Early vs. late definitive fixation of pelvic ring fractures in resuscitated polytraumatized patients: a systematic review and meta-analysis

The aim of this systematic review is to compare the short-term clinical outcomes between early (EDF) and late definitive fixation (LDF) in polytraumatized patients with pelvic ring fractures (PRF). In accordance with PRISMA guidelines, a comprehensive search using Boolean operators was performed in June 2022 from the following databases: Embase, Medline and Cochrane Library. Studies comparing EDF and LDF for PRF in polytrauma patients defined as ISS > 15 were included. All included cohorts performed definitive fixation after haemodynamic stabilisation or adequate response to resuscitation. Random effects meta-analyses of pooled raw data were employed using the Mantel-Haenszel and Inverse -variance methods. The methodological quality of studies was assessed using the Newcastle Ottawa Scale. Out of 869 studies screened, 10 were included in the meta-analysis with a total of 2918 patients. All included studies were retrospective; no randomized trials were identified. The most common time point used by 7 studies to define EDF was within 24 h of hospital admission and LDF (> 24 h). The most common reasons for LDF were surgeon’s choice, availability of pelvic surgeon and transfer from other hospitals. Our meta-analysis revealed that EDF was associated with a reduced length of hospital stay (WMD=-3.52 days; 95% CI: [-5.43 to -1.62], p < 0.0003) and lower incidence of ARDS (RR = 0.50; 95% CI: [0.26 to 0.96], p = 0.04). No significant association was found in mortality, length of ICU stay, multi-organ failure, sepsis and surgical site infection between EDF and LDF. These findings suggest that early definitive fixation may be a safe and viable option with no increased risk of complications and mortality. However, the adequacy of resuscitation and the estimate of physiologic reserve should be balanced with the risks of operative fixation in all patients. Further prospective validation studies are warranted to test the predictive ability of the various proposed trauma care models and stratify patients for EDF.