This review reported that fixation of all injured pelvic ring components in patients with pelvic ring disruptions was associated with a better quality of reduction, lower malunion rate and higher rate of undisturbed gait, but no established beneficial effects for other outcomes. Poor quality data (acknowledged by the authors) and use of indirect comparisons between interventions suggest a cautious interpretation.

To assess the effects of different methods of treating pelvic ring disruptions on the quality and maintenance of reduction, short-term clinical results and long-term functional outcome.

MEDLINE was searched from January 1975 to March 2007 for studies written in English. Search terms were reported. Reference lists of retrieved articles were searched for additional studies.

Studies that assessed the effects of different methods of managing pelvic ring disruption in groups of at least 15 patients were eligible for inclusion in the review. Studies in children (aged less than 14 years) were excluded from the review, as were experimental studies and studies of patients with open pelvic fractures or isolated sacral/acetabular fractures. Eligible studies had to clearly report intervention methods and data related to short-term clinical outcomes or long-term functional outcomes. The review also defined important outcomes and types of pelvic ring injury.

The most commonly reported treatment in the included studies was posterior pelvic fixation, followed by anterior pelvic fixation and non-operative treatment. Included participants had anterior, posterior or both types of pelvic fracture. Mean age of participants ranged from 26 to 39 years. The male-female ratio ranged from 0.8 to 7.6. The proportion of open fractures ranged from 3% to 26%. Associated injuries were experienced in 43% to 91% of participants. Lumbosacral plexus injury was experienced by 8% to 47% of participants and genitourinary dysfunction by 0 to 36%. Anteroposterior compensation was experienced by 0 to 48% of patients, lateral compensation by 0 to 65% and vertical shear by 19% to 100%. Included outcomes were quality of reduction, union rates, complication rate, failure rate, pain intensity, undisturbed gait, return to previous employment and quality of life.

Studies were assessed for inclusion by two independent reviewers. Discrepancies were resolved through consensus.

Study quality was assessed with the following criteria: type of study design (randomised controlled trial (RCT), non-RCT and case series); blinding of outcome assessors; follow-up rate greater than 80%; use of pre-specified follow-up intervals; and use of a functional score. Each study was awarded a score (up to a maximum of 12 points).

The authors did not report how many reviewers performed the validity assessment, but it appeared that at least two reviewers performed the assessment independently.

Data were extracted as median percentage rates or scores (quality of life scales) with ranges.

The authors stated neither how data were extracted for the review nor how many reviewers performed the data extraction.

Studies were grouped by intervention and fracture type. Data were summarised in a narrative with accompanying tables of study characteristics and outcomes; p values were reported where appropriate.

Twenty seven case-series (n=1,641, 28 groups or cohorts of patients) were included in the review. Most of the quality components in the studies were rated as fair or poor quality; the median quality score was 5 out of 12 (range 2 to 8).

Quality of reduction: For non-operative patients, quality of reduction was reported as excellent for 46%, good for 40% and poor for 38.5% (median figures). In the interior fixation of the anterior pelvis group equivalent figures reported were 43.5% excellent, 23% good and 19% poor. In the interior fixation of the posterior pelvis group the figures reported were 73% excellent, 19% good and 7% poor. Comparisons between internal fixation and non-operative treatment significantly favoured internal fixation for excellent reduction (p=0.06) and favoured posterior fixation over anterior fixation for excellent reduction (p=0.04).

Malunion: Median malunion rates were 30.3% (range 23% to 37.5%) for non-operative patients, 42% (range 9% to 64%) for anterior fixation and 7% (0 to 44%) for posterior fixation; internal fixation was significantly favoured over non-operative treatment (p=0.02).

Undisturbed gait: The median rate of undisturbed gait was significantly better (p=0.04) in patients who underwent internal fixation in comparison with the non-operative group; 68% in the non-operative group, 84% in the anterior fixation group and 84.5% in the posterior fixation group.

There were no statistically significant differences between the different treatments for infection, pin track infection, loss of reduction, implant failure, pain intensity and quality of life.

The results suggested that fixation of all injured pelvic ring components was associated with a better quality of reduction, lower malunion rate and higher rate of undisturbed gait, but no established beneficial effects for other outcomes.

This review answered a clear research question using broad criteria for types of eligible study design. Literature searches were limited by language, which may have introduced language bias. Searches were limited by start date, for which the authors provide no justification. No specific attempts were made to locate unpublished data, so there was a risk of publication bias. Some attempts were made to reduce the risk of reviewer error and bias during study selection and quality assessment; it was unclear whether similar precautions were taken when extracting the study data. Study quality was assessed with appropriate criteria. Quality was described as poor or at best fair, which was expected given the inclusion of only case series. Data were synthesised in a narrative that compared median rates and percentage values. Statistical significance was assessed using p values. Further details about the types of interventions included in the studies would have been helpful, but given the apparent differences in populations between the studies the use of a narrative synthesis appeared appropriate. Comparisons between interventions were based on indirect evidence and so should be interpreted with caution. Overall, the poor quality of the data (acknowledged by the authors) and use of indirect comparisons between interventions suggest a cautious interpretation.

Practice: The authors stated that there was insufficient evidence on which to base a clinical decision about the best treatment for unstable pelvic ring injuries.

Research: The authors did not explicitly state any implications for research, although it appeared from their findings and discussion that an adequately powered randomised controlled trial was required to compare the different treatments for pelvic ring disruptions.

None reported.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.