Pelvis and Acetabulum Fracture Treatment

Over the last 20 years, orthopaedic trauma surgeons have been faced with a growing number of patients with severe pelvic injuries. Improvements in automobile safety, prehospital care, resuscitation, and transport as well as standardized protocols for treatment have all contributed to improved survival after these devastating injuries. Articles like that by Burgess and coauthors highlighted that understanding the mechanism of pelvic injury and rapidly identifying those patients at highest risk for hemorrhage can allow surgeons to more rapidly initiate treatment and contribute to the overall survival of our patients.1 Whereas this initially led to a more widespread use of resuscitative external fixator placement, this method has been largely supplanted by the use of pelvic binders or antishock sheeting.2 Further lifesaving measures like pelvic packing have also been espoused for the patient in whom other treatments have failed to restore hemodynamic stability, and articles like that of Ertel have demonstrated that standardized protocol-driven initial treatment regimens can be crucial in maximizing the initial survival rate after severe pelvic injury.3FigureOnce stabilized, definitive treatment becomes critical. However, even as we strive to improve functional outcome by restoring the patient's pelvic ring anatomy, concomitant neurologic and urologic injuries may result in lifelong debilitating symptoms or disabilities. Articles like that of Copeland bring this issue to light, demonstrating the residual dysfunction that may result from these sequelae of pelvic injuries and how it can affect a patient long after the skeletal injuries have healed.4 Even outcome studies like that of Matta and Tornetta, which looked at a select group of patients with unstable posterior pelvic ring disruptions, found that although good outcomes can be achieved after severe pelvic injuries, over one third of their patients had a neurologic injury that compromised their overall function.5 Although there may always be unavoidable consequences of severe pelvic injury, surgeons must still question the way pelvic injuries are treated and continue to explore controversies that may ultimately alter treatment regimens or outcomes. Recent articles focusing on thromboembolic prophylaxis and the role of percutaneous fixation continue to challenge our current protocols and explore the role of new treatment options.6-8 Other articles like those of Bellabarba and Schildhauer have introduced new fixation options for difficult pelvic injuries that were not always well-addressed by other techniques.9,10 Unlike the treatment of pelvic ring injuries, however, the treatment of fractures of the acetabulum has not altered much over the last decade. One exception has been the elegant description of the vascular anatomy of the hip and the development of the trochanteric flip osteotomy.11 This has proved useful in the treatment both of certain acetabular fractures as well as other complex hip reconstructions. Since the untimely passing of Emile Letournel, however, most fracture surgeons continue to strive just to reproduce his results.12 Joel Matta has confirmed that by using Letournel's protocol for obtaining appropriate radiographs, understanding and classifying the fracture, and choosing an appropriate surgical approach, good or excellent outcomes can be achieved in up to 84% of patients with acetabular fractures.13 Review of classic articles by both authors, published 33 years apart, emphasize that although orthopaedic traumatology is often a dynamic and rapidly changing field, in this area at least, surgeons can study the techniques and protocols of the leaders in the field and reproducibly improve our patients' outcomes. Mark C. Reilly, MD From the UMD-New Jersey Medical School Division of Orthopaedic Trauma Newark, New Jersey