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Perioperative management of acetabular and pelvic fractures: evidence-based recommendations
Ramakanth R Yakkanti1, Neil V Mohile1, Wayne B Cohen-Levy2
1Department of Orthopaedic Surgery, University of Miami University Hospital, West Wing, 1321 NW 14th st, Suite 306, Miami, FL, 33125, USA.
Insights
Early surgical intervention and tranexamic acid (TXA) are recommended for managing periprosthetic ankle fractures (PAF). Routine use of inferior vena cava filters (IVCF) and negative pressure wound therapy (NPWT) is not supported by current literature.
Area of Science:
- Orthopaedic Surgery
- Trauma Management
- Evidence-Based Medicine
Background:
- The American Academy of Orthopaedic Surgeons currently lacks clinical practice guidelines for periprosthetic ankle fracture (PAF) management.
- This review consolidates current literature to inform perioperative care for PAF.
Purpose of the Study:
- To review and synthesize existing literature on the perioperative management of periprosthetic ankle fractures (PAF).
- To provide evidence-based recommendations in the absence of formal clinical practice guidelines.
Main Methods:
- A comprehensive literature search was conducted across PubMed, Cochrane, and Embase databases.
- Key topics reviewed included timing of fixation, venous thromboembolism (VTE) prophylaxis, tranexamic acid (TXA) use, and heterotopic ossification (HO) prophylaxis.
Main Results:
- Literature supports early surgical intervention (within 5 days) and routine intraoperative TXA for PAF.
- Routine use of incisional negative pressure wound therapy (iNPWT) and inferior vena cava filters (IVCF) is not supported.
- Evidence is insufficient for routine cell salvage or intraoperative antibiotic powder use.
Conclusions:
- Radiation therapy is supported for heterotopic ossification (HO) prophylaxis.
- Routine chemical VTE prophylaxis is recommended, but optimal agents and duration require further study.
- Early surgical fixation and intraoperative TXA are key components of effective PAF management.
Purpose:
The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.
Methods:
A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.
Results:
A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.
Conclusion:
The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.
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