Ever since Judet and Letournel studied the pelvi-acetabular fractures in 1960s and provided a detailed framework for their management,1 this subspeciality has evolved into one of the most exciting domains for the orthopedic trauma surgeons. The last two decades have immensely helped in increasing the understanding of pelvi-acetabular fracture morphology, biomechanics, associated comorbidities, and principles of fracture fixation has provided a perfect foundation for the growth of this subspeciality. The advent of newer surgical approaches, different types of plates for specific fracture patterns, use of therapeutic agents for prevention of intraoperative blood loss and advances in the sphere of radiological diagnostics and interventions have also made tremendous impact on the management outcomes of these complex injuries. The use of pelvic binder in the prehospital care, preperitoneal packing, angioembolization and resuscitative Iliosacral screws in the acute care scenario of pelvic injuries along with the advent of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) technique have all contributed to decreasing mortality of pelvic injury patients world over.2,3
The present global burden of this injury has shifted to the lower and middle income countries where the trauma incidence is the highest in the world. At present, these countries have most of the injuries occurring in the younger age group in contrast to the developed world where elderly population due to their increased numbers, active lifestyle and decreased bone quality also contribute substantially.4 The challenges faced in the developing world include not only inadequate infrastructure but limited resources and lack of holistic approach to polytrauma management. All these factors contribute to the increased mortality and morbidity in these injuries in the developing world.5
The elderly population with pelvi-acetabular fractures present with a unique set of challenges for the treating surgeons. Their comorbidities, multidrug intake and imbalance may contribute to increased mortality and morbidity. Their incidence is also expected to double in the next 2 decades. The definitive treatment strategy for these geriatric fractures has not been clearly defined and adds to the management challenges. Administration of daily Parathyroid hormone (PTH) has been found to be of benefit in fragility fractures of pelvis in reducing the healing time and also pain reduction.6 The role of ORIF and Arthroplasty also needs to be considered with an open mind in the elderly acetabular fractures with the aim of early rehabilitation and return to preinjury status.7 The main objective of managing these geriatric injuries remains early mobilization, pain reduction and good functional outcomes.
Another issue is the lack of documentation of the injury patterns of these fractures specially from the developing world which leads to lack of adequate data on the injury burden in these countries. This restricts the development of management strategies focused specifically to their problems. A regional or international level trauma registry can aid in the analysis of epidemiological characteristics of these fractures and also develop protocols for their management. This global cooperation shall be helpful in making the availability of uniform standard of care globally and provide homogenous outcomes of its management.
Though there are challenges, the future of pelvi-acetabular surgery holds immense opportunities with a decisive shift towards more minimal invasive surgeries along with the advent of patient-specific fixation devices and navigation assisted surgeries. These innovations shall help reduce the surgical morbidity of the patient and assist in preoperative planning, intraoperative real-time tracking and robotic assistance to ensure precise implant placement. The use of 3D printing and templating can also assist in achieving the best possible fixation with smaller exposures and decreased surgical time.8 Virtual Reality technology is also making inroads in the field of orthopedic trauma and its use in training the surgeons to decrease their learning curve shall also be the thing to look for in improving the patient care.9 The surgical implants and the techniques of reduction also hold great potential of improvement with the possibility of arthroscopic assisted fixation of acetabular columns and also the future prospects of laparoscopic/endoscopic assisted reduction and possible fixation of the medially displaced acetabular fractures.10
The future of this subspeciality of orthopedic trauma has never looked more exciting and promising than now. All the stakeholders from across the world need to pool their resources to meet the challenges of managing these complex injuries comprising all the age groups. Building upon the knowledge base of the past along with the surgical experience of the present with the promise of the emerging futuristic technologies shall enable us to make better informed medical decisions and improve the patient outcome in this challenging fracture.
Contributor Information
Vivek Trikha, Email: vivektrikha@aiims.edu.
Paul Tornetta, Email: paul.tornetta@bmc.org.
References
- 1.Judet R., Judet J., Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction: preliminary report. J Bone Joint Surg. 1964;46(8):1615–1675. [PubMed] [Google Scholar]
- 2.Burlew C.C., Moore E.E., Stahel P.F. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233–242. doi: 10.1097/TA.0000000000001324. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Borger van der Burg B.L.S., van Dongen T.T.C.F., Morrison J.J. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. 2018;44(4):535–550. doi: 10.1007/s00068-018-0959-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Trikha V., Ganesh V., Cabrera D., Bansal H., Mittal S., Sharma V. Epidemiological assessment of acetabular fractures in a level one trauma centre: a 7-Year observational study. Journal of Clinical Orthopaedics and Trauma. 2020 doi: 10.1016/j.jcot.2020.09.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Gupta A., Gupta E. Challenges in organizing trauma care systems in India. Indian J Community Med. 2009 Jan;34(1):75–76. doi: 10.4103/0970-0218.45383. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Peichl P., Holzer L., Maier R., Holzer G. Parathyroid hormone 1–84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg. 2011;93:1583–1587. doi: 10.2106/JBJS.J.01379. [DOI] [PubMed] [Google Scholar]
- 7.Firoozabadi R., Cross W.W., Krieg J.C., Routt ML “Chip”. Acetabular fractures in the senior population-epidemiology, mortality and treatments. Arch Bone Jt Surg. 2017;5(2):96–102. [PMC free article] [PubMed] [Google Scholar]
- 8.Zeng C., Xing W., Wu Z., Huang H., Huang W. A combination of three-dimensional printing and computer-assisted virtual surgical procedure for preoperative planning of acetabular fracture reduction. Injury. 2016 Oct 1;47(10):2223–2227. doi: 10.1016/j.injury.2016.03.015. [DOI] [PubMed] [Google Scholar]
- 9.Vr for Training Orthopedic Surgeons . 2018. VR focus.https://www.vrfocus.com/2018/07/vr-for-training-orthopaedic-surgeons/ [Google Scholar]
- 10.Zeng C.J., Huang W.H., Huang H.J., Wu Z.L. Laparoscopic acetabular fracture fixation after three-dimensional modelling and printing. Indian J Orthop. 2017 Sep-Oct;51(5):620–623. doi: 10.4103/0019-5413.214215. [DOI] [PMC free article] [PubMed] [Google Scholar]