1 Introduction

The assessment of a patient with an acetabular fracture, as with any patient involved in a trauma, must be recognized as a fluid process. Acetabular fractures often have a clear indication for surgery and many have a clearly optimal approach; however, the traumatically injured patient often presents situations and risks that are not easily quantified in simple research. Characteristics of the patient, the injury, and the evolving status of multiple organ systems must all be taken into account to optimize patient outcome. This chapter considers issues relevant in both the operative and nonoperative management of acetabular fractures of various types. These issues are most often framed, somewhat intuitively, as questions. Is it an isolated injury? If not, how will the management of other injuries impact on the care of the acetabular fracture and vice-versa? Will reconstruction clearly improve outcome? Are there medical comorbidities to consider in terms of perioperative medical management, patient positioning, or type of anesthetic management? More generally: Are there factors present that must be considered to ensure the best possible outcome, regardless of the type of treatment undertaken? To answer these questions, it is necessary to have an understanding of possible complications and how a patient’s premorbid physiology and acute injuries interact to tip the scale in favor of a complication occurring.

2 Evaluation of the patient as a whole

Routine history of a patient with an acetabular fracture should include an assessment of baseline functional level of activity, nutritional status, and family history of venous thromboembolic disease (VTED) or bleeding disorders. A thorough understanding of functional demands of the patient is necessary for an accurate prognosis. This should include both vocational requirements and hobbies. Physical examination must focus on all other injuries, distal neurological and vascular examination, and soft-tissue conditions not only in the area of possible surgical approaches but also throughout the body. It may not be possible for all other wounds to be healed, but an understanding of possible sites of bacterial contamination is essential. A cohesive plan addressing all soft-tissue concerns within the context of the patient with an acetabular fracture should be in place before operative treatment of the acetabulum. Neurological examination must include evaluation of tibialis anterior (L4), extensor hallucis longus (L5), and peroneal muscles (S1). Between 16% and 40% of acetabular fractures have an associated sciatic neuropathy, the higher value being associated with fracture dislocations [1]. Subtle peroneal neuropathy can elude the examiner if foot eversion is not examined. Sensory examination must be specific through these dermatomes and refer to the contralateral limb to have validity. Vascular examination and workup should follow the routine for all extremity injuries.

Prophylaxis against VTED should begin as soon after initial injury as feasible given the underlying risks and associated injuries. There remains no solid evidence in favor of one method of prophylaxis over another in this population [2]. Low-molecular-weight heparins, factor-X inhibitors, and subcutaneous heparin all have advantages in certain patients, although all have shown evidence of increased bleeding complications in other studies. It is probably more important to accurately assess the underlying patient risk [3]. All patients should be assessed for family history of VTED and underlying conditions (eg, cancer) that predispose to both VTED and increased bleeding. Although the use of inferior vena cava filters and preoperative screening has been advocated by some [4], there is no clear evidence to support routine use of either [5, 6]. Any filter should be removable, as long-term filter use has been shown to lead to a significant rate of complications [7].

Patients awaiting surgery must be protected from procedures that compromise any necessary or desired approaches for acetabular reconstruction, if possible. This mandates coordinated care across various surgical teams and interventional radiologists even during the resuscitation phase. The authors have seen “prophylactic” embolization of the superior gluteal artery without evidence of either extravasations or local bony injury, and even embolization of the ramus profundus branch of the medial femoral circumflex artery by aggressive interventional radiologists. Communication among the treating teams is mandatory in any of these patients to prevent such potentially catastrophic interventions.

3 Evaluation of the patient as a surgical candidate

Grouping patients into two intersecting categories related to age (young/active versus elderly/inactive) and associated conditions (multiply injured/medically ill versus isolated injury) can be useful. If these categories are considered as a continuum of outcomes, risk stratification becomes more easily qualified, although often not more quantifiable. Obviously the young, active, and healthy patient with an isolated displaced fracture has the best chance of successfully avoiding complications and benefiting from surgical treatment [8, 9]. Such a patient can be treated within a few days of injury and expect an excellent outcome if reconstruction is adequate. However, if sepsis and secondary drug-resistant, ventilator-associated pneumonia develop in the intensive care unit (ICU) following small bowel resection in this same young, healthy patient, successful acute reconstruction of the hip cannot be ensured. In the latter situation, later reconstruction, which is more likely to result in less than perfect reduction, must be weighed against the higher risk of infection if reconstruction is done acutely.

Finally, consider the elderly, infirm patients who have multiple traumatic injuries: these patients may have little to gain and much to lose from attempts at acute reconstruction. If these patients cannot be offered mobilization with the ability to protect weight bearing, they may be better off proving themselves survivors while bed to chair transfer is ongoing. A safer and more predictable delayed hip arthroplasty can be attempted electively to treat secondary pain and restore function once the fracture has healed. However, the literature offers little assistance in assessing the acceptable limits of age and infirmity. Favorable outcomes following open reduction and internal fixation have been reported in patients into their ninth decade [10, 11]. Poor outcomes seem related to conditions associated with age rather than age itself [8, 12, 13]. Recent research [14, 15] on frailty as a predictor of outcome suggests that some additional parameters (eg, grip strength, weight loss, exhaustion, low physical activity, and walking speed) can be considered to help in determining whether the patient should be candidate for major surgery.

4 Medical optimization and anesthetic management

All evidence suggests that earlier reconstruction leads to better reduction [8, 11, 16, 17]. Mobilizing patients early can also be expected to limit secondary morbidity [18]. The unknown factor is at what point surgical risks increase enough to make delaying surgery necessary. Generally blood loss is increased when surgery is performed within the first 2 days, and especially when the patient has associated fracture types. Increased intraoperative bleeding can make reduction more difficult, prolong surgery time, and increase surgical stress on the patient. The authors usually reserve early operative intervention (first 24 hours) to irreducible dislocations and large intraarticular fragments that are compromising articular cartilage. Once again, the questions of frailty and associated trauma become relevant. With increasing frailty or associated physiological stress from trauma, delay may be prudent even in these cases to best protect the patient.

Reducing the risk of infection must be of primary concern to the surgeon before undertaking operative treatment. Infection rates in acetabular surgery are clearly higher with certain approaches [19]. Risk of infection also increases with high body mass index, prolonged duration of surgery, increased blood loss, compromised soft-tissue status (eg, Morel lesions), and length of ICU stay [20]. Although there is sufficient evidence in terms of quality of reduction with early surgery, delay is recommended if any correctable factor can be identified that may increase likelihood of infection. Elevated white blood cell counts should be trending down if possible. Surgery should be delayed in patients with temperatures higher than 38.6° C unless it is clear that proceeding with surgery will acutely improve the patient’s overall physiology. Morel-Lavallée lesions may be successfully addressed either early or late [21, 22]. An increased risk of infection probably exists in either case simply because of local soft-tissue compromise. Guidelines for the appropriate administration of prophylactic antibiotics are now part of the surgical care improvement protocols in the United States. These include recommendations for timing and choice of antibiotic before incision, as well as repeated dosing during surgery dependent on duration of surgery and/or amount of blood loss. However, the data supporting these guidelines are largely based on rates of infection in elective surgery, and the results of adherence to such protocols remain unclear [23−25]. Many patients undergoing acetabular reconstruction have risk factors for resistant organisms such that alternate antibiotics should be considered. The local profile of surrounding community-acquired methicillin−resistant Staphylococcus aureus (MRSA), as well as ICU and hospital flora, must be considered in many cases. Some hospitals use routine screening via skin and/or nasal swabbing to assess for MRSA. Importantly, be aware of hospital’s policy, as the information regarding such surveillance cultures may not be communicated to consulting services.

5 General guidelines for anesthesia for pelvic fractures

Given the evidence on the importance of early reconstruction, anesthesiologists must be prepared to bring patients to the operating room that, in other circumstances, they would justifiably recommend postponing surgery. Safe surgery requires development of a comprehensive, patient-centered anesthetic plan. Overall, some things can be noted about pelvic fracture operations:

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  Patients typically require (or at least benefit from) muscle relaxation for proper exposure.

  
  
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  Major blood loss is a risk associated with surgery.

  
  
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  The integrity of the sciatic nerve or its associated roots may need to be monitored.

Although specific injuries in a patient with polytrauma can radically affect an anesthesia plan, it is helpful to outline a standard anesthetic design that may be modified in certain circumstances. In addition to standard monitoring and intravenous access, these patients will benefit from arterial catheterization for monitoring blood pressure and obtaining samples for various blood studies. A right radial arterial catheter with a left-sided blood pressure cuff may be useful when there is possible injury to the aortic intima and probably should be standard procedure for these patients whenever possible. Large-bore peripheral venous access and a central venous catheter for following trends of central venous pressures are also usually indicated.

Patients who may have major blood loss associated with complicated pelvic injuries or concomitant pulmonary/chest injuries are probably best served when they are intubated and under controlled ventilation. General anesthesia also allows for somatosensory-evoked potentials (SSEPs) to monitor sciatic nerve function. To the extent that muscle relaxation is necessary for surgical exposure, muscle relaxants can be used. However, use of muscle relaxants may be problematic if electromyography (EMG) is also used to monitor the sciatic nerve. The addition of a low-dose epidural to a general anesthetic offers many benefits and is standard practice of the authors. Bupivacaine 0.25% in doses of about 10 mL does not adversely affect SSEPs or EMGs [26]. These doses are probably not adequate for surgery on their own, but when combined with general anesthesia they provide excellent surgical conditions that obviate the need for intravenous muscle relaxants, contribute to controlled hypotension when desired, and allow for patients to awaken without pain. This last issue is more than a mere nicety. Patients with pelvic pain are not comfortable breathing deeply and require opiates for treatment. As discussed below, patients have better respiratory outcomes when they are given an epidural compared with other modalities. By using an epidural for anesthesia management, it is possible to limit opiate doses used for general anesthesia or to avoid opiates altogether and still have adequate analgesia at the end of surgery.

Contemporary evidence supports the conclusion that epidural analgesia may significantly improve outcomes. A large metaanalysis [27] showed reduced mortality with epidural analgesia compared with general anesthesia, and a reduction in venous thromboembolism, myocardial infarction, respiratory depression, and renal failure. A study [28] on hip fracture surgery revealed reduced mortality with regional anesthesia. Another large study [29] of more than 259,000 patients indicated improved survival with epidural anesthesia particularly in orthopedic surgery. Epidural catheters placed for surgery also can be used for postoperative analgesia. Epidural analgesia may also contribute to improved mortality [30] and fewer pulmonary complications [31]. This latter effect may be the result of needing fewer opiates postoperatively or needing fewer neuromuscular blocking drugs during surgery. Residual neuromuscular blockade has been demonstrated to occur frequently at the end of surgery [32] and has been implicated in compromising pulmonary function [33, 34].

Placement of an epidural catheter in these patients can be challenging. Positioning a patient with a painful pelvic fracture for an epidural usually requires sedation and analgesia. The American Society of Regional Anesthesia cautions against the placement of epidurals in sedated patients [35, 36]. They suggest that a patient’s ability to report pain as a result of needle proximity to nerves is impaired by sedation and may lead to increased risk of nerve injury. Although no data are offered to support this position, it is probably prudent to have patients as awake as possible to report paresthesias during placement. However, the benefits of using lumbar epidurals are probably sufficient to outweigh any associated risks, regardless of the level of sedation or anesthesia required for comfortable patient positioning for access.