The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta.

There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication.

The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation.

This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study.

The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection.

Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003).

This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection.

The effect of early surgery on hip fracture outcomes has received considerable study and although it has been suggested that early surgical treatment of these fractures leads to better patient outcomes, the findings are inconclusive. The American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP) prospectively collects blinded, risk-adjusted patient-level data on surgical patients in over 600 participating hospitals worldwide. The primary objective of this study was to determine the proportion of ACS-NSQIP hospital patients that are currently being treated within the UK's National Institute for Health and Care Excellence (NICE) time to hip fracture surgery benchmark. The secondary objectives were to identify risk factors for missing the benchmark, and determine if the benchmark is associated with improved 30-day patient outcomes.

Patients that underwent hip fracture surgery between 2005–2013 and entered in the ACS-NSQIP database were included in the study. Counts and proportions were used to determine how frequently the NICE benchmark was met. Multivariate regression analysis was used to identify significant predictors of missing the NICE benchmark and determine if missing the benchmark was associated with 30-day mortality/complications rates.

26,006 patients met the study enrolment criteria. 71.4% of patients were treated within the NICE benchmark and 89.4% were treated by post-admission day two. Gender, dyspnea, infectious illness, bleeding disorders, preoperative hematocrit, preoperative platelet count, arthroplasty procedure type, race other than White, and hip fracture diagnosis were all statistically significant predictors of missing the benchmark (p<0.01). Meeting the NICE benchmark was not associated with reductions in major complications (OR=0.93, CI=0.83–1.05, p=0.23), nor a clinically significant difference in postoperative length of stay (LOS) (parameter estimate=0.77, p<0.01); however, it was associated with a decreased 30-day mortality (OR=0.88, CI=0.78–0.99, p=0.03) and the likelihood of minor complications (OR=0.92, CI=0.84–0.995, p=0.04).

ACS-NSQIP hospitals are currently compatible with the NICE benchmark. However, data from the ACS-NSQIP database suggests that surgical treatment within the NICE benchmark may be unnecessarily narrow. Extending the benchmark to post-operative day two did not significantly increase the risk of 30-day mortality and minor complications; nor did it extend the average LOS. Neither the NICE benchmark, nor the extended two-day standard, was associated with reductions in major complications. The findings highlight the importance of further prospective investigation to monitor the effect of time to surgery benchmarks.