Safe definitive surgery in unstable pelvic ring injuries - a retrospective cohort study

Unstable pelvic ring injuries in polytrauma patients remain among the most lethal injury patterns, largely due to hemorrhage and the physiological burden of staged surgical management. While temporary external fixation is widely used as part of damage-control strategies, early definitive posterior stabilization using percutaneous sacroiliac "rescue screws" may provide sufficient mechanical stability while reducing cumulative operative stress. However, comparative clinical data supporting this approach remain scarce. This study investigates operative strategies, timing, and early outcomes in a consecutive cohort of severely injured patients with unstable pelvic ring fractures treated at a Level-1 trauma center.

We performed a retrospective cohort study including patients aged ≥ 16 years with high-energy unstable pelvic ring injuries (Young and Burgess APC II-III, LC III, combined mechanism, and vertical shear) and an Injury Severity Score (ISS) > 16. Demographic data, injury severity, hemodynamic status on admission, operative strategies, number of surgical procedures, and length of hospital stay were analyzed. Outcomes were compared between early definitive posterior fixation and temporary external fixation. Statistical significance was defined as p < 0.05.

Seventy-two patients were included (mean age 43.6 ± 17.3 years; 72.2% male), reflecting a severely injured cohort with a mean ISS of 30.4 ± 10.6; 30.6% presented with hemodynamic shock on admission. Early definitive posterior stabilization without prior temporary external fixation was achieved in n = 63 patients (87.5%). Temporary external fixation was required in n = 9 patients (12.5%), who demonstrated significantly greater injury severity, including higher ISS (41.0 ± 11.3 vs. 28.9 ± 9.8), higher NISS (45.7 ± 12.5 vs. 30.8 ± 10.4), and a higher incidence of shock on admission (44.4 versus. 28.6%). Compared with early definitive fixation, external fixation was associated with a substantially higher operative burden (2.31 ± 0.85 vs. 1.41 ± 0.67 procedures) and prolonged hospitalization (31.9 ± 30.2 vs. 23.4 ± 25.3 days). Radiographic reduction quality did not differ between the groups, with a mean residual sacroiliac joint diastasis of 4.14 ± 1.21 mm in the SDS group and 4.11 ± 0.71 mm in the ExFix group; according to the Matta and Saucedo criteria, all reductions in both groups were graded as anatomic or nearly anatomic. Importantly, early posterior fixation using percutaneous sacroiliac rescue screws was not associated with an increase in early fixation-related complications, even in initially unstable patients.

In a Level-1 trauma setting, early definitive posterior stabilization using percutaneous sacroiliac rescue screws is feasible and safe in most patients with unstable pelvic ring injuries. Compared with traditional staged management using temporary external fixation, this strategy was associated with a reduced cumulative operative burden and a shorter hospital length of stay without compromising early safety. Given the small number of patients managed with external fixation, these comparative findings should be interpreted with caution. External fixation should be reserved for select patients with extreme injury severity or specific limiting factors for safe definitive surgery. These findings question the routine use of staged damage-control strategies and support early posterior definitive fixation as a component of modern pelvic trauma care.