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Declining mortality after open pelvis fracture in North America
Soroush Shabani1, Annie Zhang1, Julian Wier1
1Keck School of Medicine of the University of Southern California, Los Angeles, USA.
Insights
In-hospital mortality for open pelvis fractures decreased from 2017 to 2022. This decline is linked to evolving management strategies, including increased use of preperitoneal pelvic packing (PPP) and decreased use of exploratory laparotomy (EL).
Area of Science:
- Trauma Surgery
- Surgical Critical Care
- Orthopedic Trauma
Background:
- Open pelvis fractures present significant mortality risks, necessitating a multidisciplinary approach.
- Management strategies, including angioembolization (AE), exploratory laparotomy (EL), and preperitoneal pelvic packing (PPP), have evolved.
- The association between these evolving practices and mortality outcomes remains unclear.
Purpose of the Study:
- To evaluate trends in in-hospital mortality for open pelvis fractures.
- To assess the impact of changes in resuscitation and hemorrhage control interventions on mortality.
- To determine if evolving practice patterns are associated with reduced mortality.
Main Methods:
- Retrospective analysis of adult patients with open pelvis fractures (2017-2022) from the American College of Surgeons Trauma Quality Improvement Program.
- Primary outcome: in-hospital mortality. Adjusted risk of mortality calculated using multivariable logistic regression.
- Intervention trends (AE, EL, PPP) assessed annually using Chi-square and Kruskal-Wallis tests.
Main Results:
- A total of 10,172 patients were analyzed; mean adjusted mortality was 10.78%, significantly decreasing by 0.43% per year (p=0.001).
- Angioembolization (AE) rates remained stable. Exploratory laparotomy (EL) rates decreased (0.60%/year, p<0.001), while preperitoneal pelvic packing (PPP) rates increased (0.76%/year, p<0.001).
- Mid-tier trauma centers (400-600 beds) reported increased admissions for open pelvis fractures.
Conclusions:
- In-hospital mortality following open pelvis fractures declined between 2017 and 2022.
- This improvement correlates with evolving acute management practices for associated hypotension.
- Increased utilization of PPP and decreased use of EL reflect these practice pattern shifts.
Purpose:
Open pelvis fractures are associated with a high rate of mortality and require a multidisciplinary approach to resuscitation, hemorrhage control, and fracture stabilization. The patients presenting with these injuries, practice guidelines, and use early of interventions including angioembolization (AE), exploratory laparotomy (EL), and preperitoneal pelvic packing (PPP) have changed over time. It is not known if these changes are associated with mortality.
Methods:
Adults presenting with an open pelvis fracture between 2017 and 2022 were retrospectively identified from the American College of Surgeons Trauma Quality Improvement Program. The primary outcome was in-hospital mortality identified by "deceased" or "expired" emergency department or hospital discharge disposition. Patient-level adjusted risk of mortality was calculated by multivariable logistic regression considering patient comorbid conditions, injury characteristics, interventions, and facility characteristics across observed years. Adjusted mortality risk relative to AE, EL, and PPP interventions was assessed per year by Chi-square and Kruskal-Wallis tests.
Results:
Of 10,172 eligible patients identified, 81.44% were male. The mean adjusted mortality was 10.78% and significantly decreased by 0.43% per year (p = 0.001). AE was performed for 4.42% of patients and did not significantly change per year. EL was performed for 8.03% of patients and decreased by 0.60%/year (p < 0.001). PPP was performed for 7.56% of patients and increased by 0.76%/year (p < 0.001). Trauma centers of mid-tier size (400-600 beds) reported increasing admissions of open pelvis fractures.
Conclusion:
In-hospital mortality after open pelvis fracture declined 2017-2022 as practice patterns evolved for the acute management of associated hypotension, including increased use of PPP and decreased use of EL.
Level Of Evidence:
Prognostic Level III.
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