JBJS has long promoted the use of high-level studies to facilitate evidence-based decision making. Still, each year only approximately 10% to 12% of published articles provide Level-I evidence. Although that percentage is increasing, the slope of the upward curve is gentle, largely because of the difficulty in designing and conducting randomized controlled trials (RCTs), and in gathering enough data from existing RCTs to conduct Level-I meta-analyses. The challenge of designing and conducting Level-I studies in orthopaedic surgery is compounded by our need to treat many conditions that are not common enough to make a controlled trial feasible. Consequently, there will always be room for Level-III and Level-IV research in the pages of The Journal (see related JBJS Editorial).
A Level-IV study that focuses on a surgical approach is rare, but in the September 2, 2020 issue of JBJS, Liu et al. describe preliminary results from a new concealed-incision, extrapelvic surgical approach to the anterior pelvic ring. This so-called “Fu-Liu approach” was investigated to treat pubic symphysis diastasis and parasymphyseal fractures, including those of the anterior column. Among the advantages of this approach over the more traditional Pfannenstiel approach are the following:
- Easier protection of the spermatic cord in males and the round ligament of the uterus in females
- Less risk to peritoneal internal organs, iliac blood vessels, and femoral nerves
- Improved aesthetic outcomes (The 2 small incisions are ultimately covered under perineal hair.)
- Relatively short learning curve
As our field continues to innovate toward less-invasive surgical interventions, such creative approaches are welcome. What we need now are comparative trials focused on this surgical approach versus the time-honored Pfannenstiel approach to convince surgeons and assure patients that the Fu-Liu approach yields limited complications and equal or better radiographic and patient-reported functional outcomes.
Because the conditions to which this approach can be applied are quite variable, such a trial would likely have to be multicenter and focused on pure, open-book, isolated pelvic fractures. We look forward to receiving and reviewing the manuscript describing an adequately powered trial that directly compares these two approaches.
Marc Swiontkowski, MD