Standard practice in the treatment of unstable pelvic ring injuries: an international survey

Abstract

Purpose Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. Methods A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). Results The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). Conclusion The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences’ impact on outcomes needs to be further explored.

Immediate management of a stable patient with unstable pelvis

“…Pelvic binder use should be standard in high-impact blunt trauma patients, independently of the trauma mechanism (16). In a survey carried out by the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) trauma committee in 2022 among 358 surgeons from 80 countries, pelvic binder use for pre-hospital treatment was nearly the rule (17). However, in a study performed in The Netherlands in 2023, the helicopter emergency medical services pre-hospital sensitivity of unstable pelvic ring injury assessment and non-invasive pelvic binder device application rate was very low (18).…”

“…Since C-clamps cannot be used if the iliac bone is harmed, and proper positioning may be even more difficult in the immediate clinical setting when the patient is in the emergency room in a supine position, it is used by a large number of surgeons. In any case, a binder is as efficient as a C-clamp, and whenever possible, a binder should be the choice (12,17).…”

“…Nowadays, just after admission when a proper diagnosis is made, immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures produces excellent technical results (2, 31) (Figs. [17][18][19][20][21][22]. It has the advantage that it is also a definitive treatment.…”

“…In conclusion, in the survey carried out by the SICOT trauma committee, CT scan was used by 93%, most trauma surgeons use a routine pre-hospital pelvic binder, external fixation was the standard method of acute fixation, and ilio-sacral screws were the most used technique for definitive fixation, but not as immediate treatment (17). Having a well-trained surgeon on call in any hospital that promptly performs accurate fixation is very rare, although in the case of pelvic fractures and hemorrhagic shock, it may be critical (33).…”

“…In these cases, immediate osteosynthesis can be performed, provided that simple surgery, such as iliosacral screw, is suitable for good stability achievement (Figs. [17][18][19][20][21][22].…”