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

Abstract

Background In 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. Methods Patients 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. Results During 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). Conclusions Based 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.

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

“…The WSES guidelines suggest that the management of pelvic trauma must consider physiological and mechanical derangement [ 17 , 19 ]. An international validation using the National Trauma Data Bank proved that the WSES guidelines were an accurate and reproducible classification system for pelvic injuries [ 18 ]. However, for open pelvic fractures, which are more dangerous than closed fractures, it is important to evaluate whether the WSES guidelines are still accurate and applicable.…”

“…In patients with open pelvic fracture, the soft tissue injury from crush impact and hemorrhage from a hemostatic procedure may impair tissue perfusion, and the open contaminated wound may aggravate the infection condition. Previous reports that discussed the WSES guidelines for pelvic fractures suggested the evaluation of associated vascular injuries [ 17 , 18 ]. The role of vascular injuries is more significant than the mechanical stability of the pelvis in the mortality associated with pelvic fractures.…”

“…The conventional classification systems for pelvic fractures, including the Tile classification system and Young–Burgess classification system, evaluate pelvic fractures based on mechanical fracture patterns [ 14 , 15 ]. However, in addition to mechanical instability, high-energy impact-related hemorrhage may result in unstable hemodynamics in pelvic fracture patients [ 16 – 18 ]. Hence, the World Society of Emergency Surgery (WSES) comprising surgeons and experts around the world published a novel classification system for pelvic injury in 2017 [ 19 ].…”