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

Abstract

Background Open 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). Methods Open 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. Results A 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). Conclusions The 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.

Anatomy and Classification of Pelvic Trauma

“…Besides hemorrhage control, the management of wound infection and the potential development of sepsis are crucial in the management of open pelvic fractures (broad-spectrum antibiotics for gram-positive and gram-negative bacteria, surgical debridement, and creation of a diverting colostomy). According to Li et al, the WSES classification is applicable when managing patients with open pelvic fractures; however, they emphasize that by adding the onset of sepsis as an additional variable (WSES classification + sepsis), a better prediction of mortality is achieved in cases of open pelvic fractures [22].…”

“…Sepsis is associated with only 2-4% of all pelvic fractures but carries a mortality rate of up to 45% [19][20][21]. Therefore, an open pelvic fracture can be regarded as a specific pattern of disease with distinct injury severity and treatment strategies [22].…”