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Vijayakumar V, Bansal H, Farooque K, Sharma V. An unusual case of symmetric quadruple limb fractures. Chin J Traumatol 2023; 26:303-307. [PMID: 36575105 PMCID: PMC10533537 DOI: 10.1016/j.cjtee.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 10/03/2022] [Accepted: 11/13/2022] [Indexed: 12/12/2022] Open
Abstract
A 19-year-old man had an accidental fall from the 2nd floor and sustained multiple injuries. On radiological evaluation, the patient had symmetrical quadruple limb involvement with bilateral humerus shaft, bilateral olecranon, bilateral femur shaft, and bilateral patella fractures. The patient was actively managed using damage control orthopaedics, and a sequence of skeletal fixation was planned based on the hemodynamic stability and periodical serum lactate assessment. Symmetrical quadruple limb fractures are very rare, which could be associated with higher mortality. A meticulous clinical evaluation, periodical blood parameter assessment and strict adherence to the principles of damage control orthopaedics can be conducive to prevent life-endangering complications.
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Affiliation(s)
- Vivek Vijayakumar
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Hemant Bansal
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Kamran Farooque
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Sharma
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Baker HP, Lin Y, Dahm J, Portney DA, Dillman DB, Strelzow JA. Bilateral femur fractures are associated with concomitant femoral neck fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:409-414. [PMID: 35038011 DOI: 10.1007/s00590-022-03207-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study is to determine the rate of femoral neck fractures in patients who have sustained bilateral femur fractures compared to unilateral femur fractures. DESIGN AND SETTING A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS All patients treated for a femur fracture between May 1, 2018 and December 31, 2020 were included. RESULTS Twenty-one patients sustained bilateral femur fractures (11%) and 166 sustained unilateral femur fractures. Fifteen associated ipsilateral femoral neck fractures were identified. Eight of the 15 (53%) associated femoral neck fractures were observed in patients who sustained bilateral femur fractures. Eight of the 21 patients with bilateral femur fractures, 42 fractures in total, had an associated ipsilateral femoral neck fracture (38% of patients; 19% of fractures, respectively), while only seven of the 166 patients (4%) with a unilateral femur fracture had an associated femoral neck fracture (p < 0.001). Of the 208 femur fractures, 19 (9%) were open fractures. Ten of the 21 patients with bilateral femur fractures, 42 fractures in total, were identified to have an open femur fracture (48% of patients, 24% of fractures), while only nine of the 166 (5%) unilateral femur fractures were open (p < 0.001). CONCLUSIONS Our results demonstrate an association between bilateral femur fractures, open femur fractures, and associated femoral neck fractures. Surgeons treating these injuries should maintain a high index of suspicion for associated ipsilateral proximal.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA. .,, 5758 S. Maryland Avenue, Department 4B, Chicago, IL, 60637, USA.
| | - Ye Lin
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - James Dahm
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Daniel A Portney
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Daryl B Dillman
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
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Mansour A, Vivace BJ, Nyland J, Rashid SF, Wilson A, Engorn JR, Swindle JS, Zamora R. Early intramedullary nailing of bilateral femur fractures: who might benefit most? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03453-2. [PMID: 36538126 DOI: 10.1007/s00590-022-03453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use. METHODS A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt. RESULTS Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O2 partial pressure (paO2) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR. CONCLUSIONS Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.
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Affiliation(s)
- Ali Mansour
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | | | - John Nyland
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
- Norton Orthopedic Institute, Louisville, USA
| | - Salwa F Rashid
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Ayana Wilson
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
- University of Louisville School of Medicine, Louisville, USA
| | - Jeffrey R Engorn
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
- University of Louisville School of Medicine, Louisville, USA
| | - Jordan Scot Swindle
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Rodolfo Zamora
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA.
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Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy-based case-control study on 4895 fatalities. Arch Orthop Trauma Surg 2022; 142:2645-2658. [PMID: 34196773 DOI: 10.1007/s00402-021-03997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs. PATIENTS AND METHODS A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed. RESULTS The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%). CONCLUSION This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.
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Cosgrove CT, Wolinsky PR, Berkes MB, McAndrew CM, Stwalley DL, Miller AN. A Comparison of the Prevalence of, Demographics of, and Effects on Outcomes of Bilateral Versus Unilateral Femoral Shaft Fractures: A Retrospective Cohort Analysis From the National Trauma Data Bank. J Orthop Trauma 2022; 36:349-354. [PMID: 35727002 DOI: 10.1097/bot.0000000000002322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To document the prevalence of, and the effect on outcomes, operatively treated bilateral femur fractures treated using contemporary treatments. DESIGN A retrospective cohort using data from the National Trauma Data Bank. PARTICIPANTS In total, 119,213 patients in the National Trauma Data Bank between the years 2007 and 2015 who had operatively treated femoral shaft fractures. MAIN OUTCOME MEASUREMENTS Complication rates, hospital length of stay (LOS), days in the intensive care unit (ICU LOS), days on a ventilator, and mortality rates. RESULTS Patients with bilateral femur fractures had increased overall complications (0.74 vs. 0.50, P < 0.0001), a longer LOS (14.3 vs. 9.2, P < 0.0001), an increased ICU LOS (5.3 vs. 2.4, P < 0.0001), and more days on a ventilator (3.1 vs. 1.3, P < 0.0001), when compared with unilateral fractures. Bilateral femoral shaft fractures were independently associated with worse outcomes in all primary domains when adjusted by Injury Severity Score (P < 0.0001), apart from mortality rates. Age-adjusted bilateral injuries were independently associated with worse outcomes in all primary domains (P < 0.0001) except for the overall complication rate. A delay in fracture fixation beyond 24 hours was associated with increased mortality (P < 0.0001) and worse outcomes for all other primary measures (P < 0.0001 to P = 0.0278) for all patients. CONCLUSIONS Bilateral femoral shaft fractures are an independent marker for increased hospital and ICU LOS, number of days on a ventilator, and increased complication rates, when compared with unilateral injuries and adjusted for age and Injury Severity Score. Timely definitive fixation, in a physiologically appropriate patient, is critical because a delay is associated with worse inpatient outcome measures and higher mortality rates. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher T Cosgrove
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Philip R Wolinsky
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA; and
| | - Marschall B Berkes
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christopher M McAndrew
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Dustin L Stwalley
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
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Rondanelli AM, Gómez-Sierra MA, Ossa AA, Hernández RD, Torres M. Damage control in orthopaedical and traumatology. Colomb Med (Cali) 2022; 52:e4184802. [PMID: 35027781 PMCID: PMC8754164 DOI: 10.25100/cm.v52i2.4802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/30/2021] [Accepted: 06/27/2021] [Indexed: 01/08/2023] Open
Abstract
In Orthopedics, damage control is indicated in patients with pelvic and/or long bone fractures associated with hemodynamic instability. It is inappropriate to perform a complex definitive reduction and fixation surgery for severely injured trauma patients with hemodynamic instability. In these cases, it is recommended to perform minimally invasive procedures that temporarily stabilize the fractures and bleeding control. Closed or open fractures of the long bones such as femur, tibia, humerus, and pelvis can lead to hemodynamic instability and shock. Thus, orthopedic damage control becomes a priority. However, if the patient is hemodynamically stable, it is recommended to stabilize all fractures with an early permanent internal fixation. These patients will have a shorter hospital length of stay and a reduction in mechanical ventilation, blood components transfusions and complications. Therefore, the concept of orthopedic damage control should be individualized according to the hemodynamic status and the severity of the injuries. Open fractures, dislocations, and vascular injuries could lead to permanent sequelae and complications if a correct management and approach are not performed.
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Affiliation(s)
- Alfredo Martínez Rondanelli
- Fundación Valle del Lili, Departamento de Cirugía Ortopédica, Cali, Colombia.,Universidad ICESI, Cali, Colombia
| | - María Antonia Gómez-Sierra
- Fundación Valle del Lili, Departamento de Cirugía Ortopédica, Cali, Colombia.,Universidad ICESI, Cali, Colombia
| | - Arley Alberto Ossa
- Fundación Valle del Lili, Departamento de Cirugía Ortopédica, Cali, Colombia.,Universidad ICESI, Cali, Colombia.,Hospital Universitario del Valle, Departamento de Cirugía Ortopédica, Cali, Colombia
| | - Rubén Darío Hernández
- Hospital Universitario del Valle, Departamento de Cirugía Ortopédica, Cali, Colombia
| | - Mauricio Torres
- Fundación Valle del Lili, Departamento de Cirugía Ortopédica, Cali, Colombia.,Universidad ICESI, Cali, Colombia
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Flagstad IR, Tatman LM, Heare A, Parikh HR, Albersheim M, Atchison J, Breslin M, Davis P, Feinstein S, Hak DJ, Labrum JT, Lufrano RC, Lund EA, Connelly D, Matar RN, Nadeau J, Ries de Chaffin D, Rodriguez-Buitrago AF, Schmidt T, Shaw N, Simske N, Siy AB, Titter J, Vang S, Wagstrom E, Westberg JR, Hahn J, Mauffrey C, Mir HR, O'Toole RV, Obremskey WT, Sanders RW, Schmidt AH, Vallier HA, Whiting PS, Cunningham BP. Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review. J Orthop Trauma 2021; 35:499-504. [PMID: 33512861 DOI: 10.1097/bot.0000000000002055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. DESIGN A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. SETTING Ten Level-1 trauma centers. PATIENTS/PARTICIPANTS Two hundred forty-six patients with bilateral femur fractures. INTERVENTIONS Intramedullary nailing. MAIN OUTCOME MEASURES Incidence of complications. RESULTS A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). CONCLUSIONS This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
- Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, FL
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Jared Atchison
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Patrick Davis
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Shawn Feinstein
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - David J Hak
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Reuben C Lufrano
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Erik A Lund
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Daniel Connelly
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Robert N Matar
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, OH
| | - Jason Nadeau
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | | | | | - Tegan Schmidt
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Nichole Shaw
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Alexander B Siy
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Julie Titter
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Emily Wagstrom
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jerald R Westberg
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jesse Hahn
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Hassan R Mir
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Robert V O'Toole
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Roy W Sanders
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Andrew H Schmidt
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Heather A Vallier
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Paul S Whiting
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orhopaedics, TRIA Orthopaedics Center, Bloomington, MN; and
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN
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Flagstad IR, Tatman LM, Albersheim M, Heare A, Parikh HR, Vang S, Westberg JR, de Chaffin DR, Schmidt T, Breslin M, Simske N, Siy AB, Lufrano RC, Rodriguez-Buitrago AF, Labrum JT, Shaw N, Only AJ, Nadeau J, Davis P, Steverson B, Lund EA, Connelly D, Atchison J, Mauffrey C, Hak DJ, Titter J, Feinstein S, Hahn J, Sagi C, Whiting PS, Mir HR, Schmidt AH, Wagstrom E, Obremskey WT, O'Toole RV, Vallier HA, Cunningham B. Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation. Injury 2021; 52:2395-2402. [PMID: 33712297 DOI: 10.1016/j.injury.2021.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/16/2021] [Accepted: 02/28/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries. METHODS Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit. RESULTS Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X2 statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94). CONCLUSION In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Miami Hospital Ortho Clinic, 1400 N.W. 12th Avenue, Suite 2, Miami, FL 33136, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Sandy Vang
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101, USA
| | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Danielle Ries de Chaffin
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Tegan Schmidt
- Department of Orthopaedic Surgery, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alexander B Siy
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Reuben C Lufrano
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Andres F Rodriguez-Buitrago
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Nichole Shaw
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Arthur J Only
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA
| | - Jason Nadeau
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Patrick Davis
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Barbara Steverson
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Erik A Lund
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Daniel Connelly
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Jared Atchison
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Cyril Mauffrey
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - David J Hak
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Julie Titter
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Shawn Feinstein
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Jesse Hahn
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Claude Sagi
- Department of Orthopaedic Surgery, University of Cincinnati, Medical Sciences Building Room 3109 231 Albert Sabin Way, PO Box 670531, Cincinnati, OH 45267, USA
| | - Paul S Whiting
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Hassan R Mir
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Emily Wagstrom
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Brian Cunningham
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA.
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Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis? Orthop Traumatol Surg Res 2021; 107:102864. [PMID: 33621700 DOI: 10.1016/j.otsr.2021.102864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/29/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. MATERIALS AND METHODS This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. RESULTS Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DISCUSSION Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. CONCLUSION Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. LEVEL OF EVIDENCE IV; retrospective study.
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What are the differences in outcomes between simple and complicated FSF managed by early IMN? Arch Orthop Trauma Surg 2020; 140:1037-1045. [PMID: 31845060 DOI: 10.1007/s00402-019-03325-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail. METHODS Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24 h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25). RESULTS Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151 min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104 min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002). CONCLUSION Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.
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The Incidence and Risk Factors Associated With the Need for Fasciotomy in Tibia and Forearm Fractures: An Analysis of the National Trauma Data Bank. J Orthop Trauma 2020; 34:e154-e158. [PMID: 31738240 PMCID: PMC7991978 DOI: 10.1097/bot.0000000000001702] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aims of this study were to analyze a large national trauma database to determine the incidence of, risk factors for, and outcomes after a fasciotomy of the lower leg or forearm after fracture. METHODS Data from the National Trauma Data Bank for the years 2004-2016 were analyzed, and we identified 301,351 patients with forearm fractures and 369,237 patients with tibial fractures. Risk factors, length of stay (LOS), and mortality were assessed to determine associations with an injury that required a fasciotomy. RESULTS A total of 1.22% of the forearm fractures and 3.79% of the tibial fractures had a fasciotomy. Patients with a fasciotomy were more likely to have invasive procedures (P < 0.0001); have injuries resulting from machinery, motor vehicle collisions, and firearms (P < 0.0001); and smoke, use drugs, and/or alcohol (P < 0.05) compared with patients who did not undergo fasciotomies. Fasciotomy procedures were associated with longer LOS and higher mortality rate (P < 0.05). CONCLUSIONS The incidence of a fasciotomy is less than 5% in tibia or forearm fractures. Patients who underwent fasciotomy have higher energy injuries, increased alcohol or drug use, higher rates of surgical interventions, and increased LOS. Furthermore, having a fasciotomy is associated with increased mortality rate. When counseling patients and evaluating surgeon/hospital performance, fasciotomies can serve as an indicator and modifier for a more complex trauma pathology. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Dodd AC, Bulka C, Jahangir A, Mir HR, Obremskey WT, Sethi MK. Predictors of 30-day mortality following hip/pelvis fractures. Orthop Traumatol Surg Res 2016; 102:707-10. [PMID: 27496661 DOI: 10.1016/j.otsr.2016.05.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 05/12/2016] [Accepted: 05/30/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION With the cost of healthcare in the United States reaching $2.9 trillion in 2013 and expected to increase with a growing geriatric population, the Center for Medicare and Medicaid Services (CMS) and Hospital Quality Alliance (HQA) began publicly reporting 30-day mortality rates so that hospitals and physicians may begin to confront clinical problems and promote high-quality and patient-centered care. Though the 30-day mortality is considered a highly effective tool in measuring hospital performance, little data actually exists that explores the rate and risk factors for trauma-related hip and pelvis fractures. Therefore, in this study, we sought to explore the risk factors associated with 30-day mortality in trauma-related hip and pelvic fractures. MATERIALS AND METHODS Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 341,062 patients undergoing orthopaedic procedures from 2005 to 2013 were identified through a Current Procedural Terminology (CPT) code search. A second CPT code search identified 24,805 patients who sustained a hip/pelvis fracture. Patient demographics, preoperative comorbidities, operative characteristics and postoperative complications were collected and compared using Chi-squared test, Wilcoxon-Mann-Whitney test and multivariate logistic regression analysis. RESULTS Preoperative and postoperative risk factors for 30-day mortality following a hip/pelvis fracture were found: ASA classification, ascites, disseminated cancer, dyspnea, functional status, history of congestive heart failure (CHF), history of chronic obstructive pulmonary disease (COPD), a recent blood transfusion, and the postoperative complications: pneumonia, myocardial infarction, stroke, and septic shock. DISCUSSION Several preoperative patient risk factors and postoperative complications greatly increased the odds for patient mortality following 30-days after initial surgery. Orthopaedic surgeons can utilize these predictive risk factors to better improve patient care. LEVEL OF EVIDENCE Retrospective study. Level IV.
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Affiliation(s)
- A C Dodd
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
| | - C Bulka
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
| | - A Jahangir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
| | - H R Mir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
| | - W T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
| | - M K Sethi
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA.
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Damage Control Orthopedics in Multitrauma Patients: A Pediatric Case Presentation and Literature Review. Trauma Mon 2016. [DOI: 10.5812/traumamon.32856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Wang D, Gilbert JR, Shaw MA, Shakir S, Losee JE, Billiar TR, Cooper GM. Toll-like receptor 4 mediates the regenerative effects of bone grafts for calvarial bone repair. Tissue Eng Part A 2016; 21:1299-308. [PMID: 25603990 DOI: 10.1089/ten.tea.2014.0215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Craniofacial trauma is difficult to repair and presents a significant burden to the healthcare system. The inflammatory response following bone trauma is critical to initiate healing, serving to recruit inflammatory and progenitor cells and to promote angiogenesis. A role for inflammation in graft-induced bone regeneration has been suggested, but is still not well understood. The current study assessed the impact of Toll-like receptor (TLR4) signaling on calvarial repair in the presence of morselized bone components. Calvarial defects in wild-type and global TLR4(-/-) knockout mouse strains were treated with fractionated bone components in the presence or absence of a TLR4 neutralizing peptide. Defect healing was subsequently evaluated over 28 days by microcomputed tomography and histology. The matrix-enriched fraction of morselized bone stimulated calvarial bone repair comparably with intact bone graft, although the capacity for grafts to induce calvarial bone repair was significantly diminished by inhibition or genetic ablation of TLR4. Overall, our findings suggest that the matrix component of bone graft stimulates calvarial bone repair in a TLR4-dependent manner. These results support the need to better understand the role of inflammation in the design and implementation of strategies to improve bone healing.
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Affiliation(s)
- Dan Wang
- 1 Department of Stomatology, Tenth People's Hospital of Tongji University , Shanghai, China
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Lane MK, Nahm NJ, Vallier HA. Morbidity and Mortality of Bilateral Femur Fractures. Orthopedics 2015; 38:e588-92. [PMID: 26186320 DOI: 10.3928/01477447-20150701-56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 10/07/2014] [Indexed: 02/03/2023]
Abstract
Bilateral femur fractures have been associated with frequent morbidity and mortality. Associated injuries and massive hemorrhage contributed to mortality rates that were as high as 27% in previous reports. The goals of this study were to determine the frequency of associated complications, including mortality, and to identify which patient and injury features are associated with increased morbidity and mortality. The authors proposed that some patients with bilateral femur fractures may undergo early definitive fixation with an acceptable rate of complications. Patients who had bilateral femur fractures during the same injury event were retrospectively reviewed. Demographic characteristics, associated injuries, and the type and timing of treatment were determined. Complications were identified. The authors identified 50 men and 22 women, with a mean age of 41.5 years, who had high-energy bilateral femur fractures. These patients accounted for 5.5% of all femur fractures treated at the authors' institution over a period of 11 years. Two patients died before fixation. In addition, 13 other patients (19%) had 21 complications, including pneumonia in 6 (8.6%) and deep venous thrombosis in 7 (10%). No patient had adult respiratory distress syndrome, but 2 died of multiple organ failure. All patients with pulmonary complications had an underlying chest injury (P=.004). The overall mortality rate was 6.9%, and mortality was associated with higher mean age and higher Injury Severity Score (ISS). Of the 60 patients who had definitive fixation within 24 hours of injury, 53 (88%) had no complications. Complication rates were similar to those reported in the literature, with a mortality rate of 6.9%, including 3 patients who died after femoral fixation. Mortality was associated with advanced age and higher ISS. Chest injuries were associated with pulmonary complications. Most patients had early definitive fixation without complications, but it is not possible to predict which patients may be safely treated on an early basis.
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Lichte P, Weber C, Sellei RM, Hildebrand F, Lefering R, Pape HC, Kobbe P. Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome? Injury 2014; 45:1985-9. [PMID: 25458064 DOI: 10.1016/j.injury.2014.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 09/07/2014] [Accepted: 10/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Long bone fractures are assumed to be an independent risk factor for systemic complications and death after trauma. Multiple studies have identified an increased risk for mortality and morbidity in patients with bilateral femoral fractures. Data about bilateral tibial shaft fractures is rare. The aim of our study was to analyze if patients with bilateral tibial shaft fractures are at higher risk for systemic complications. METHODS We performed a retrospective analysis of the TraumaRegister DGU® from 1993 to 2008. Inclusion criteria were unilateral or bilateral tibial shaft fractures and an age ≥16. Additionally to the overall collective we analyzed different subgroups (divided into different injury severities and treatment periods). RESULTS 1899 patients with unilateral and 175 patients with bilateral tibial shaft fractures were included. Age, gender and mean ISS (25.8 vs. 26.2, p = 0.51) in the two groups were comparable. Regarding the entire study population, patients with bilateral tibial shaft fractures showed no significant higher incidence of respiratory organ failure (29.5% vs. 23.1%, p = 0.076) or mortality (20.0% vs. 16.3%, p = 0.203). However, subgroup analysis showed a significant higher rate of pulmonary organ failure for bilateral tibial shaft fractures as compared to unilateral tibial shaft fractures in the group ISS < 25 (20.7% vs. 11.7%, p = 0.023). Multivariate regression analysis identified the additional tibial shaft fracture as an independent risk factor for pulmonary organ failure (OR = 1.56) but not for mortality. DISCUSSION The additional tibial shaft fracture is an independent risk factor for pulmonary organ failure but not for multiple organ failure or mortality. The impact of the additional tibial shaft fracture is especially pronounced in less severely injured patients (ISS < 25). These findings are comparable to results of bilateral femoral fracture studies and we therefore suggest to treat patients with bilateral tibial shaft fractures with the same caution as those with bilateral femoral fractures.
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A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society. J Trauma Acute Care Surg 2014; 76:1288-93. [PMID: 24747462 DOI: 10.1097/ta.0000000000000167] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Today, there is a trend toward damage-control orthopedics (DCO) in the management of multiple trauma patients with long bone fractures. However, there is no widely accepted concept. A risk-adapted approach seems to result in low acute morbidity and mortality. Multiple trauma patients with bilateral femoral shaft fractures (FSFs) are considered to be more severely injured. The objective of this study was to validate the risk-adapted approach in the management of multiple trauma patients with bilateral FSF. METHODS Data analysis is based on the trauma registry of the German Trauma Society (1993-2008, n = 42,248). Multiple trauma patients with bilateral FSF were analyzed in subgroups according to the type of primary operative strategy. Outcome parameters were mortality and major complications as (multiple) organ failure and sepsis. RESULTS A total of 379 patients with bilateral FSF were divided into four groups as follows: (1) no operation (8.4%), (2) bilateral temporary external fixation (DCO) (50.9%), bilateral primary definitive osteosynthesis (early total care [ETC]) (25.1%), and primary definitive osteosynthesis of one FSF and DCO contralaterally (mixed) (15.6%). Compared with the ETC group, the DCO group was more severely injured. The incidence of (multiple) organ failure and mortality rates were higher in the DCO group but without significance. Adjusted for injury severity, there was no significant difference of mortality rates between DCO and ETC. Injury severity and mortality rates were significantly increased in the no-operation group. The mixed group was similar to the ETC group regarding injury severity and outcome. CONCLUSION In Germany, both DCO and ETC are practiced in multiple trauma patients with bilateral FSF so far. The unstable or potentially unstable patient is reasonably treated with DCO. The clearly stable patient is reasonably treated with nailing. When in doubt, the patient is probably not totally stable, and the safest precaution may be to use DCO as a risk-adapted approach. LEVEL OF EVIDENCE Therapeutic study, level IV. Epidemiologic study, level III.
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Patel KV, Brennan KL, Davis ML, Jupiter DC, Brennan ML. High-energy femur fractures increase morbidity but not mortality in elderly patients. Clin Orthop Relat Res 2014; 472:1030-5. [PMID: 24166074 PMCID: PMC3916609 DOI: 10.1007/s11999-013-3349-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 10/14/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Trauma centers are projected to have an increase in the number of elderly patients with high-energy femur fractures. Greater morbidity and mortality have been observed in these patients. Further clarification regarding the impact of high-energy femur fractures is necessary in this population. QUESTIONS/PURPOSES Our purpose was to assess the influence of high-energy femur fractures on mortality and morbidity in patients 60 years and older. Specifically, we asked (1) if the presence of a high-energy femur fracture increases in-hospital, 6-month, and 1-year mortality in patients 60 years and older, and (2) if there is a difference in morbidity (number of complications, intensive care unit [ICU] and total hospital length of stay, discharge disposition, accompanying fractures, and surgical intervention) between patients 60 years and older with and without high-energy femur fractures. METHODS A retrospective review of 242 patients was performed. Patients with traumatic brain injury or spine injury with a neurologic deficit were excluded. A control group, including patients admitted secondary to high-energy trauma without femur fractures, was matched by gender and Injury Severity Score (ISS). In-hospital mortality, 6-month and 1-year mortality, complications, ICU and total hospital length of stay, discharge disposition, accompanying fractures, surgical intervention, and covariates were recorded. Statistical analyses using Fisher's exact test, ANOVA, Kaplan-Meier estimates, and Cox regression models were performed to show differences in mortality (in-hospital, 6-month, 1-year), complications, length of ICU and total hospital stay, discharge disposition, surgical intervention, and accompanying fractures between elderly patients with and without femur fractures. The average ages of the patients were 72.8 years (± 9 years) in the femur fracture group and 71.8 years (± 9 years) in the control group. Sex, age, ISS, and comorbidities were homogenous between groups. RESULTS In-hospital (p = 0.45), 6-month (p = 0.79), and 1-year mortality (p = 0.55) did not differ in patients with and without high-energy femur fractures. Elderly patients with high-energy femur fractures had an increased number of complications (p = 0.029), longer total hospital length of stay (p = 0.039), were discharged more commonly to rehabilitation centers (p < 0.005), had more accompanying long bone fractures (p = 0.002), and were more likely to have surgery (p < 0.001). Average ICU length of stay was similar between the two groups (p = 0.17). CONCLUSIONS High-energy femur fractures increased morbidity in patients 60 years and older; however, no increase in mortality was observed in our patients. Concomitant injuries may play a more critical role in this population. Additional studies are necessary to clarify the role of high-energy femur fracture mortality in this age group. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kushal V. Patel
- Scott and White Memorial Hospital, 2401 S 31st Street, Temple, TX 76508 USA
| | - Kindyle L. Brennan
- Scott and White Memorial Hospital, 2401 S 31st Street, Temple, TX 76508 USA
| | - Matthew L. Davis
- Scott and White Memorial Hospital, 2401 S 31st Street, Temple, TX 76508 USA
| | - Daniel C. Jupiter
- Scott and White Memorial Hospital, 2401 S 31st Street, Temple, TX 76508 USA
| | - Michael L. Brennan
- Scott and White Memorial Hospital, 2401 S 31st Street, Temple, TX 76508 USA
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Abstract
OBJECTIVES To determine whether previously reported high mortality rates associated with bilateral femoral fractures have decreased over time. DESIGN Retrospective review. SETTING Urban academic trauma center. STUDY GROUP 54 adults with bilateral femoral fractures treated at our center from 2000 to 2006. The 108 fractures were initially treated with external fixation (11%), reamed antegrade nailing (23%), and reamed retrograde nailing (67%). Unilateral control group: 461 patients with unilateral femoral fractures treated at our center from 2002 to 2005. INTERVENTION Univariate analysis compared our results with those of a published historical control group from the same center approximately 15 years ago (study period, 1984-1990). MAIN OUTCOME MEASUREMENTS Mortality rates. RESULTS We noted marked differences between the current mortality rate associated with bilateral femoral fractures and that of the historical control group. The mortality rate decreased over time at our center for both bilateral (26%-7%, P = 0.002) and unilateral (12%-2%, P = 0.0001) fractures. Mortality rates were still significantly higher (P = 0.037) for bilateral (7%) than for unilateral (2%) fractures. CONCLUSIONS Mortality rates and Injury Severity Scores were reduced for bilateral and unilateral femoral fractures compared with data reported 15 years ago from the same center. The improved outcome might be related in part to changes in resuscitation, triage, intensive care, and orthopaedic management of the patients. However, considering that the Injury Severity Score also significantly decreased, the improvement might have occurred because of changes in injury patterns, perhaps secondary to improved safety features in motor vehicles. LEVEL OF EVIDENCE Prognostic level III. See instructions for authors for a complete description of levels of evidence.
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Abstract
Worldwide, trauma is responsible for more than 10,000 deaths each day with hundreds of thousands seriously injured. Current trauma resuscitation strategies are based on supporting haemostasis, maintaining circulating volume and rapidly identifying sites of blood loss. Approaches include hypotensive/hypovolaemic resuscitation, avoidance of colloids and crystalloids, early blood product based resuscitation, early imaging to identify sites of blood loss and damage control surgery. In this paper, we focus on ways to minimise blood loss and preserve the circulating volume. These include minimal movement of the patient, splinting fractures, use of tourniquets, application of local haemostatic dressings/agents, keeping the patient warm and giving tranexamic acid to improve clot strength. The recent CRASH-2 trial provided unequivocal evidence that tranexamic acid reduces mortality in bleeding trauma patients. This will be discussed in detail. When employed as part of a package of care in a well-rehearsed trauma system, these interventions to preserve the remaining circulating volume have the potential to save lives and allow patients to survive until timely definitive haemostasis can occur.
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Affiliation(s)
- A Chesters
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - I Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - T Harris
- Queen Mary, University of London and Bart's Health NHS Trust, London, UK
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Pfeifer R, Darwiche S, Kohut L, Billiar TR, Pape HC. Cumulative effects of bone and soft tissue injury on systemic inflammation: a pilot study. Clin Orthop Relat Res 2013; 471:2815-21. [PMID: 23479238 PMCID: PMC3734413 DOI: 10.1007/s11999-013-2908-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In multiply injured patients, bilateral femur fractures invoke a substantial systemic inflammatory impact and remote organ dysfunction. However, it is unclear whether isolated bone or soft tissue injury contributes to the systemic inflammatory response and organ injury after fracture. QUESTIONS/PURPOSES We therefore asked whether the systemic inflammatory response and remote organ dysfunction are attributable to the bone fragment injection, adjacent soft tissue injury, or both. METHODS Male C57/BL6 mice (8-10 weeks old, 20-30 g) were assigned to four groups: bone fragment injection (BF, n = 9) group; soft tissue injury (STI, n = 9) group; BF + STI (n = 9) group, in which both insults were applied; and control group, in which neither insult was applied. Animals were sacrificed at 6 hours. As surrogates for systemic inflammation, we measured serum IL-6, IL-10, osteopontin, and alanine aminotransferase (ALT) and nuclear factor (NF)-κB and myeloperoxidase (MPO) in the lung. RESULTS The systemic inflammatory response (mean IL-6 level) was similar in the BF (61.8 pg/mL) and STI (67.9 pg/mL) groups. The combination (BF + STI) of both traumatic insults induced an increase in mean levels of inflammatory parameters (IL-6: 189.1 pg/mL) but not in MPO levels (1.21 ng/mL) as compared with the BF (0.82 ng/mL) and STI (1.26 ng/mL) groups. The model produced little evidence of remote organ inflammation. CONCLUSIONS Our findings suggest both bone and soft tissue injury are required to induce systemic changes. The absence of remote organ inflammation suggests further fracture-associated factors, such as hemorrhage and fat liberation, may be more critical for induction of remote organ damage. CLINICAL RELEVANCE Both bone and soft tissue injuries contribute to the systemic inflammatory response.
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Affiliation(s)
- Roman Pfeifer
- />Department of Orthopaedic Surgery, University of Aachen Medical Center, Pauwelsstr 30, 52074 Aachen, Germany , />Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Sophie Darwiche
- />Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Lauryn Kohut
- />Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Timothy R. Billiar
- />Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Hans-Christoph Pape
- />Department of Orthopaedic Surgery, University of Aachen Medical Center, Pauwelsstr 30, 52074 Aachen, Germany
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Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients. ISRN ORTHOPEDICS 2013; 2013:329452. [PMID: 24959356 PMCID: PMC4045290 DOI: 10.1155/2013/329452] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/20/2013] [Indexed: 01/27/2023]
Abstract
The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.
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Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, Lefering R, Pape HC. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013; 44:221-5. [PMID: 23040674 DOI: 10.1016/j.injury.2012.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 09/11/2012] [Accepted: 09/13/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bilateral femoral shaft fractures have been reported to be an independent risk factor for morbidity and mortality; however, the value of these studies is limited due to small sample sizes and the timing of these studies before the establishment of damage control orthopaedics. The objective of this study was to compare the incidence of morbidity and mortality in patients with bilateral vs. unilateral femoral shaft fractures in the era of damage control orthopaedics. METHODS Retrospective analysis of the TraumaRegister DGU from 2002 to 2005. Inclusion criteria were uni- or bilateral femoral shaft fractures and complete demographic data documentation. Univariate data analysis and logistic regression analysis were performed with SPSS. RESULTS Between 2002 and 2005, 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures were identified. Patients with bilateral femoral shaft fractures had a significantly higher Injury Severity Score (ISS) (29.5 vs. 25.7 points), a significantly higher incidence of pulmonary (34.7% vs. 20.6%) and multiple organ failure (25.0% vs. 14.6%) as well as a significantly higher mortality rate (16.9% vs. 9.4%). In the overall patient population, early total care (ETC) was significantly more often performed in patients with unilateral femoral shaft fractures (50.9% vs. 33.6%). Logistic regression analysis revealed no significant association between bilateral femoral shaft fractures and multiple organ failure or mortality; however, bilateral femoral shaft fractures are an independent risk factor for pulmonary failure. Subgroup analysis revealed that the impact of the bilateral femoral shaft fracture was especially pronounced in patients with an ISS<25 points. DISCUSSION Bilateral femoral shaft fractures are an independent risk factor for pulmonary failure but not for multiple organ failure or mortality. The impact of the additional femoral shaft fracture for pulmonary failure appears to be especially pronounced in the less severely injured patients, whose injuries are often underestimated when stratified with the ISS. Patients with bilateral femoral shaft fractures have significantly more often severe abdominal injuries as well as severe blood loss which may account for the increased mortality rate. Therefore, the presence of bilateral femoral shaft fractures should be recognised as an increased risk for systemic complications.
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Affiliation(s)
- Philipp Kobbe
- Department of Orthopaedic Trauma Surgery, University Hospital RWTH Aachen, Germany.
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Pfeifer R, Rixen D, Husebye EE, Pardini D, Müller M, Dumont C, Oestern HG, Giannoudis P, Pape HC. Do stable multiply injured patients with bilateral femur fractures have higher complication rates? An investigation by the EPOFF study group. Eur J Trauma Emerg Surg 2011; 38:185-90. [PMID: 26815836 DOI: 10.1007/s00068-011-0147-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Polytrauma patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have sustained unilateral fractures. The current study tests the hypothesis that the high incidence of posttraumatic complications in patients who do not have a severe head or chest injury is caused by accompanying injuries rather than by the additional femur fracture. METHODS Inclusion criteria New Injury Severity Score > 16 points; AIS score value of the chest ≤3 points and no severe head injury. Two study groups: a unilateral group (USF group) (n = 146) and a bilateral femur shaft fracture group (BSF group) (n = 19). Endpoints monitored were length of stay in the intensive care unit, duration on a ventilator, and several postsurgical complications (e.g., SEPSIS, acute lung injury). Statistics Fisher's exact test for binary variables, and independent t-tests and regression analyses for continuous indicators of injury severity and clinical outcomes. RESULTS Patients with bilateral femur fractures had a significantly higher incidence of hemothorax. Moreover, they received blood transfusions more often upon admission, and exhibited a longer ICU stay (p = 0.008). However, this patient group did not exhibit a significantly higher incidence of postsurgical complications (p = 0.1) than those with unilateral fractures. After adjusting for injury severity, no difference in the length of the ICU stay was observed. Bilateral fracture patients who were in an uncertain condition preoperatively had a longer length of stay in the ICU postoperatively (p = 0.002). CONCLUSIONS In the absence of major head or chest injuries, patients with multiple injuries and bilateral femur shaft fractures have a similar complication rate to polytrauma patients with unilateral fractures. Moreover, an uncertain condition preoperatively was associated with an increased stay in the intensive care unit. The results support the idea that associated injuries rather than the additional femur fracture are responsible for complications during the clinical stay.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany. .,Department of Trauma Surgery, University of Aachen Medical Center, Aachen, Germany.
| | - Dieter Rixen
- Department of Orthopaedics and Trauma Surgery, University of Witten Herdecke and Cologne, Witten, Germany
| | | | - Dustin Pardini
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Müller
- Department Trauma Surgery, Plastic and Reconstructive Surgery, University of Göttingen, Göttingen, Germany
| | - Clemens Dumont
- Department Trauma Surgery, Plastic and Reconstructive Surgery, University of Göttingen, Göttingen, Germany
| | | | - Peter Giannoudis
- Department of Trauma and Orthopaedics, University of Leeds, Leeds, UK
| | - Hans-Christoph Pape
- Department of Orthopaedic Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany.
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Citak M, Suero EM, O'Loughlin PF, Arvani M, Hüfner T, Krettek C, Citak M. Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures. Arch Orthop Trauma Surg 2011; 131:823-7. [PMID: 21191605 DOI: 10.1007/s00402-010-1245-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study was designed to evaluate the incidence of femoral malrotation in bilateral femoral shaft fractures. MATERIALS AND METHODS All closed bilateral femoral shaft fractures in patients aged 18 or over treated between April 2000 and December 2009 were included in the current study. All patients received a postoperative CT-scan to estimate femoral antetorsion and leg length. All bilateral fractures were treated with intramedullary nailing on a radiolucent table. Retrospectively, all patients were analyzed according to the following parameters: (1) femoral antetorsion of both limbs and antetorsion difference in degrees, (2) femoral length discrepancy (cm), (3) incidence of femoral malrotation >15°, (4) revision rate due to femoral malrotation. RESULTS A total of 24 patients (11 [45.8%] female; 13 [52.8%] male) with bilateral femoral shaft fractures were included in this study of average age 38 years (median 38 years, range 18-74 years). Clinically relevant malrotation (greater than 15°) was found in 10 cases (41.2%), whereas in 4 cases (40%) a revision surgery was required. DISCUSSION Bilateral femoral shaft fractures are associated with a high incidence of clinically relevant femoral malrotation over 15°. Measurement of intraoperative femoral antetorsion in bilateral femoral shaft fractures is quite difficult and currently only feasible postoperatively.
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Affiliation(s)
- Mustafa Citak
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
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Pfeifer R, Kobbe P, Darwiche SS, Billiar TR, Pape HC. Role of hemorrhage in the induction of systemic inflammation and remote organ damage: analysis of combined pseudo-fracture and hemorrhagic shock. J Orthop Res 2011; 29:270-4. [PMID: 20690183 DOI: 10.1002/jor.21214] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study was performed to analyze the role of hemorrhage-induced hypotension in the induction of systemic inflammation and remote organ dysfunction. Male C57/BL6 mice (6- to 10-week old and 20-30 g) were used. Animals were either subjected to pseudo-fracture [PF; standardized soft-tissue injury and injection of crushed bone, PF group: n = 9], or PF combined with hemorrhagic shock (HS + PF group: n = 6). Endpoint was 6 h. Systemic inflammation was assessed by IL-6 and IL-10 levels. Myeloperoxidase (MPO) and NF-κB activity in the lung and liver tissue were obtained to assess remote organ damage. The increases of systemic cytokines are similar for animals subjected to PF and PF + HS (IL-6: 189 pg/ml ± 32.5 vs. 160 pg/ml ± 5.3; IL-10: 60.3 pg/ml ± 15.8 vs. 88 pg/ml ± 32.4). Furthermore, the features (ALT; NF-κB) of liver injury are equally elevated in mice subjected to PF (76.9 U/L ± 4.5) and HS + PF (80 U/L ± 5.5). Lung injury, addressed by MPO activity was more severe in group HS + PF (2.95 ng/ml ± 0.32) than in group PF (1.21 ng/ml ± 0.2). Both PF and additional HS cause a systemic inflammatory response. In addition, hemorrhage seems to be associated with remote affects on the lung.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA.
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Prediction of pulmonary morbidity and mortality in patients with femur fracture. ACTA ACUST UNITED AC 2011; 69:1527-35; discussion 1535-6. [PMID: 21150530 DOI: 10.1097/ta.0b013e3181f8fa3b] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We aimed to determine the effect of femur fractures on mortality, pulmonary complications, and adult respiratory distress syndrome (ARDS). In addition, we aimed to compare the effect of femur fractures with other major musculoskeletal injuries and to determine the effect of timing to surgery on these complications. METHODS All patients were identified from the trauma registries of two Level I trauma centers. Outcomes were defined at mortality in hospital, pulmonary complications, and ARDS in hospital. Regression analysis was used to determine the effect of femur fractures, while controlling for age, Abbreviated Injury Scales, Glasgow Coma Scale, and systolic blood pressure at presentation. We compared femur fractures with other major musculoskeletal injuries in similar models. Within the patients with femur fracture, time to surgery (< 8 hours, 8 hours to 24 hours, and > 24 hours) was evaluated using similar regression analysis. RESULTS Of the total 90,510 patients, 3,938 (4.35%) died in the hospital, 2,055 (2.27%) had a pulmonary complication, and 285 (0.31%) developed ARDS. Femur fracture is statistically predictive of mortality (odds ratio [OR], 1.606; 95% confidence interval [CI], 1.288-2.002) and pulmonary complications (OR, 1.659; 95% CI, 1.329-2.070), when controlling for other injury factors. This was comparable with the effect of pelvic fracture and other major musculoskeletal injuries. Femur fracture had a strong relationship with ARDS (OR, 2.129; 95% CI, 1.382-3.278). Patients treated in the 8 hours to 24 hours window had the lowest mortality risk (OR, 0.140; 95% CI, 0.052-0.375), and there was a trend to increased risk of ARDS in a delay to surgery of > 24 hours. CONCLUSIONS Femur fractures are a major musculoskeletal injury and increase the risk of mortality and pulmonary complications as much as any other musculoskeletal injuries. There is a unique relationship between ARDS and femur fractures, and this must be considered carefully in treatment planning for these patients.
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Menzel CL, Pfeifer R, Darwiche SS, Kobbe P, Gill R, Shapiro RA, Loughran P, Vodovotz Y, Scott MJ, Zenati MS, Billiar TR, Pape HC. Models of lower extremity damage in mice: time course of organ damage and immune response. J Surg Res 2010; 166:e149-56. [PMID: 21276982 DOI: 10.1016/j.jss.2010.11.914] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 11/07/2010] [Accepted: 11/23/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Post-traumatic inflammatory changes have been identified as major causes of altered organ function and failure. Both hemorrhage and soft tissue damage induce these inflammatory changes. Exposure to heterologous bone in animal models has recently been shown to mimic this inflammatory response in a stable and reproducible fashion. This follow-up study tests the hypothesis that inflammatory responses are comparable between a novel trauma model ("pseudofracture", PFx) and a bilateral femur fracture (BFF) model. MATERIALS AND METHODS In C57BL/6 mice, markers for remote organ dysfunction and inflammatory responses were compared in four groups (control/sham/BFF/PFx) at the time points 2, 4, and 6 h. RESULTS Hepatocellular damage in BFF and PFx was highly comparable in extent and evolution, as shown by similar levels of NFkappaB activation and plasma ALT. Pulmonary inflammatory responses were also comparably elevated in both trauma models as early as 2 h after trauma as measured by myeloperoxidase activity (MPO). Muscle damage was provoked in both BFF and PFx mice over the time course, although BFF induced significantly higher AST and CK levels. IL-6 levels were also similar with early and sustained increases over time in both trauma models. CONCLUSIONS Both BFF and PFx create similar reproducible inflammatory and remote organ responses. PFx will be a useful model to study longer term inflammatory effects that cannot be studied using BFF.
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Affiliation(s)
- Christoph L Menzel
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA
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Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. ACTA ACUST UNITED AC 2010; 69:405-10. [PMID: 20699750 DOI: 10.1097/ta.0b013e3181e6138a] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions. STUDY DESIGN An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003. METHODS Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. RESULTS Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality. CONCLUSIONS The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.
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Sears BW, Volkmer D, Yong S, Himes RD, Lauing K, Morgan M, Stover MD, Callaci JJ. Correlation of measurable serum markers of inflammation with lung levels following bilateral femur fracture in a rat model. J Inflamm Res 2010; 2010:105-114. [PMID: 21442011 PMCID: PMC3062967 DOI: 10.2147/jir.s12853] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Evaluation of the systemic inflammatory status following major orthopedic trauma has become an important adjunct in basing post-injury clinical decisions. In the present study, we examined the correlation of serum and lung inflammatory marker levels following bilateral femur fracture. Materials and methods 45 Sprague Dawley rats underwent sham operation or bilateral femoral intramedullary pinning and mid-diaphyseal closed fracture via blunt guillotine. Animals were euthanized at specific time points after injury. Serum and lung tissue were collected, and 24 inflammatory markers were analyzed by immunoassay. Lung histology was evaluated by a blinded pathologist. Results Bilateral femur fracture significantly increased serum markers of inflammation including interleukin (IL)-2, IL-6, IL-10, GM-CSF, KC/GRO, MCP-1, and WBC. Femur fracture significantly increased serum and lung levels of IL-1a and KC/GRO at 6 hours. Lung levels of IL-6 demonstrated a trend towards significance. Histologic changes in pulmonary tissue after fracture included pulmonary edema and bone elements including cellular hematopoietic cells, bone fragments and marrow emboli. Discussion and conclusion Our results indicate that bilateral femur fracture with fixation in rats results in increases in serum markers of inflammation. Among the inflammatory markers measured, rise in the serum KC/GRO (CINC-1), a homolog to human IL-8, correlated with elevated levels of lung KC/GRO. Ultimately, analysis of serum levels of KC/GRO (CINC-1), or human IL-8, may be a useful adjunct to guide clinical decisions regarding surgical timing.
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Affiliation(s)
- Benjamin W Sears
- Department of Orthopaedics, Loyola University Medical Center, Maywood, IL, USA
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Ehsan A, Stevanovic M. Skeletally mature patients with bilateral distal radius fractures have more associated injuries. Clin Orthop Relat Res 2010; 468:238-42. [PMID: 19424674 PMCID: PMC2795827 DOI: 10.1007/s11999-009-0869-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2008] [Accepted: 04/16/2009] [Indexed: 01/31/2023]
Abstract
Bilateral distal radius fractures are rare injuries and only a handful of case reports exist. Understanding the demographic variables and associated injuries in patients with these fractures may improve awareness and treatment of concomitant injuries. We determined the differences in mode of trauma and associated injuries between skeletally mature and skeletally immature patients with bilateral distal radius fractures. We retrospectively reviewed the records of 93 patients with bilateral distal radius fractures. We compared demographic data, fracture patterns, mode of injury, treatment modality, and associated injuries for skeletally mature and immature patients. The mean age of all patients sustaining a bilateral injury was 22.5 years and 61 (71%) were male. Of the 51 (55%) skeletally immature patients, 37 (73%) were male, and 44 (86%) sustained a low-energy mechanism of injury. Of the 42 (45%) skeletally mature patients, 29 (69%) were male, and 37 (88%) sustained a high-energy mechanism of injury. Skeletally mature patients had a 38% rate of associated injuries versus 4% found in skeletally immature patients. Skeletally mature patients sustained bilateral distal radius fractures through higher-energy mechanisms and presented with more frequent associated injuries compared with the skeletally immature patients.
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Affiliation(s)
- Amirhesam Ehsan
- Department of Orthopaedic Surgery, University of Southern California, 2025 Zonal Avenue, GNH 3900, Los Angeles, CA 90089, USA.
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Abstract
In order to evaluate the impact of simultaneous intramedullary nailing in patients with bilateral femoral fractures on systemic complications a comprehensive review of the literature was performed. Four studies reporting the results of 197 patients following trauma were analysed. The mean Injury Severity Score was 20.6 (range, 9-75). According to the data available, reamed intramedullary nailing was performed in 96% of the cases. The incidence of fat embolism was 4.1%, ARDS 14.6% and pulmonary embolism 6.9%. The overall mortality was 6%. The mean hospital stay was 17.9 days (range, 4-108). Bilateral femoral fractures have a high risk of complications and mortality. Damage control surgery should be considered in these cases where the clinician anticipates the development of systemic complications.
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The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures. J Orthop Trauma 2009; 23:615-21. [PMID: 19897981 DOI: 10.1097/bot.0b013e3181a6a941] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position. DESIGN Retrospective cohort study, single centered. SETTING One level 1 trauma center. PATIENTS Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006. INTERVENTION Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position. OUTCOME MEASURES Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score > or =18 and all those with a femur fracture and an Abbreviated Injury Score chest > or =3. RESULTS Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score > or =18. However, for the subgroup of Abbreviated Injury Score chest > or =3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044). CONCLUSIONS For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.
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Steinhausen E, Yücel N, Maegele M, Neugebauer E, Bouillon B, Rixen D. Multiple Femur- und Tibiaschaftfrakturen des Mehrfachverletzten. Unfallchirurg 2009; 112:652-5. [DOI: 10.1007/s00113-009-1622-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Local exposure of bone components to injured soft tissue induces Toll-like receptor 4-dependent systemic inflammation with acute lung injury. Shock 2009; 30:686-91. [PMID: 18461022 DOI: 10.1097/shk.0b013e31816f257e] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Remote and systemic inflammatory responses after long bone fractures have been well described, but the mechanisms underlying these changes remain unexplained. We hypothesized that bone components locally exposed to injured soft tissue are capable of inducing a systemic inflammatory response associated with acute lung injury, and that this inflammatory cascade requires Toll-like receptor 4 (TLR-4) signaling. Accordingly, male C3H/HeOuJ (TLR-4-competent) and C3H/HeJ (TLR-4-mutant) mice were injected with various bone components (bone marrow cells, bone marrow supernatant, and bone suspension, respectively) in bilaterally injured thigh muscles and euthanized after 6 h. Serum TNF-alpha, IL-6, and IL-10 levels, and pulmonary myeloperoxidase activity was measured using specific enzyme-linked immunosorbent assay kits. Pulmonary permeability changes were assessed with bronchoalveolar lavage. Local exposure of bone components to injured soft tissue induced systemic inflammation and acute lung injury in TLR-4-competent, but not in TLR-4-mutant, animals. These findings suggest that bone components contribute to systemic inflammation and acute lung injury after long bone fractures via TLR-4 signaling and support the notion of a central role for TLR-4 in sensing tissue damage.
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Pérez Rivera O, Palanco Domínguez L. Emergency surgical treatment of hip fractures: a 7-year study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2009. [DOI: 10.1016/s1988-8856(09)70145-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pérez Rivera O, Palanco Domínguez L. Tratamiento quirúrgico de urgencia en la fractura de cadera: estudio de siete años. Rev Esp Cir Ortop Traumatol (Engl Ed) 2009. [DOI: 10.1016/j.recot.2008.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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The stress response to bilateral femoral fractures: a comparison of primary intramedullary nailing and external fixation. J Orthop Trauma 2009; 23:90-7; discussion 98-9. [PMID: 19169099 DOI: 10.1097/bot.0b013e31819194c6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Concern has recently been expressed with regard to the physiologic effects of primary intramedullary femoral nailing in seriously injured patients. "Damage control orthopaedics" techniques have been proposed, which comprise principally the use of primary external fixation. The aim of this study was to compare the physiologic effects of external femoral fixation with those of intramedullary stabilization over the first 24 hours after femoral fracture using an established large animal (ovine) trauma model. METHODS Under terminal anesthesia, bilateral high-energy femoral fractures and hypovolemic shock were produced using a pneumatic actuator. Twenty-four sheep were randomized into 4 groups and monitored for 24 hours. Group 1--control, group 2--trauma only, group 3--trauma and external fixation, and group 4--trauma and reamed intramedullary nailing. Outcome measures included the following: pulmonary embolic load (transesophageal echocardiography), metabolic base excess, plasma coagulation markers, and polymorphonuclear cell counts obtained from bronchoalveolar lavage samples. RESULTS The total embolic load was significantly higher (P < 0.001) in the intramedullary nailing group. All trauma groups had a significant increase (P < 0.05) in prothrombin times with a fall in antithrombin III and fibrinogen levels. However, the type of fracture stabilization used did not significantly affect any of the other outcome measurements. CONCLUSIONS A higher pulmonary embolic load can be expected during early intramedullary femoral fracture stabilization compared with primary external fixation. However, the degree of stimulation to systemic coagulation and pulmonary inflammation by each type of surgery was comparable.
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Patterns of cytokine release and evolution of remote organ dysfunction after bilateral femur fracture. Shock 2008; 30:43-7. [PMID: 18562923 DOI: 10.1097/shk.0b013e31815d190b] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The interaction between the complex pattern of cytokine release and remote organ dysfunction after trauma is incompletely understood. The aim of this study was to investigate the pattern of cytokine release and its association with the evolution of remote organ dysfunction after bilateral femur fracture. Male C57/BL6 mice were euthanized at six different time points (1-6 h) after bilateral femur fracture. Serum cytokine concentrations were measured with the Luminex multiplexing platform, and serum alanine aminotransferase levels were measured with the Vitros 950 Chemistry System. Hepatic and pulmonary myeloperoxidase activity was determined with an enzyme-linked immunosorbent assay kit. Permeability changes of the lung were assessed via bronchoalveolar lavage, and those of the liver via assessment of edema formation. Serum TNF-alpha was unchanged in the fracture group throughout the experiment. Serum IL-6 and keratinocyte levels peaked at 5 h postinjury, whereas IL-10 levels peaked at 2 and 6 h. A brief IL-1beta peak was observed at 3 h after fracture. Hepatic and pulmonary myeloperoxidase activity was significantly elevated within 1 h after trauma. Hepatic permeability was significantly increased within 2 h, and pulmonary permeability was significantly increased within 6 h after injury. Serum alanine aminotransferase levels peaked at 3 and 5 h postinjury. The pattern of serum IL-6, keratinocyte, IL-10, and IL-1beta release was dynamic, whereas no significant elevations in TNF-alpha were observed. The early hepatic and pulmonary infiltration of polymorphonuclear cells occurred in the absence of significantly elevated serum cytokine levels, suggesting that either early minor changes with an unbalance in inflammatory mediators or locally produced cytokines may initiate this process.
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Abstract
OBJECTIVE The purpose of this study was to evaluate the use of retrograde nailing to treat patients with bilateral femur fractures. DESIGN AND SETTING A retrospective review of prospectively obtained trauma databases was completed at 9 Level 1 trauma centers. PATIENTS In all, 3767 patients with femur fractures were identified. Of those, 89 (46 males, 43 females) had bilateral femur fractures treated with reamed, retrograde intramedullary nails within 48 hours after injury. The charts were reviewed for pertinent data. RESULTS The average cohort age was 30 years (16-63 years). The average Injury Severity Score was 21 (9-50). Eighty-five patients (96%) had associated injuries. Thirteen patients (14.6%) developed adult respiratory distress syndrome; 8 had thoracic injuries. There were 4 patients (4%) with fat embolism syndrome, 2 were delayed longer than 24 hours to the operating room. There were 5 deaths (5.6% mortality) in the retrograde nailing group. Thoracic injury was found to be associated with death rate (P < 0.07). CONCLUSIONS Bilateral femur fractures are indicative of severe injuries with mortality rates as high as 40%. There are no specific studies addressing the outcomes of bilateral femur fractures treated with retrograde nailing. In this largest retrospective study to date, the overall death rate of 5.6% was significantly lower than historical controls. The effect of timing and duration of surgery and other injuries is not completely known. In conclusion, retrograde nailing of bilateral femur fractures is an acceptable treatment for bilateral femur fractures.
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The role of fracture-associated soft tissue injury in the induction of systemic inflammation and remote organ dysfunction after bilateral femur fracture. J Orthop Trauma 2008; 22:385-90. [PMID: 18594302 DOI: 10.1097/bot.0b013e318175dd88] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The storage of preformed cytokines in soft tissue as well as the immunocompetence of adipocytes has been reported. We hypothesized that fracture-associated soft tissue injury plays a pivotal role in the induction of systemic inflammation and remote organ dysfunction after fracture. MATERIALS AND METHODS Male C57/BL6 mice sustained either severe soft tissue injury to both thighs (STI), bilateral femur fracture with minimal soft tissue injury (Fx), or the combination of both (Fx+STI) and were euthanized 6 hours after injury. Serum cytokine concentrations were measured using the Luminex multiplexing platform, and serum ALT levels were measured with the Vitros 950 Chemistry System. Hepatic myeloperoxidase activity, a marker for polymorphonuclear cell infiltration, and hepatic IL-6 levels were determined using ELISA kits. Hepatic permeability changes were assessed via measurement of edema formation. RESULTS STI as well as Fx both induced significantly elevated serum IL-6 and L-10 levels as compared with Sham animals (P < 0.05). Further, serum IL-6 and IL-10 levels were significantly higher after STI as compared with Fx (P < 0.05). Serum KC and MCP-1 levels were significantly elevated after STI but not after Fx (P < 0.05). STI as well as Fx resulted in significantly increased serum ALT levels and hepatic polymorphonuclear cell infiltration. The combination of both injuries resulted in further increased systemic inflammatory mediators as well as marked liver inflammation and dysfunction represented by significantly elevated serum ALT levels, hepatic polymorphonuclear cell infiltration, hepatic IL-6 concentrations, and hepatic edema formation as compared with Sham animals (P < 0.05). CONCLUSIONS Although STI and Fx both induced a systemic inflammatory response, this was more pronounced after STI. However, the combination of both injuries (Fx+STI) was required to induce marked liver dysfunction. Our data indicate that fracture-associated soft tissue injury is a major contributor to the systemic inflammatory response after bilateral femur fracture. This should be recognized especially in multiply injured patients, who are susceptible to systemic inflammation with remote organ dysfunction.
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Abstract
Damage control orthopaedics (DCO) describes a philosophy for the management of the patient with multiple bony injuries. The fundamental principles are that fractures and traumatic soft tissue injuries (the `wound organ') should be stabilised promptly with the minimum physiological insult to the patient, and that initial surgery should be regarded as a staged part of the resuscitation process. This article discusses the history of DCO; the scientific basis behind DCO principles; patient selection for DCO; the principles of resuscitation in the multiply injured; the evidence for and against DCO; and possible future advances.
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Affiliation(s)
- Mark R Philipson
- SpR Trauma and Orthopaedics, Friarage Hospital, Northallerton, North Yorkshire, DL6 1JG, UK
| | - Paul J Parker
- Consultant Orthopaedic Surgeon, Friarage Hospital, Northallerton, North Yorkshire, DL6 1JG, UK, , Senior Lecturer in Orthopaedics, Academic Department of Military Surgery and Trauma
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Kontakis GM, Tossounidis T, Weiss K, Pape HC, Giannoudis PV. Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures. Injury 2006; 37 Suppl 4:S19-24. [PMID: 16990057 DOI: 10.1016/j.injury.2006.08.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Few data are available in the literature regarding fat embolism in cases of bilateral femoral and pathological femoral fractures. The incidence of bilateral femoral fractures ranges from 2-9.5% of the total number of patients with femoral fractures, and they usually occur in high energy trauma and multi-trauma patients. Although injury severity scores tend to underestimate the severity of these injuries, fat embolism seems to occur in increased frequency ranging from 4.8-7.5%. Intramedullary nailing, which is the preferred surgical treatment, triggers a systemic inflammatory response that poses an additional burden to pulmonary function. In addition, the femur is a common site of metastatic bone disease. The treatment of impending and actual pathological fractures is complicated by increased rates of lung damage due to various factors. Fat embolism during treatment--mainly with intramedullary nails--generally seems to range from 0-10%.
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Kwong Y, Chong M, Hassan A, Kelly R. Severity of injuries associated with femoral fractures as a result of motor vehicle collisions. Arch Orthop Trauma Surg 2006; 126:454-7. [PMID: 16721616 DOI: 10.1007/s00402-006-0151-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Femoral fractures are often the result of high-velocity injuries, and the early identification of associated injuries is important. The purpose of this study was to review the associated injuries present in a current UK series of patients who sustain femoral fractures as a result of motor vehicle accidents. MATERIALS AND METHODS All cases of femoral fractures were extracted from the UK co-operative crash injury study (CCIS) database, from 1998 to 2002. Associated injuries, skeletal and non-skeletal, were identified by body region and severity (according to the abbreviated injury scale and injury severity scale). RESULTS A total of 5,841 crashes were investigated in that time period, and there were 365 car occupants who sustained a femoral fracture. The 16-35 age group accounted for nearly half of all cases. A total of 313 patients (85.2%) had at least one other concomitant significant injury, of which 84 (23.0%) had skeletal injury only, 45 (12.3%) had non-skeletal injury only, and 184 (50.4%) had both. The opposite lower limb was the most common skeletal injury, and thoracic injuries were the most common visceral injuries. Thoracic injuries also accounted for the most serious injuries (AIS 4-6). The overall mortality was 40.5% in our series. CONCLUSION Concomitant injuries are to be expected in the majority of cases of femoral fractures sustained as a result of MVCs. There should be a low threshold for involving a general surgical team in the management of these cases.
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Affiliation(s)
- Yune Kwong
- Trauma and Orthopaedics, University of Warwick, Coventry, UK.
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Timlin M, Toomey D, Condron C, Power C, Street J, Murray P, Bouchier-Hayes D. Fracture Hematoma Is a Potent Proinflammatory Mediator of Neutrophil Function. ACTA ACUST UNITED AC 2005; 58:1223-9. [PMID: 15995474 DOI: 10.1097/01.ta.0000169866.88781.f1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with multiple skeletal injuries are susceptible to acute respiratory distress syndrome and multiple organ failure, which result from hyperactivation of the immune system. This study was designed to evaluate in vitro the proinflammatory properties of fracture hematoma (FH). METHODS FH was isolated from patients undergoing emergent open reduction and internal fixation for isolated closed fractures. Neutrophils (PMNs), isolated from healthy volunteers, were exposed to the FH supernatant and activation was examined (CD11b and CD18 adhesion receptor expression and respiratory burst). PMN phagocytosis, apoptosis, and transmigration across an endothelial barrier were also assessed. RESULTS FH increased PMN respiratory burst (control, 100; FH-treated, 186) and phagocytosis (control, 100; FH-treated, 172) but had no effect on adhesion receptor expression. Transendothelial migration of PMNs was unaffected, although FH was toxic to endothelial cells. In contrast, apoptosis of FH-treated PMNs was delayed (control, 46; FH-treated, 8). CONCLUSION These effects, although beneficial at the site of injury in the context of antibactericidal function, may cause PMN-mediated tissue injury systemically.
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Affiliation(s)
- Marcus Timlin
- Departments of Orthopaedics, Royal College of Surgeons in Ireland, Education & Research Centre, Beaumont Hospital, Dublin, Ireland.
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Zalavras C, Velmahos GC, Chan L, Demetriades D, Patzakis MJ. Risk factors for respiratory failure following femoral fractures: the role of multiple intramedullary nailing. Injury 2005; 36:751-7. [PMID: 15910828 DOI: 10.1016/j.injury.2005.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 01/22/2005] [Accepted: 01/22/2005] [Indexed: 02/02/2023]
Abstract
Controversy exists on the relationship between intramedullary nailing (IMN) and the timing of fixation in the development of respiratory failure (RF) following femoral fractures. The purpose of this study is to identify risk factors for RF and evaluate the role of multiple IMN in the above setting. We prospectively observed 126 consecutive patients with femoral fractures for the development of RF. Twenty-one patients (17%) developed RF. This occurred before fracture fixation in 11 patients and after IMN in 10 patients; five after multiple IMN and five after a single IMN procedure. Patients who underwent multiple IMN demonstrated a significant increase of RF after fracture fixation (5/8,) compared to patients with one IMN procedure (5/114, 4.4%, p<0.001). Stepwise regression analysis identified two independent RF risk factors: thoracic injury and multiple IMN (odds ratios: 40.6 and 25.6, respectively). Thoracic injury and multiple IMN procedures are independent risk factors for RF in patients with femoral fractures, and the combination of the above conditions is highly predictive of the development of RF.
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Affiliation(s)
- Charalampos Zalavras
- Keck School of Medicine, University of Southern California, orthopaedic Surgery, LAC+USC Medical Center, 1200 N State St GNH 3900, Los Angeles, CA 90033, USA.
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Abstract
BACKGROUND Trauma is a major cause of mortality and morbidity worldwide. Methods of assessing outcome have evolved with management of trauma victims. RESULTS AND DISCUSSION The wide variety of scoring instruments available to assess the injured patient may be divided into three groups: anatomical, physiological and combined systems. Anatomical systems depend on an accurate description of the injuries sustained. Physiological systems measure the effects of injury on the patient's physiological reserves. Combined systems contain elements of both anatomical and physiological scores. Prospectively, scoring systems help in description, triage, treatment decisions and estimating outcome. Retrospective scoring is helpful in audit, in quality control, in comparing treatment methods or centres, and in identifying unexpected outcomes. Limitations may be inherent in the system or may reflect inaccurate or incomplete data collection.
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Affiliation(s)
- R Kingston
- Department of Orthopaedic Surgery, Adelaide and Meath Hospital, Tallaght, Dublin
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Abstract
Several patterns of severe lower limb injuries are presented. They all indicate high energy trauma and affect the immediate care of the patient. The improvement of evacuation systems and resuscitating methods in intensive care create many reconstruction challenges for the orthopaedic surgeon. Awareness of the different combinations which are presented can serve as a tool that may be helpful in these demanding injuries. Guidelines for management of combined injuries are essential to improve the outcome of these life-threatening situations.
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Affiliation(s)
- M Liebergall
- Orthopaedic Surgery Department, Hadassah-Hebrew University Medical School, Jerusalem.
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Hauser CJ, Desai N, Fekete Z, Livingston DH, Deitch EA. Priming of neutrophil [Ca2+]i signaling and oxidative burst by human fracture fluids. THE JOURNAL OF TRAUMA 1999; 47:854-8. [PMID: 10568711 DOI: 10.1097/00005373-199911000-00006] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with major fracture/soft-tissue injuries are at risk for adult respiratory distress syndrome after secondary infection. Fracture fluids (FF) are rich in neutrophil (PMN) -specific chemokines such as interleukin-8. PMN respond to both interleukin-8 and bacterial stimuli with calcium ([Ca2+]i) fluxes, which can initiate respiratory burst (RB). We hypothesize that small amounts of FF entering the circulation could exaggerate PMN [Ca2+]i and RB responses, potentially increasing the risk of adult respiratory distress syndrome. METHODS FF were obtained from 10 patients at open fixation of the femur 2 to 5 days postinjury. Volunteer PMN were isolated and loaded with fura dye. PMN were preincubated either in 30% autologous plasma (AP)/70% buffer, or in 5% FF/25% AP/70% buffer. Cells were resuspended in buffer with 1,2,3-dihydrorhodamine and stimulated with low-dose n-formyl-methionyl-leucyl-phenylalanine (fMLP). [Ca2+]i was assayed by fura fluorescence at 505 nm after excitation at 340/380 nm. RB was assessed by 1,2,3-dihydrorhodamine fluorescence at 530 nm after 488 nm excitation. RESULTS PMN basal [Ca2+]i was higher after FF incubation than AP incubation (94+/-12 vs. 61+/-9 nmol/L, p = 0.0002). Peak [Ca2+]i response to fMLP was 475+/-47 nmol/L after FF but only 356+/-22 nmol/L after AP (p = 0.01). Two hundred seconds after fMLP, [Ca2+]i remained higher after FF (172+/-17 vs. 145+/-9 nmol/L, p = 0.04). Basal RB was slightly higher after FF than AP (13.4+/-0.3 vs. 11.3+/-0.3 units, p = 0.051) as was the maximal rate of extracellular oxidant release (1.10+/-0.17 vs. 0.76+/-0.16 units/s, p = 0.004) and total oxidant production (42.5+/-0.8 vs. 31.7+/-0.8 units, p = 0.006). CONCLUSION Small amounts of FF in plasma can exaggerate PMN [Ca2+]i flux and RB responses to subsequent bacterial stimuli. These findings are consistent with the hypothesis that release of FF into the circulation primes PMN and, thus, may predispose to adult respiratory distress syndrome. Such PMN priming events might have important implications for both the operative and medical management of patients with major fractures.
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Affiliation(s)
- C J Hauser
- Department of Surgery, UMD-New Jersey Medical School, Newark 07103, USA.
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