BACKGROUND: The benefit of routine early fecal diversion in blunt open pelvic fractures remains uncertain. We examined its association with pelvic infection and short-term mortality.
METHODS: MEDLINE/PubMed, Embase, Scopus, Web of Science Core Collection, and CENTRAL were searched from inception through 12 August 2026, with citation searching. Comparative observational studies were synthesized using crude risk ratios (RRs), REML random-effects models, modified Hartung-Knapp confidence intervals, and Mantel-Haenszel sensitivity analyses without continuity correction. Two reviewers independently selected studies, extracted data, and assessed ROBINS-I risk of bias and GRADE certainty.
RESULTS: Eighteen observational comparative reports were retained. Potential cohort overlap prevented a valid unique overall participant total. Eight cohorts contributed to broad pelvic infection (171 participants; seven estimable): RR 0.78 (95% CI 0.35-1.70; I²=19.6%). The stricter outcome-definition analysis included five cohorts (88 participants; four estimable): RR 0.72 (95% CI 0.07-6.97). Excluding two author-reported infected hematomas through an existing replacement sensitivity gave RR 0.84 (95% CI 0.34-2.05). Eight mortality cohorts (236 participants) yielded RR 0.82 (95% CI 0.33-2.07; I²=19.0%). Post-2006 evidence remained inconclusive for infection (three cohorts; RR 0.74, 95% CI 0.009-58.85) and mortality (five cohorts; RR 1.19, 95% CI 0.27-5.26). Diversion was preferentially used in patients with more severe injuries. All reports had Serious or Critical risk of bias; certainty was very low.
CONCLUSIONS: Available evidence does not establish a reduction in pelvic infection or short-term mortality with routine early diversion. Confounding, inconsistent outcome ascertainment, and imprecision prevent causal conclusions or exclusion of benefit in selected high-risk injuries.
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