clavien–Dindo Scoring System in Trauma (ACDiT score of ≥1). Results: Patients in the post-GTC group (n = 111) were older (median age 82.0 years) compared to the pre-GTC group (n = 108, median age 80.0 years, p = 0.016). No differences were found in sex, body mass index, ASA class, or ACCI (all p > 0.05). Patients in the post-GTC group used vitamin K antagonists or direct oral anticoagulants more frequently (21.3% versus 10.8%). The incidence of non-surgical treatment and mortality was comparable between groups, while LOS tended to be shorter in the post-GTC group (7.0 days versus 9.0 days, p = 0.076). In the post-GTC group, the detection of urinary tract infections (UTI) increased (35.2% versus 16.2%, p = 0.001), and the delirium diagnoses tended to increase (13.0% versus 6.3%, p = 0.094), while an ACDiT score of ≥1 was comparable between groups (p = 0.169). Conclusions: In this study including lumbar spine, thoracic spine, and pelvic ring geriatric fragility fractures, patients in the post-GTC group were more medically complex. More UTIs and the tendency for increased delirium detection was observed in the post-GTC group, likely due to improved diagnostic testing. Nonetheless, the necessity of deviation from initial management plans (ACDiT score of ≥1) was comparable between groups, potentially a positive result of OGCM.

Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study

BackgroundIn 2017, a novel classification for pelvic injuries was established by the World Society of Emergency Surgery (WSES). We validated its effectiveness using nationwide real-world data. The roles of associated vascular injury and open fracture in this system were also evaluated.MethodsPatients with pelvic fractures in the National Trauma Data Bank 2015 dataset were retrospectively studied. First, the mortality rates were compared by WSES classification. Second, independent predictors of mortality were evaluated using a multivariate logistic regression model. Patients with and without associated vascular injuries and the same hemodynamic and pelvic ring stability statuses were compared. Patients with associated vascular injuries were compared to the proportion of nonsurvivors and survivors with unstable pelvic ring injuries. Third, the outcomes were compared between patients with open pelvic fracture and closed pelvic fracture in the mild, moderate and severe WSES classes.ResultsDuring the 12-month study period, 44,163 blunt pelvic fracture patients were included. The mortality rates were 1.8%, 3.8% and 10.6% for the mild, moderate and severe WSES classes, respectively (p < 0.001). MLR analysis showed that unstable pelvic ring injury did not significantly affect mortality (p = 0.549), whereas open pelvic fracture and associated vascular injury were independent predictors of mortality (odds of mortality: open pelvic fracture 1.630, p < 0.001; associated vascular injury 1.602, p < 0.001). Patients with associated vascular injuries showed that there was no significant difference in the proportion of patients with unstable pelvic ring injuries between survivors and nonsurvivors (37.2% vs. 32.7%, p = 0.323). In all three classes, patients with open pelvic fractures had significantly higher mortality rates and infection rates than patients with closed fractures (mortality rates: minor 3.5% vs. 1.8%, p = 0.009, moderate 11.2% vs. 3.3%, p < 0.001, severe 23.8% vs. 9.8%, p < 0.001; infection rates: minor 3.3% vs. 0.7%, p < 0.001, moderate 6.7% vs. 2.1%, p < 0.001, severe 7.9% vs. 2.8%, p < 0.001).ConclusionsBased on this nationwide study, the WSES guideline provides an accurate and reproducible classification of pelvic fractures. It is recommended that open/closed fractures and associated vascular injuries be evaluated as supplements of the WSES classification.

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.

Definitive Management Option of Pelvic Ring Injury

Pelvic ring injury is a rare condition with the incidence of hip fracture about 3% to 8% of all fractures. However, the majority of pelvic fracture patients have a high morbidity rate that could threaten their survival. The majority cause of hip fracture is high energy blunt trauma and is related to polytrauma incident. The main goals of management for pelvic ring injury are to restore the form and stability of the pelvic. The main goal is to prevent nonunion and malunion, which lead to chronic pain and disability. This review is focused on the strengths and weaknesses of the management option, approach and complication for pelvic ring fracture surgery. Complications of pelvic ring fracture surgery are bleeding, nerve damage, DVT, pulmonary embolism, soft tissue injury, sepsis, and malunion of the pelvis and nonunion. Management for pelvic ring fracture surgery is used based on the location and configuration of the fracture, implant availability, surgeon’s preference, and experience.

Ability of a Machine Learning Algorithm to Predict the Need for Perioperative Red Blood Cells Transfusion in Pelvic Fracture Patients: A Multicenter Cohort Study in China.

Background: Predicting the perioperative requirement for red blood cells (RBCs) transfusion in patients with the pelvic fracture may be challenging. In this study, we constructed a perioperative RBCs transfusion predictive model (ternary classifications) based on a machine learning algorithm.Materials and Methods: This study included perioperative adult patients with pelvic trauma hospitalized across six Chinese centers between September 2012 and June 2019. An extreme gradient boosting (XGBoost) algorithm was used to predict the need for perioperative RBCs transfusion, with data being split into training test (80%), which was subjected to 5-fold cross-validation, and test set (20%). The ability of the predictive transfusion model was compared with blood preparation based on surgeons' experience and other predictive models, including random forest, gradient boosting decision tree, K-nearest neighbor, logistic regression, and Gaussian naïve Bayes classifier models. Data of 33 patients from one of the hospitals were prospectively collected for model validation.Results: Among 510 patients, 192 (37.65%) have not received any perioperative RBCs transfusion, 127 (24.90%) received less-transfusion (RBCs < 4U), and 191 (37.45%) received more-transfusion (RBCs ≥ 4U). Machine learning-based transfusion predictive model produced the best performance with the accuracy of 83.34%, and Kappa coefficient of 0.7967 compared with other methods (blood preparation based on surgeons' experience with the accuracy of 65.94%, and Kappa coefficient of 0.5704; the random forest method with an accuracy of 82.35%, and Kappa coefficient of 0.7858; the gradient boosting decision tree with an accuracy of 79.41%, and Kappa coefficient of 0.7742; the K-nearest neighbor with an accuracy of 53.92%, and Kappa coefficient of 0.3341). In the prospective dataset, it also had a food performance with accuracy 81.82%.Conclusion: This multicenter retrospective cohort study described the construction of an accurate model that could predict perioperative RBCs transfusion in patients with pelvic fractures.