Maj. Patrick Osborn, MD, performs surgery at a military unit in Korea.

AAOS Now

Published 12/1/2007
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Annie Hayashi

Is the ‘gold standard’ losing its luster?

Pelvic packing may produce better results than pelvic angiography

“People with pelvic fractures come into our emergency department from a helicopter or ambulance and are in the operating room within 20 minutes,” reported Maj. Patrick Osborn, MD, at the recent Orthopaedic Trauma Association annual meeting. “The evolution of a procedure for retroperitoneal pelvic packing has been a multidisciplinary effort with our general surgery colleagues and has translated into quick decisive care for these seriously injured trauma patients.”

Even more significant, using the pelvic packing procedure has decreased the mortality of patients with pelvic fractures at his Level I trauma center to 20 percent.

“The gold standard” vs. pelvic packing
Hemodynamically unstable patients with pelvic fractures were treated in two separate timeframes and by two different protocols. Early pelvic angiography, the current “gold standard,” was used from 1998 until September 2004. After September 2004, patients were treated with direct retroperitoneal pelvic packing.

The study matched 20 angiography patients with 20 patients treated with pelvic packing by age and injury severity score. Patient demographics, physiologic markers, transfusions, and acute outcomes were recorded from time of injury until 24 hours postintervention. Patients were followed until they were discharged or died.

Fewer transfusions, better mortality
The differences between the two protocols were quite significant, as the following results indicate:

  • The patients who received angiography were treated in a median of 130 minutes; patients who were “packed” were treated in a median of 45 minutes.
  • Patients in the pelvic packing protocol required significantly fewer blood transfusions following intervention—the mean of 11.8 units of packed red blood cells through the packing procedure dropped to a mean of 6.9 units during the next 24 hours.
  • The number of transfusion units needed for patients in the angiography group, however, did not change following intervention; patients required a mean of 9.2 units pre-intervention and a mean of 10.1 units postintervention.
  • Ten patients in the angiography group required embolization of bleeding arteries, but only three patients treated with pelvic packing needed it.
  • Among patients in the angiography protocol, six died—two from acute pelvic hemorrhaging. Although four of the patients in the pelvic packing group died, none of the deaths was due to acute exsanguination.

Conclusions
Dr. Osborn strongly supported additional research to compare pelvic angiography with pelvic packing. He would like to see studies using larger cohorts and multiple centers.

Based on the results of his research, he believes that “pelvic packing allows us to provide simultaneous—not consecutive—treatment, addresses venous bleeding, and helps us stabilize and transport the patient from austere areas without interventional radiology support.”

He adds that by decreasing blood transfusion requirements, pelvic packing may have clinical significance in reducing multiorgan failure and mortality for these seriously injured patients.

Co-authors for the study, “Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two protocols treating hemodynamically unstable patients with pelvic fractures,” include Wade Russell Smith, MD; Steven J. Morgan, MD; Clay Cothren, MD; and Ernest Moore, MD.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org