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Treatment Discrepancy for Pelvic Fracture Patients With Urethral Injuries

A Survey of Orthopaedic and Urologic Surgeons

Johnsen, Niels V. MD*; Firoozabadi, Reza MD, MA; Voelzke, Bryan B. MD

doi: 10.1097/BOT.0000000000001482
Opinions and Surveys
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Objectives: In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI.

Methods: An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making.

Results: Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient.

Conclusions: There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes.

Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

*Department of Urology and Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; and

Departments of Orthopaedics, and

Urology, University of Washington, Seattle, WA.

Reprints: Reza Firoozabadi, MD, MA, Harborview Medical Center, Box 359868, 325 Ninth Avenue, Seattle, WA 98104 (e-mail: Rezaf2@uw.edu).

The authors report no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jorthotrauma.com).

Accepted March 06, 2019

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INTRODUCTION

Pelvic fracture urethral injuries (PFUI) are a rare occurrence, with contemporary series suggesting an incidence of just 2% in men following significant pelvic trauma.1,2 Previous research has identified specific pelvic injury patterns that are associated with an increased risk of urethral injury, particularly pubic symphysis diastasis and displaced fractures of the inferomedial pubic body.3 These injuries often occur in conjunction with posterior ring injuries and, as such, often require open reduction with internal fixation (ORIF) of the anterior pelvic ring injury by the orthopaedic surgery team to obtain pelvic stability.

The current American Urological Association (AUA) guidelines recommend acute management of the urethral injury in these patients with either endoscopic realignment (where a flexible cystoscope is used to facilitate placement of a urethral catheter) or placement of a suprapubic tube (SPT).4 Although the acute management of PFUI remains controversial among urologists, the impact that acute urethral management decisions have on subsequent orthopaedic pelvic fracture management decisions has not been previously evaluated in the literature. To examine this issue, we surveyed orthopaedic surgeons and urologists with expertise in pelvic trauma to assess practice patterns, preferred treatments, and the role of interdisciplinary interactions in the management of patients with PFUI. We hypothesized that a disconnect exists between urologists and orthopaedic surgeons in the preferred management of PFUI patients and that this lack of agreement may negatively impact patient outcomes.

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MATERIALS AND METHODS

Survey Structure

Two distinct survey questionnaires were designed for the members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS), respectively. These groups were chosen due to the perceived increased exposure and experience in the management of PFUI patients. The questionnaires contained items that were similar between surveys, as well as items uniquely targeted to either OTA or GURS members. Each survey was composed of questions that addressed 4 distinct clinical areas of interest: (1) the experience and training of providers in the management of traumatic pelvic fractures, (2) the role of associated urethral injuries in orthopaedic management decisions, (3) the role of urethral injury management in orthopaedic management decisions, and (4) the secondary impact and risks associated with placement of an SPT for urethral injury management. These survey instruments were composed of new items not previously validated in the existing literature (see questionnaires, Supplemental Digital Content 1, http://links.lww.com/JOT/A684 and Supplemental Digital Content 2, http://links.lww.com/JOT/A685).

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Questionnaire Administration

After questionnaire design, the final survey instruments were created using REDCap (Research Electronic Data Capture) tools hosted at the University of Washington. REDCap is a secure, Web-based application that allows data capture in a standardized fashion and provides automated procedures for exportation of data to statistical analysis programs. The respective online surveys were delivered electronically via REDCap to members of the OTA and GURS utilizing their society electronic mailing lists, as well as posted on the OTA Web site. The surveys were active from September 2017 through August 2018. Participation was voluntary, and responses were collected and stored anonymously utilizing the REDCap system.

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Statistical Analysis

All survey data were collected in REDCap and then exported to Stata/IC version 13.1. For items similar between OTA and GURS surveys, univariate analysis was performed to compare respondent answers between orthopaedic and urologic surgeons. All statistical tests were 2 sided with a P value of less than 0.05 considered significant.

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RESULTS

Fifty-three GURS members and 64 OTA members responded to the survey, for an overall response rate of 17%. Although the majority of both GURS and OTA respondents practice at Level 1 and Level 2 trauma centers, OTA respondents were more likely to work at Level 1 centers (P < 0.01; Table 1). There was no significant difference between OTA and GURS respondents in terms of time in practice since training completion, with both groups showing similar response rates from providers less than 5 years, between 5 and 10 years, and more than 10 years out from training. There was no difference in the number of PFUI patients seen annually between OTA and GURS respondents, with the majority of respondents reporting that they manage between 1 and 10 PFUI per year (71% of GURS respondents and 88% of OTA respondents; P = 0.4).

TABLE 1

TABLE 1

The preferred acute urethral injury management of PFUI was divided among GURS respondents, with 43% preferring SPT placement and 57% preferring endoscopic realignment (Fig. 1). However, OTA respondents strongly preferred endoscopic realignment (73% vs. 27%). Similarly, although 92% of GURS respondents reported that they did not believe that placement of an SPT in patients undergoing ORIF increased pelvic hardware infection risks, an identical 92% of OTA respondents reported that they did believe that SPT increases the risk of infection (P < 0.01; Fig. 1).

FIGURE 1

FIGURE 1

Regarding the GURS-specific questionnaire, 66% of GURS respondents do not consider the operative plan of the orthopaedic team when planning urethral management strategies (ie, endoscopic realignment or SPT), although 58% reported that in their experience, orthopaedic surgeons are less inclined to proceed with ORIF in the setting of an SPT. Forty-seven percent of GURS respondents felt that endoscopic realignment would be the preferred management strategy by orthopaedic surgeons, whereas a similar 47% felt that SPT placement would be preferred.

Regarding the OTA-specific questionnaire, 83% of OTA respondents stated that a concomitant urethral injury following pelvic fracture impacts orthopaedic operative decision making. Furthermore, 92% of OTA respondents stated that an SPT in particular affects operative decision making. Seventy-three percent of OTA respondents preferred endoscopic realignment of the urethra, with a similar 75% stating that they were less inclined to proceed with ORIF in patients with an SPT. Of note, most OTA respondents (70%) would perform external pelvic fixation following SPT, despite a notable belief among respondents (78%) that patient outcomes following external fixation are inferior to ORIF. Particular pelvic fracture configurations believed by OTA respondents to have the highest risk for infectious complications following ORIF in the setting of SPT were pubic diastasis (91%), acetabular fractures (41%), and pubic rami fractures (31%).

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DISCUSSION

Multidisciplinary coordination in the management of acutely injured pelvic trauma patients has resulted in significant reductions in both morbidity and mortality.5–7 Advancements in resuscitation techniques and early treatment of hemodynamic instability with pelvic fixation and angioembolization have drastically improved overall survival.8–10 As a result, the impact of acute management decisions on long-term patient outcomes and quality of life has risen in importance. For PFUI patients, the morbidities of both urethral injuries and pelvic fractures can be significant. Unfortunately, the role of interdisciplinary dialogue and collaboration in optimizing patient outcomes has previously been overlooked.

In the present study, we found there to be significant discordance between urologists and orthopaedic surgeons regarding the impact that urethral injuries and their management have on pelvic fracture management. Most interestingly, our results suggest that a significant difference in opinion regarding the impact of interservice management decisions exists, highlighted by the drastic discrepancy between the views of urologists and orthopaedic surgeons regarding the infectious risks associated with ORIF following SPT. Taken together, this study emphasizes the need to improve interdisciplinary dialogue and cooperation between managing services treating PFUI patients and to provide objective, quality data to support management decisions and maximize patient outcomes.

Changes in the management of PFUI by urologists over the past decade have resulted in heterogeneity regarding preferred strategies.11–14 The current AUA guidelines provide recommendations that allow providers the ability to choose endoscopic realignment or SPT for acute management of PFUI.4 This heterogeneity is evident in the present study, where 43% of responding urologists preferred endoscopic realignment and 57% preferred SPT placement. Although the long-term benefits of endoscopic realignment are debatable, the principal aim is to avoid major urethral reconstruction by preventing or minimizing the occurrence of significant urethral distraction defects.12 However, at certain centers, the decision to proceed with endoscopic realignment and urethral catheter placement is driven by requests from orthopaedic surgeons who will not perform ORIF of anterior pelvic injuries in the presence of an SPT due to the belief that the SPT increases the risk of pelvic hardware infection.11 Despite this, only one-third of GURS respondents considered orthopaedic management when determining acute urologic management. These data suggest a lack of collaboration between urologists and orthopaedists regarding the management of these patients. Furthermore, although the present study does not address the role that interdisciplinary dialogue plays in influencing management strategies, it does highlight the potential impact that improved coordination of care may have in affecting patient outcomes.

The present study highlights significant differences in opinion regarding the infectious risks associated with SPT in patients undergoing ORIF, with 92% of urologists stating that SPT do not increase the risk of infection and an identical 92% of orthopaedists stating that they do. A single prior study exists in the literature that attempted to specifically address this question. Utilizing data from the National Trauma Data Bank, our group found no statistically significant association between SPT placement and infection risk in patients with PFUI who underwent ORIF during their index hospitalization.15 This study, however, was limited significantly by a lack of longitudinal follow-up after index hospitalization discharge and a lack of information regarding temporality of treatments (ie, when SPT were placed or removed relative to ORIF).

The assertion that SPTs increase the risk of pelvic hardware infection, nonetheless, can be found throughout the orthopaedic literature. Many of the often-cited reports, however, are either anecdotal or reflect surgeon preference. Although Routt et al6 are often cited in claims that SPT increases the risk of hardware infections, closer evaluation of their study revealed that it was the preference of the authors not to use SPT due to perceived concerns of infection, rather than a discrete finding of the study itself. Although a number of similar claims exist in the literature,16–20 only a single case series from 1990 reports a true infectious complication in a single patient who underwent ORIF of an acetabular fracture and SPT placement.21 Notably, due to the lack of quality of evidence that SPT increases the risk of pelvic hardware infections, the 2014 AUA Urotrauma guidelines state that it is the position of the AUA that SPT can be safely placed in patients undergoing pelvic ORIF.4 Notably, this statement was based on the expert opinion of the guidelines committee without substantial supporting evidence. Although hardware infection is undoubtedly a severe complication with significant implications, the paucity of information on the topic and the diametrically opposed views held by urologists and orthopaedists highlight the need for better data for surgeons to use in decision making and to better inform multidisciplinary care.

Pelvic ORIF has been shown to provide improved anatomical and functional results as compared with external fixation, which has been associated with worse pain, instability, and functional limitations.22–25 Our results show support for these conclusions among orthopaedists, with 78% of those surveyed stating that in a patient otherwise a candidate for ORIF, external fixation results in an inferior outcome. However, many orthopaedists believe that a primary indication for definitive management with external fixation is the presence of soft tissue injury or contamination that “precludes” internal fixation.26 Avoidance of SPT in the setting of ORIF is presumably based on the presumption that leakage from the SPT tract to the surrounding soft tissue can increase risks of internal hardware infection; however, there is at present no objective evidence that SPTs are prone to leakage or increase infectious risks.

How to integrate the findings of this study into improved interdisciplinary dialogue and joint decision making remains difficult. This is largely due to a lack of high-quality data on 2 fronts: (1) the risks/benefits of endoscopic realignment for PFUI patients from a urologic standpoint and (2) the infectious risks associated with SPT in patients who require ORIF. Many urologists across the country are adamantly opposed to endoscopic realignment, as they believe that this procedure unnecessarily delays time to definitive treatment of the urethral injury and has a less than 10% chance of successfully avoiding the development of a subsequent fibrotic urethral defect that requires adjuvant treatment.11,14 Although data from our own institution has suggested that endoscopic realignment does not negatively impact the success for those who ultimately require a subsequent urethroplasty, strong debate regarding acute urethral management within the urologic community persists.11

In the absence of compelling data to prove an association between SPT and hardware infection following ORIF, many urologists will likely continue to place SPT without consideration of the orthopaedic implications. Similarly, unless there is persuasive longitudinal data that shows no increased risk of infection in patients undergoing SPT placement and concomitant pelvic ORIF, the majority of orthopaedic trauma surgeons will remain unwilling to place internal hardware in patients with SPT. Data from the present study illuminate this controversy and aim to stimulate a dialogue between services to minimize the negative impact that operative decisions may have on comanaging services. Developing multidisciplinary care pathways, such as those already in place to manage acute pelvic injuries, and agreed upon management principles will help to optimize patient-centered outcomes until higher-quality data are available to better inform providers.

There are a number of limitations of this study. The survey response rates from both GURS and OTA members were low and did not include the opinions of the majority of society members. In-group differences were, however, small, suggesting relatively high agreement within each specialty. Second, we do not have information on fellowship training of respondents, which could impact opinions and decision making. Third, all survey participants have surgical practices that see PFUI patients on a much more frequent basis than average community providers, and thus, their opinions are likely influenced by their experiences and may differ significantly from providers in lower-volume trauma practices. Fourth, our relatively low numbers do not allow for robust subgroup analysis to determine if specialist's opinions are influenced by the frequency of exposure or experience with PFUI. Finally, how interdisciplinary dialogue and decision making currently occur, what considerations are taken into account and how these are weighted are not well known and were not addressed with the current instrument. Further research will be required to better understand these factors.

There exists a significant disconnect between urologists and orthopedists regarding the preferred urologic management of PFUI patients. Higher-quality data are needed to better elucidate the true infectious risks associated with ORIF following SPT. Until these data are available to inform multidisciplinary management decisions, improved interservice dialogue is necessary to optimize both collaboration and patient outcomes.

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Keywords:

pelvic fracture; suprapubic tube; urethral injury; internal fixation; pelvic fracture

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