Alterations in the Systemic Inflammatory Response after Early Total Care and Damage Control Procedures for Femoral Shaft Fracture in Severely Injured Patients

Efficacy of damage control orthopedics strategy in the management of lower limb trauma

Background

Little is known about the efficacy of damage control (DC) surgery in the management of lower limb trauma. Here we compared the clinical parameters and complication rates of such patients received either DC or emergency comprehensive (EC) surgery treatment.

Methods

This study is a retrospective study on patients with lower limb trauma that received surgical treatment. Data of 120 patients were divided into DC and EC surgery groups. Clinical parameters obtained at hospital admission and complications during follow-up were analyzed. Injury Severity Score (ISS), Gustilo classification and Mangled Extremity Severity Score (MESS) were used to assess trauma severity, open fractures and viability of injured limb, respectively.

Results

Age, sex, ISS, fracture type, injury site, MESS, operation time, blood loss, pulmonary and cranial injuries were compared. We found that patients in the DC group had more severe injury as reflected by the higher injury severity score (ISS) (28.1 ± 10.9 vs 21.3 ± 7.4, P < 0.001). ISS was also identified as a significant influencer for the treatment selection (P < 0.001). In addition, patients treated with DC surgery demonstrated less complications (7 cases vs 27 cases), which was supported by the propensity score logistic regression analysis (Odd ratio 4.667).

Conclusions

DC surgery is more often selected to treat patients with more severe lower limb injuries, which leads to lower complication rates.

Independent predictors of systemic inflammatory response syndrome for intramedullary nailing of femoral shaft fractures: Analysis of national inpatient sample database

Background

The systemic inflammatory response syndrome (SIRS) is a clinical reaction that can occur due to a variety of stimuli. Reamed intramedullary femoral nailing is a common orthopedic surgery that has been shown to induce SIRS. To date, no nationwide analyses have been performed to evaluate the incidence, risk factors, and economic burdens of SIRS following intramedullary femoral nailing for femoral shaft fractures. The objective of this study is to investigate the independent predictors, incidence, post-operative, and economic burden of SIRS among patients treated with intramedullary nailing for femoral shaft fractures.

Methods

We utilized the 2016-2019 National Inpatient Sample (NIS) to identify patients who underwent intramedullary femoral nailing and were diagnosed with non-infectious SIRS (NI-SIRS) based on ICD-10-CM coding. Identified patients who underwent intramedullary femoral nailing were dichotomized into SIRS and Non-SIRS groups to assess independent predictors of SIRS development, and to compare post-operative complications and costs.

Results

A total of 65,240 patients with femur shaft fractures underwent IMFN, of which 665 (1.0 %) developed NI-SIRS. Patients with NI-SIRS had a higher incidence of laparotomy (OR = 13.97, p < 0.001), initial treatment with external fixation (OR = 1.845, p < 0.001), and late application of external fixation (OR = 4.884, p = 0.005). Routine discharge (OR = 0.491, p < 0.001) was less likely in patients with NI-SIRS. Length of stay (12.38 days vs 7.16 days, p < 0.001) and total charges ($278, 590 vs $145,118, p < 0.001) were both increased in patients with NI-SIRS.

Conclusion

NI-SIRS is associated with increasing injury severity and post-operative complications. Those that developed NI-SIRS experienced higher healthcare resource utilization. Risk factors associated with development of NI-SIRS warrant further investigation.

Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated.

METHODS

We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score.

RESULTS

We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected.

CONCLUSION

We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.

Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES

PURPOSE

Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology.

METHODS

A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades.

RESULTS

4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000.

CONCLUSION

Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

Conversion of External Fixator to Intramedullary Nail in Tibial fractures

INTRODUCTION

Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe.

METHODS

After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts.

RESULTS

Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group.

DISCUSSION

Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates.

LEVEL OF EVIDENCE

Level IV-case series.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

[Fracture management in polytrauma]

The management of polytrauma patients is a complex multidisciplinary and dynamic task. The early and comprehensive assessment of the clinical condition is of great importance with respect to the timing and the individual decision-making on surgical fracture treatment. Stable patients benefit from early definitive fracture treatment, whereas for unstable patients, the concept of multistage fracture treatment with temporary minimally invasive stabilization has gained wide acceptance. These concepts, known as early total care (ETC) and damage control orthopedics (DCO), have been extended in recent decades by dynamic and injury-adapted treatment protocols, such as early appropriate care (EAC) or safe definitive orthopedic surgery (SDS): Therefore, patients in an initially unclear condition (borderline patients) can now also be treated with an individually adapted care concept as soon as possible.

Parkland Trauma Index of Mortality: Real-Time Predictive Model for Trauma Patients

OBJECTIVE

Vital signs and laboratory values are used to guide decisions to use damage control techniques in lieu of early definitive fracture fixation. Previous models attempted to predict mortality risk but have limited utility. There is a need for a dynamic model that captures evolving physiologic changes during a trauma patient's hospital course.

METHODS

The Parkland Trauma Index of Mortality (PTIM) is a machine learning algorithm that uses electronic medical record data to predict mortality within 48 hours during the first 3 days of hospitalization. It updates every hour, recalculating as physiology changes. The model was developed using 1935 trauma patient encounters from 2009 to 2014 and validated on 516 patient encounters from 2015 to 2016. Model performance was evaluated statistically. Data were collected retrospectively on its performance after 1 year of clinical use.

RESULTS

In the validation data set, PTIM accurately predicted 52 of the sixty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 82.5% [95% confidence interval (CI), 73.1%-91.9%]. The specificity was 93.6% (95% CI, 92.5%-94.8%), and the positive predictive value (PPV) was 32.5% (95% CI, 25.2%-39.7%). PTIM predicted survival for 1608 time intervals and was incorrect only 11 times, yielding a negative predictive value of 99.3% (95% CI, 98.9%-99.7%). The area under the curve of the receiver operating characteristic curve was 0.94.During the first year of clinical use, when used in 776 patients, the last PTIM score accurately predicted 20 of the twenty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 86.9% (95% CI, 73%-100%). The specificity was 94.7% (95% CI, 93%-96%), and the positive predictive value was 33.3% (95% CI, 21.4%-45%). The model predicted survival for 716 time intervals and was incorrect 3 times, yielding a negative predictive value of 99.6% (95% CI, 99.1%-100%). The area under the curve of the receiver operating characteristic curve was 0.97.

CONCLUSIONS

By adapting with the patient's physiologic response to trauma and relying on electronic medical record data alone, the PTIM overcomes many of the limitations of previous models. It may help inform decision-making for trauma patients early in their hospitalization.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early fixation strategies for high energy pelvic ring injuries - the Zurich algorithm

In isolated high energy pelvic ring injuries, early surgical and nonsurgical fixation belongs to the rescue tools required for rapid recovery. With the increasing use of pelvic binders on scene, these patients frequently arrive in a better condition at the level I trauma centre than without any measures of immobilisation. We describe our surgical tools to achieve rapid fixation within the first hours after arrival, taking into account if additional injuries or special stations are relevant.

Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review

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.

Polytrauma: update on basic science and clinical evidence

The management of multiply injured or severely injured patients is a complex and dynamic process. Timely and safe fracture fixation is a critical component of the multidisciplinary care that these patients require. Effective management of these patients, and their orthopaedic injuries, requires a strong understanding of the pathophysiology of the response to trauma and indicators of patient status, as well as an appreciation for the dynamic nature of these parameters. Substantial progress in both clinical and basic science research in this area has advanced our understanding of these concepts and our approach to management of the polytraumatized patient. This article summarizes a symposium on this topic that was presented by an international panel of experts at the 2020 Virtual Annual Meeting of the Orthopaedic Trauma Association.

There Is No Role for Damage Control Orthopedics Within the Golden Hour

INTRODUCTION

Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour."

MATERIALS AND METHODS

The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour.

RESULTS

Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified.

CONCLUSIONS

Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.

Managing polytrauma patients

Embedding physiological markers into treatment algorithms has helped trauma teams rationalise interventions safely and signifies a departure from the dichotomy of damage control orthopaedics (DCO) and early total care (ETC) to early appropriate care (EAC). This has been shown to reduce length of stay and cost to treating centres. This article seeks to provide a clear summary of current concepts for managing orthopaedic injuries in the multiply injured patient.

Fracture fixation in the polytrauma patient: Markers that matter

Timing and type of fracture fixation in the multiply-injured trauma patient have been important and controversial topics. Ideal care for these patients come from providers who communicate well with one another in a team fashion and view the whole person, rather than focusing on injury to individual systems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which may have profound impact upon outcomes. The concept of Early Total Care arose from the realization that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most patients. However, insufficient assessment and understanding of the physiological status of polytraumatized patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other procedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improvement of acidosis.

Complement Activation and Organ Damage After Trauma-Differential Immune Response Based on Surgical Treatment Strategy

Background: The complement system is part of the innate immunity, is activated immediately after trauma and is associated with adult respiratory distress syndrome, acute lung injury, multiple organ failure, and with death of multiply injured patients. The aim of the study was to investigate the complement activation in multiply injured pigs as well as its effects on the heart in vivo and in vitro. Moreover, the impact of reamed vs. non-reamed intramedullary nailing was examined with regard to the complement activation after multiple trauma in pigs.

Materials and Methods: Male pigs received multiple trauma, followed by femoral nailing with/without prior conventional reaming. Systemic complement hemolytic activity (CH-50 and AH-50) as well as the local cardiac expression of C3a receptor, C5a receptors1/2, and the deposition of the fragments C3b/iC3b/C3c was determined in vivo after trauma. Human cardiomyocytes were exposed to C3a or C5a and analyzed regarding calcium signaling and mitochondrial respiration.

Results: Systemic complement activation increased within 6 h after trauma and was mediated via the classical and the alternative pathway. Furthermore, complement activation correlated with invasiveness of fracture treatment. The expression of receptors for complement activation were altered locally in vivo in left ventricles. C3a and C5a acted detrimentally on human cardiomyocytes by affecting their functionality and their mitochondrial respiration in vitro.

Conclusion: After multiple trauma, an early activation of the complement system is triggered, affecting the heart in vivo as well as in vitro, leading to complement-induced cardiac dysfunction. The intensity of complement activation after multiple trauma might correlate with the invasiveness of fracture treatment. Reaming of the femoral canal might contribute to an enhanced “second hit” response after trauma. Consequently, the choice of fracture treatment might imply the clinical outcome of the critically injured patients and might be therefore crucial for their survival.

Influence of a temporary stabilization device on respiratory status in patients with severe trauma with a femoral shaft fracture treated by damage control strategy

Background

There are few studies on the safety and respiratory consequences of the use of a skeletal traction (ST) device in the management of femoral shaft fractures with damage control orthopaedics (DCO) strategy, particularly in cases of prolonged use. The aim of this study was to assess the influence of ST compared with an external fixator (EF) on respiratory complications and mechanical ventilation requirements in patients with severe trauma with a femoral shaft fracture managed by DCO strategy.

Methods

We retrospectively reviewed all patients with severe trauma patients with a unilateral femoral shaft fracture admitted to our institution from 2010 to 2015. Patients who did not undergo definitive osteosynthesis during the first 24 h were included and divided into two groups: DCO-ST group and DCO-EF group. In addition to trauma severity, global management of respiratory complications, the incidence of acute respiratory distress syndrome (ARDS) and mechanical ventilation requirements and outcome were compared.

Results

Fifty-five patients were managed with DCO strategy (mean Injury Severity Score, 28.4); there were 31 in the DCO-ST group and 24 in the DCO-EF group. No significant difference in terms of the main characteristics, initial severity and associated injuries was observed between the two groups. In contrast, ARDS was found more frequently in the DCO-ST group (81% versus 54%; P = 0.035). Number of ventilation days also tended to be higher in the DCO-ST group (9 days [IQR 3–15 days] versus 7 [IQR 2–16 days]; P = 0.24). No difference was found for mortality and hospitalization duration between the DCO-ST and DCO-EF groups.

Conclusion

The prolonged use of an ST device in the present cohort was associated with a higher incidence of impaired respiratory function. Therefore, our findings suggest that EF is preferable to ST in the DCO setting for femoral shaft fracture, especially in trauma patients at high risk of developing delayed respiratory failure.

Is Systemic Inflammatory Response Syndrome Relevant to Pulmonary Complications and Mortality in Multiply Injured Children?

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a well-recognized phenomenon in adult trauma populations. The "initial hit" of the traumatic event is often coupled with a systemic immune response characterized by changes in vital signs and laboratory indicators. A "second hit" from surgery during this time frame often results in acute lung injury, along with deterioration of the patient's clinical condition. We hypothesized that children and adolescents would experience SIRS physiology, but would not experience adult respiratory distress syndrome (ARDS) or "second hit" related death to the extent seen in the adult populations.

METHODS

We queried the trauma database of our level 1 pediatric trauma center from January 2005 to December 2015 for patients with injury severity scores of >16. We used the electronic medical record to track SIRS criteria in patients days 1 to 4 posttrauma. Trends were examined in patients with an orthopaedic injury (OI) and with no orthopaedic injury. Patients were further subcategorized and analyzed by age group based on the convention for definition of pediatric SIRS. Patients in the orthopaedic cohort were further examined for pulmonary complications and death. Logistic regression was used to identify risk factors for SIRS physiology in the first 4 days of hospitalization.

RESULTS

81.4% (OI) and 69.1% no orthopaedic injury reached the threshold for SIRS within their first 4 days of hospitalization. Nine patients died in the hospital. Only 3 OI patients developed the criteria for ARDS, and only 3 patients with orthopaedic injuries died, 2 died within 24 hours of presentation and 1 within 48 hours, all had severe brain trauma. Increasing age groups showed increasing proportion of patients with SIRS. Increasing injury severity score and increasing age were independent predictors of SIRS during days 1 to 4.

DISCUSSION

SIRS seems to be as common in children as the reported rates for adults, and the proportion of SIRS in children increases with increasing age and injury severity. The high mortality rate and rate of ARDS observed in adults was not observed in our cohort. The presence or absence of major orthopaedic injuries was not a significant predictor. The SIRS response in polytraumatized children is poorly understood. The clinical phenomenon of acute lung injury/ARDS is observed less often in children, but the exact mechanism by which this occurs is unknown.

LEVEL OF EVIDENCE

Level III-case control.

Damage control orthopedics and decreased in-hospital mortality: A nationwide study

INTRODUCTION

While various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database.

PATIENTS AND METHODS

We retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score.

RESULTS

Of the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41-0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20-0.46; P < 0.01).

CONCLUSIONS

DCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.

Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparative Analysis of Modified Mini-Pterional and Standard Pterional Craniotomies

Background

Minimally invasive surgical techniques for cerebral aneurysms have been developed.

Aims

To compare the efficacy and safety of modified mini-pterional (mMPT) and standard pterional (PT) craniotomies for ruptured anterior circulation aneurysms.

Materials and Methods

A total of 45 patients with ruptured anterior circulation aneurysms underwent surgical clipping; for 21 patients PT was used and for 24 patients mMPT was used. Initial clinical demographics and outcomes were retrospectively compared. A systemic inflammatory response syndrome (SIRS) score was derived by summing the number of variables meeting standard criteria for SIRS.

Results

The two groups were comparable with initial clinical demographics. Total operative time was significantly shorter in the mMPT (166.6 minutes, P = 0.001) compared with the PT (235 minutes). The rate of permanent operative morbidity were similar in both groups (P = 0.92). The mean SIRS score at 24 hours after the completion of the operation was significantly lower for patients in the mMPT group (0.96, P = 0.01) as compared to the patients in the PT group (1.81). The rate of postoperative symptomatic vasospasm was significantly lower in patients operated through the mMPT (8.3%, P = 0.03) than the PT (38.1%). Good outcome at discharge was more frequently seen in the mMPT (91.7%) than in the PT (70%), but this difference was not statistically significant (P = 0.11).

Conclusion

The mMPT craniotomy is a safe and less invasive approach for ruptured anterior circulation aneurysms, leading to a significant lower rate of postoperative symptomatic vasospasm and a marginally significant improvement in clinical outcomes.

Computational evidence for an early, amplified systemic inflammation program in polytrauma patients with severe extremity injuries

Extremity and soft tissue injuries contribute significantly to inflammation and adverse in-hospital outcomes for trauma survivors; accordingly, we examined the complex association between clinical outcomes inflammatory responses in this setting using in silico tools. Two stringently propensity-matched, moderately/severely injured (Injury Severity Score > 16) patient sub-cohorts of ~30 patients each were derived retrospectively from a cohort of 472 blunt trauma survivors and segregated based on their degree of extremity injury severity (above or below 3 on the Abbreviated Injury Scale). Serial blood samples were analyzed for 31 plasma inflammatory mediators. In addition to standard statistical analyses, Dynamic Network Analysis (DyNA) and Principal Component Analysis (PCA) were used to model systemic inflammation following trauma. Patients in the severe extremity injury sub-cohort experienced longer intensive care unit length of stay (LOS), total LOS, and days on a mechanical ventilator, with higher Marshall Multiple Organ Dysfunction (MOD) Scores over the first 7 days post-injury as compared to the mild/moderate extremity injury sub-cohort. The higher severity cohort had statistically significant elevated lactate, base deficit, and creatine phosphokinase on first blood draw, along with significant changes in multiple circulating inflammatory mediators. DyNA pointed to a sustained role for type 17 immunity in both sub-cohorts, along with IFN-γ in the severe extremity injury group. DyNA network complexity increased over 7 days post-injury in the severe injury group, while generally decreasing over this same time period in the mild/moderate injury group. PCA suggested a more robust activation of multiple pathways in the severe extremity injury group as compared to the mild/moderate injury group. These studies thus point to the possibility of self-sustaining inflammation following severe extremity injury vs. resolving inflammation following less severe extremity injury.

Surgical treatment strategies in pediatric trauma patients: ETC vs. DCO-an analysis of 316 pediatric trauma patients from the TraumaRegister DGU®

PURPOSE

External fixation within the damage control concept in unstable multiple trauma patients is widely accepted. Literature about its usage in the pediatric trauma population, however, is rare. The aim of the present study was to elucidate the factors associated with the application of external fixation in the severely injured child.

METHODS

Patients with severe trauma aged 0-54 years documented in the TraumaRegister DGU^® were included in this study. Demographic data, pattern of injury, injury severity, use of the damage control orthopedics (DCO) or early total care (ETC) concept, duration of mechanical ventilation, intensive care stay, and total hospital stay as well as the occurrence of complications and mortality were evaluated. Statistical evaluation was performed using SPSS (Version 21.0.0) using Chi square tests and linear regression models.

RESULTS

While injury severity was comparable between children and adults, type of accident and injury patterns showed significant differences, Overall, the majority of surgical fracture stabilization in AIS_Extremity ≥ 3 injuries followed the DCO concept in adults (60.3%) and the ETC protocol in children (49.4%). Conservative treatment was chosen for only 11.6% of all children and 9.6% of all adults. An increasing injury severity, AIS_Extremity ≥ 3 and AIS_Extremity ≥ 3 in ≥ 2 body regions, and a more advanced age were found to be independent factors in the use of the DCO concept in children.

CONCLUSION

Use of external fixation increases with age and plays a minor role in the very young trauma population. However, this does not produce a difference in outcome between children and adults.

Evaluation of inflammatory response in patients undergoing surgical treatment for early and delayed femoral fractures

INTRODUCTION

It has been shown that long bone fractures are correlated with the inflammatory response. In the initial injury, surgical reduction and fixation of fractures induce the immunoinflammatory response. This study aimed to evaluate serum variation of inflammatory markers in patients undergoing surgical treatment for early and delayed femoral fractures.

MATERIAL AND METHODS

This study aimed to evaluate serum variation of inflammatory markers in patients undergoing surgical treatment for early and delayed femoral fractures. The patients were randomly divided into two groups using the method of block randomization including early surgery (within 24 h) and delayed surgery (after 48 h). Serum levels of inflammatory markers in both groups including interleukin (IL)-1, 5, 6, tumor necrosis factor α (TNF-α) and interferon γ (IFN-γ) were determined using specific kits. From each patient 10 ml blood was collected for cytokine assay in their serum.

RESULTS

Our findings suggest that serum levels of IL-8 were markedly decreased from 12 h until 48 h postoperatively (p < 0.05). Moreover, the results indicated that serum levels of TNF-α were significantly increased in the early hours, but after 48 h a decreasing trend was detected (p < 0.05). Furthermore, serum levels of IL-10, IFN-γ, and IL-6 were significantly increased from 12 h until 48 h postoperatively (p < 0.05).

CONCLUSIONS

The inflammatory status of the patient may be a useful adjunct in clinical decisions. With an improved understanding of the molecular basis of the inflammatory response, and by identifying relevant clinical markers of inflammation, surgeons can better manage the timing of surgical stabilization.

Early versus late intramedullary nailing for traumatic femur fracture management: meta-analysis

INTRODUCTION

There is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN).

METHODS

English language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used across studies to distinguish between early and late IMN, but 24 h was the most frequently used cutoff. The quality assessment of the reviewed studies was performed with two instruments. Observational studies were assessed with the Newcastle-Ottawa Quality Assessment Scale. RCTs were assessed with the Cochrane Risk of Bias Tool.

RESULTS

We have searched 1151 references. Screening of titles and abstracts eliminated 1098 references. We retrieved 53 articles for full-text screening, 15 of which met study eligibility criteria.

CONCLUSIONS

This meta-analysis addresses the utility of IMN in patients with FF based on the current evidence; however, the modality and timing to intervene remain controversial. While we find large pooled effects in favor of early IMN, for reasons discussed, we have little confidence in the effect estimate. Moreover, the available data do not fill all the gaps in this regard; therefore, a tailored algorithm for management of FF would be of value especially in polytrauma patients.

Incidence and risk factors for complications after definitive skeletal fixation of lower extremity in multiple injury patients: a retrospective chart review

Background: The management of multiple injuries is complex. Type and timing of treatment for lower extremity fractures is a controversial subject. Although many studies have demonstrated the safety and effectiveness of early treatment, others have suggested that early definitive stabilization may cause complications, especially with chest and head injuries. The aim of this study was to determine the complications and effects of timing of fixation, and investigate risk factors for complications in multiple injuries patients with lower extremity fractures. Methods: A Retrospective chart review from Khon Kaen Trauma Registry between 2008 and 2015 were collected. All major complications were identified and collected for example acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and sepsis.  The time to definitive skeletal fixation from initial injury was identified and analyzed with multiple logistic regression. Results: 1224 multiple injuries patients with lower extremity fractures were identified. The mean age was 34±19.5 years, 74.4% were male and 25.6% female. The mean time from initial injury to definitive operation was 55.7±53.9 hours. Complications occurred with 178 patients (14.5%), the most common of which were pneumonia, ARDS and AKI. After adjusting for sex, severity of injury, we found that the operation within 24-48 hours complication was 6.67 times less common than in the early treatment group (less than 24 hours) (95% CI: 3.03 to 10.00, P-value< 0.001). Conclusions: About 15% of the multiple injuries patients with lower extremity fracture had major complications. The optimal time for definitive fixation in lower extremity fractures to reduce complications was within 24-48 hours. We found that if we operated too early (before 24 hours) or more than 48 hours after the injury it could increase the morbidity and mortality.

Analysis of skeletal muscle microcirculation in a porcine polytrauma model with haemorrhagic shock

Polytraumatised patients with haemorrhagic shock are prone to develop systemic complications, such as SIRS (systemic inflammatory response syndrome), ARDS (acute respiratory distress syndrome) and MOF (multiple organ failure). The pathomechanism of severe complications following trauma is multifactorial, and it is believed that microcirculatory dysfunction plays an important role. The aim of this study was to determine the changes in the microcirculation in musculature over time during shock and subsequent resuscitation in a porcine model of haemorrhagic shock and polytrauma. Twelve pigs (German Landrace) underwent femur fracture, liver laceration, blunt chest trauma, and haemorrhagic shock under standard anaesthesia and intensive care monitoring. Microcirculation data were measured from the vastus lateralis muscle using a combined white light spectrometry and laser spectroscopy system every 15 min during the shock and resuscitation period, and at 24, 48, and 72 h. Oxygen delivery and oxygen consumption were calculated and compared to baseline. The relative haemoglobin, local oxygen consumption, and saturation values in the microcirculation were observed significantly lower during shock, however, no changes in the microcirculatory blood flow and microcirculatory oxygen delivery were observed. After resuscitation, the microcirculatory blood flow and relative haemoglobin increased and remained elevated during the whole observation period (72 h). In this study, we observed changes in microcirculation during the trauma and shock phases. Furthermore, we also measured persistent dysfunction of the microcirculation over the observation period of 3 days after resuscitation and haemorrhagic shock. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1377-1382, 2018.

Use of the Pelvic C-Clamp to Mitigate Acute Respiratory Distress Syndrome in a Patient with an Unstable Sacral Fracture

Case

We present the case of a 21-year-old man who fell from a roof, sustaining a displaced sacral fracture with pelvic instability. He developed acute respiratory distress syndrome (ARDS) within 24 hours of injury. Placement of the pelvic C-clamp resulted in rapid resolution of pulmonary dysfunction, allowing for definitive internal fixation.

Conclusion

The C-clamp is most commonly used to control hemorrhage in unstable posterior pelvic ring injuries. Our case demonstrates a rare use of the C-clamp to stabilize the posterior pelvis in a patient with an unstable sacral fracture and ARDS, to rapidly improve pulmonary function prior to definitive surgery.

Concentration-dependent, dual roles of IL-10 in the osteogenesis of human BMSCs via P38/MAPK and NF-κB signaling pathways

Microenvironmental conditions can influence the differentiation and functional roles of mesenchymal stem cells (MSCs). Recent studies have suggested that an inflammatory microenvironment can significantly affect the osteogenic differentiation of MSCs. Here, we show, for the first time, that IL-10 has concentration-dependent, dual roles in the osteogenesis of human bone marrow mesenchymal stem cells (hBMSCs). Low physiologic concentrations of IL-10 (0.01-1.0 ng/ml) activate the p38/MAPK signaling pathway to promote the osteogenesis of hBMSCs, but higher pathologic doses of IL-10 (10-100 ng/ml) inhibit p38/MAPK signaling by activating NF-κB, inhibiting osteogenesis. These results demonstrate that p38/MAPK and NF-κB signaling mediates the double-edged sword effect of IL-10 on hBMSCs. The osteogenic impairment was reversed at higher doses of IL-10 when cells were supplemented with the NF-κB inhibitor BAY11-7082. These data provide important insights into the regulatory effects of IL-10 on the biologic behavior of hBMSCs.-Chen, E., Liu, G., Zhou, X., Zhang, W., Wang, C., Hu, D., Xue, D., Pan, Z. Concentration-dependent, dual roles of IL-10 in the osteogenesis of human BMSCs via P38/MAPK and NF-κB signaling pathways.

Cardiac Depression in Pigs after Multiple Trauma - Characterization of Posttraumatic Structural and Functional Alterations

The purpose of this study was to define the relationship between cardiac depression and morphological and immunological alterations in cardiac tissue after multiple trauma. However, the mechanistic basis of depressed cardiac function after trauma is still elusive. In a porcine polytrauma model including blunt chest trauma, liver laceration, femur fracture and haemorrhage serial trans-thoracic echocardiography was performed and correlated with cellular cardiac injury as well as with the occurrence of extracellular histones in serum. Postmortem analysis of heart tissue was performed 72 h after trauma. Ejection fraction and shortening fraction of the left ventricle were significantly impaired between 4 and 27 h after trauma. H-FABP, troponin I and extracellular histones were elevated early after trauma and returned to baseline after 24 and 48 h, respectively. Furthermore, increased nitrotyrosine and Il-1β generation and apoptosis were identified in cardiac tissue after trauma. Main structural findings revealed alteration of connexin 43 (Cx43) and co-translocation of Cx43 and zonula occludens 1 to the cytosol, reduction of α-actinin and increase of desmin in cardiomyocytes after trauma. The cellular and subcellular events demonstrated in this report may for the first time explain molecular mechanisms associated with cardiac dysfunction after multiple trauma.

Damage control surgery - experiences from a level I trauma center

Background

There is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The aim of this study was to determine parameters influencing the choice of treatment in clinical routine (DCO, ETC, or EF) in femoral or tibial shaft fractures in combination with multi-system-trauma, severe soft tissue damage or both.

Methods

Data of 236 patients with 280 fractures of long bones of the lower extremities treated at a level I trauma center were analysed. Clinical parameters on arrival (age, sex [m/f], ISS, fracture site [femur/tibia], soft tissue damage [closed or open fractures according to the Gustilo-Anderson classification], pulmonary injury [yes/no]) were collected and analysed whether they influence the choice of upcoming treatment (DCO/ETC/EF).

Results

Our findings showed that high ISS and severe soft tissue damage (grade III) significantly correlated with DCO. High ISS, old age, female sex and fracture site (tibia) correlated with EF. This group of sole use of external fixation had highest rate of complications, 69% were associated with at least one complication.

Conclusion

Severely injured patients are treated significantly more often with DCO or EF. The presence of higher ISS (≥16) and of type III open fractures increased the use of DCO. However, ISS, fracture-site, patient’s age, type III open fractures or sex (female) increased the use of EF compared to ETC.

Early surgery increases mitochondrial DNA release and lung injury in a model of elderly hip fracture and chronic obstructive pulmonary disease

Hip fractures are one of the most common injuries in elderly individuals and are associated with a high incidence of complications and mortality. Clinical guidelines recommend early reparative surgery within 24-48 h from hospital admission; however, it is currently unknown whether this principle of early surgery is applicable for patients with hip fracture and chronic obstructive pulmonary disease (COPD). To investigate the systemic inflammatory response and lung injury as a result early surgery in elderly patients with hip fracture and COPD, a COPD model was created, by daily exposure to cigarette smoke, and evaluated. Rats (5 months of age) were exposed to cigarette smoking for 37 weeks to create a COPD group. Rats not exposed to cigarette smoke formed the control group. All rats experienced hip fracture, which was subsequently treated with surgery at 24 h (early fixation; EF) or 72 h (late fixation; LF) after fracture, respectively. Serum mitochondrial DNA (mtDNA), tumor necrosis factor-α (TNF-α), interleukin (IL)-6 and IL-10 were measured at 2 and 24 h after surgery. Cytokine and myeloperoxidase (MPO) activity in the lung tissue were measured and assessed via bronchoalveolar lavage. The serum mtDNA, IL-6 and IL-10 levels in the control group and in the COPD group increased rapidly at 2 h and peaked at 24 h, while TNF-α levels peaked at 2 h and subsequently decreased. Rats that received EF in the COPD group demonstrated a significant increase of TNF-α (P<0.001 at 2 h), IL-6 (P<0.001 at 2 and 24 h), IL-10 (P=0.010 at 2 h and P=0.001 at 24 h) and mtDNA (P<0.001 at 24 h) compared with the rats that received LF. LF in experimental rats also significantly reduced the severity of MPO activity (P<0.001 and P=0.001) and permeability (P=0.009 and P=0.018) in pulmonary samples at 2 or 24 h, respectively, compared with EF. However, LF in the control group did not demonstrate a significant advantage at reducing MPO and permeability in serum and pulmonary samples. The present study indicated that early surgery increased mtDNA and cytokine release in a model of elderly hip fracture with COPD, and LF may reduce the severity of the inflammatory response and degree of permeability in pulmonary tissues.

Postinjury Inflammation and Organ Dysfunction

The development of organ dysfunction (OD) is related to the intensity and balance between trauma-induced simultaneous, opposite inflammatory responses. Early proinflammation via innate immune system activation may cause early OD, whereas antiinflammation, via inhibition of the adaptive immune system and apoptosis, may induce immunoparalysis, impaired healing, infections, and late OD. Patients discharged with low-level OD may develop the persistent inflammation-immunosuppression catabolism syndrome. Although the incidence of multiple organ failure has decreased over time, it remains morbid, lethal, and resource intensive. However, single OD, especially acute lung injury, remains frequent. Treatment is limited, and prevention remains the mainstay strategy.

Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury

AIMS

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

PATIENTS AND METHODS

A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).

RESULTS

In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications.

CONCLUSIONS

This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. Cite this article: Bone Joint J 2017;99-B:122-7.

Earthquake-Related Orthopedic Injuries in Adult Population: A Systematic Review

Introduction Earthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in "Mega-Mass-Casualty" earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system.

METHODS

The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom).

RESULTS

The searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries. Discussion Regarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection. Bortolin M , Morelli I , Voskanyan A , Joyce NR , Ciottone GR . Earthquake-related orthopedic injuries in adult population: a systematic review. Prehosp Disaster Med. 2017;32(2):201-208.

Multiple Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

OBJECTIVES

To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures.

DESIGN

Prospective, cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Fractures included femur (n = 167), pelvis (n = 74), acetabulum (n = 54), and spine (n = 107).

MAIN OUTCOME MEASUREMENTS

Complications, including pneumonia, acute respiratory distress syndrome, infections, deep venous thrombosis, pulmonary embolism, sepsis, multiple organ failure, and death, and length of stay.

RESULTS

Definitive fixation was performed concurrently with another procedure in 147 patients. They had greater ISS (29.4 vs. 24.6, P < 0.01), more transfusions (8.9 U vs. 3.6 U, P < 0.01), and longer surgery (4:22 vs. 2:41, P < 0.01) than patients with fracture fixation only, but no differences in complications. When patients who had definitive fixation in the same setting as another procedure were compared only with other patients who required more than 1 procedure performed in a staged manner on different days (n = 71), complications were fewer (33% vs. 54%, P = 0.004), and ventilation time (4.00 vs. 6.83 days), intensive care unit (ICU) stay (6.38 vs. 10.6 days), and length of stay (12.4 vs. 16.0 days) were shorter (all P ≤ 0.03) for the nonstaged patients.

CONCLUSIONS

In resuscitated patients, definitive fixation in the same setting as another procedure did not increase the frequency of complications despite greater ISS, transfusions, and surgical duration in the multiple procedure group. Multiple procedures in the same setting may reduce complications and hospital stay versus additional surgeries on other days.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Demystifying damage control in musculoskeletal trauma

Trauma care has evolved rapidly over the past decade. The benefits of operative fracture management in major trauma patients are well recognised. Concerns over early total care arose when applied broadly. The burden of additional surgical trauma could constitute a second hit, fuelling the inflammatory response and precipitating a decline into acute respiratory distress syndrome, sepsis and multiple organ dysfunction syndrome. Temporary external fixation aimed to deliver the benefits of fracture stabilisation without the risk of major surgery. This damage control orthopaedics approach was advocated for those in extremis and a poorly defined borderline group. An increasing understanding of the physiological response to major trauma means there is now a need to refine our treatment options. A number of large scale retrospective reviews indicate that early definitive fracture fixation is beneficial in the majority of major trauma patients. It is recommended that patients are selected appropriately on the basis of their response to resuscitation. The hope is that this approach (dubbed 'safe definitive fracture surgery' or 'early appropriate care') will herald an era when care is individualised for each patient and their circumstances. The novel Damage Control in Orthopaedic Trauma Surgery course at The Royal College of Surgeons of England aims to equip senior surgeons with the insights and mindset necessary to contribute to this key decision making process as well as also the technical skills to provide damage control interventions when needed, relying on the improved techniques of damage control resuscitation and advances in the understanding of early appropriate care.

Influence of implant properties and local delivery systems on the outcome in operative fracture care

Fracture fixation devices are implanted into a growing number of patients each year. This may be attributed to an increase in the popularity of operative fracture care and the development of ever more sophisticated implants, which may be used in even the most difficult clinical cases. Furthermore, as the general population ages, fragility fractures become more frequent. With the increase in number of surgical interventions, the absolute number of complications of these surgical treatments will inevitably rise. Implant-related infection and compromised fracture healing remain the most challenging and prevalent complications in operative fracture care. Any strategy that can help to reduce these complications will not only lead to a faster and more complete resumption of activities, but will also help to reduce the socio-economic impact. In this review we describe the influence of implant design and material choice on complication rates in trauma patients. Furthermore, we discuss the importance of local delivery systems, such as implant coatings and bone cement, and how these systems may have an impact on the prevalence, prevention and treatment outcome of these complications.

Extracellular heat shock protein 70 promotes osteogenesis of human mesenchymal stem cells through activation of the ERK signaling pathway

Heat shock proteins have protective effects when cells are exposed to stress. However, the relationship between extracellular heat shock protein 70 (eHSP70) and osteogenesis of hMSCs has not been reported. The results of this study showed that HSP70 (200 ng/ml) increases alkaline phosphatase activity and promotes hMSC mineralization. Under osteogenic induction conditions, HSP70 significantly upregulated the expression of osteo-specific genes, such as the runt family transcription factor Runx2 and osterix (OSX). Comparative expression profiling by microarray and pathway analyses revealed that HSP70 promotes osteogenesis of hMSCs through activation of the ERK signaling pathway. HSP70 may be a potential therapeutic agent for the treatment of bone nonunion.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BACKGROUND

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

METHODS

Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.

RESULTS

All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).

CONCLUSIONS

Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications

Background

Optimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36 h when either lactate <4.0 mmol/L, pH ≥ 7.25, or base excess (BE) ≥−5.5 mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC.

Methods

At an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.

Results

Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9 % vs. 22.1 %). ISS (p < 0.0005) and time to EAC resuscitation (p = 0.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS.

Conclusions

EAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research.

Level of evidence

Level 1: prognostic study.

Damage control orthopaedics: Variability of construct design for external fixation of the lower extremity and implications on cost

INTRODUCTION

To evaluate relative cost of external fixator constructs applied for damage control purposes in a cohort of advanced orthopaedic trainees and orthopaedic staff traumatologists. We also sought to evaluate physicians' understanding of component cost.

MATERIALS AND METHODS

Participants were asked to apply an external fixator for three separate fracture patterns in damage control fashion. A total of 19 physicians (nine PGY-4 residents, five PGY-5 residents, two orthopaedic trauma fellows and three orthopaedic staff traumatologists) participated. Total construct cost was calculated. Participants provided an estimate of the cost of each component in a fill-in format survey. Main outcome measures included cost of external fixator construct applied and the estimated cost of external fixator components.

RESULTS

Average whole sale cost of an external fixator construct was $5252 (±$1798). Of the three fracture types examined, the tibial plafond fracture external fixator construct on average cost the most, followed by the tibial plateau fracture and the femur fracture construct. The large ex-fix combination clamp was the major contributor to cost for each construct. The combination clamp may be substituted for a multi-pin clamp, resulting in significant cost savings. The self-drilling Schanz pin and the large ex-fix combination clamp were most highly underestimated (25% and 22% of their actual cost, respectively).

CONCLUSION

Innumerous construct designs exist and even small changes can significantly impact cost. Knowledge of component cost is low among staff and trainees. Education of component cost is vital to allow adequate consideration of construct design prior to fixator application.

Risk factors for nonunion after intramedullary nailing of femoral shaft fractures: Remaining controversies

INTRODUCTION

Intramedullary nailing (IMN) is the preferred treatment for femoral shaft fractures in adults. Although previous studies published good outcomes, some controversies remain. The purpose of this retrospective study was to identify factors that influence outcome after IMN for femoral shaft fractures.

MATERIALS AND METHODS

Between July 1998 and July 2013, we treated 230 patients with 248 femoral shaft fractures. Statistical analyses were performed to determine predictors of nonunion. The following set of variables was selected based on the speculation that they would contribute to the outcome: sex (male or female), smoking, obesity, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF) and reaming.

RESULTS

Initial fracture stabilization was performed by IMN in 161 (64.9%) and by EF in 87 (35.1%) fractures. There were no documented cases of deep infection. Nonunion was diagnosed in 27 patients with 28 fractures (11.3%). Factors affecting nonunion in the univariate analysis were Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture type (odds ratio [OR] 25.0; p<0.0001), Gustilo type (OR 0.64; p=0.0358), and EF (OR 0.42; p=0.0401). Multiple logistic regression analysis only identified AO/OTA fracture type (OR 22.0; p<0.0001) as a risk factor for nonunion. Fracture reaming did not change the outcome (OR 0.80; p=0.6073). A separate analysis showed that damage control EF was not a risk factor in polytrauma patients (OR 0.76; p=0.5825).

CONCLUSIONS

Fracture stabilisation with IMN is a good treatment option for femoral shaft fractures in adults. The purpose of this study was to evaluate risk factors of poor outcome after IMN of femoral shaft fractures. The present analysis revealed that there was no difference in the outcome whether the fracture was reamed or not. Univariate and multivariate analysis could only correlate AO/OTA fracture type with the occurrence of nonunion. Therefore, in this study, unreamed nailing and damage control EF were not associated with a negative outcome.

Timing of Femoral Shaft Fracture Fixation Affects Length of Hospital Stay in Patients with Multiple Injuries

Purpose :

Appropriate timing of definitive fracture care in the setting of polytrauma remains controversial. The aim of this study is to determine whether timing of definitive fixation of femur fractures impacts subsequent length of hospital stay, a surrogate for postoperative morbidity, in patients with multi-system trauma.

Methods :

Secondary analysis of data from the National Trauma Data Bank (January 1, 2000 to December 31, 2004) was performed. Adult patients who: (1) had an open or closed femoral shaft fracture, (2) had an injury severity score (ISS) greater than or equal to 15, (3) and underwent definitive internal fixation were included. Time to fixation was divided into 5 time periods based on commonly used cut-off points from the literature: (1) 12 hours or less, (2) between 12 and 24 hours, (3) between 24 and 48 hours, (4) between 48 and 120 hours, and (5) more than 120 hours. Because we consider length of stay a surrogate for adverse outcome causally affected by treatment time, the outcome variable was calculated as the duration of hospitalization following definitive treatment. Time to definitive fixation and its effect on post-treatment length of hospital stay was analyzed using median regression with inverse probability of treatment-weighting (IPTW) to control for confounding factors.

Results :

Compared to fixation during the first 12 hours after admission, median length of hospital stay was significantly higher (2.77 days; 95% confidence interval, 0.54 to 4.72) when fixation occurred between 48 and 120 hours from admission. Among the other time intervals, only treatment between twelve to twenty-four hours after admission was shown to reduce length of stay (-0.61 days; 95% confidence interval, -1.53 to 0.42) versus the referent interval of the first 12 hours, though this result did not achieve statistical significance. In order to assess the impact of shorter recorded length of stay for deceased patients, sensitivity analysis was conducted excluding all patient that underwent definitive treatment and died. Results were nearly identical for the second analysis, showing a higher post-treatment length of stay estimated for the population treated between 48 and 120 hours versus had they been treated within the first 12 hours from admission (2.53 days, 95% confidence interval, 0.27 to 4.13).

Conclusion :

Delayed fixation of femoral shaft fractures in patients with multiple injuries between 2-5 days may lead to an increase in adverse outcomes as evidenced by increased median length of hospital stay. This finding supports prior clinical reports of a perilous period where a “second hit” resulting from definitive internal fixation can occur. Whether there is an optimal window for fixation during which physiologic stress of fracture fixation does not adversely lengthen hospital stay should be the subject of future prospective study.

Morbidity and Mortality of Bilateral Femur Fractures

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.

Morbid obesity increases the risk for systemic complications in patients with femoral shaft fractures

OBJECTIVES

To determine whether morbidity and mortality were increased in morbidly obese patients who had reamed intramedullary nailing of closed femoral shaft fractures compared with similar patients of normal weight.

DESIGN

Retrospective case-control study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

All patients with closed femoral shaft fractures treated with reamed intramedullary nailing over a 5-year period were identified. Normal-weight patients (BMI < 25) were compared with overweight (25 ≤ BMI < 30), obese (30 ≤ BMI < 40), and morbidly obese patients (BMI ≥ 40).

INTERVENTION

Reamed intramedullary nailing.

MAIN OUTCOME MEASUREMENTS

Occurrence of postoperative complications.

RESULTS

Of 507 patients with 526 femoral shaft fractures (AO/OTA-32), 184 (36.3%) were of normal weight, 170 (33.5%) were overweight, 114 (22.5%) were obese, and 39 (7.7%) were morbidly obese. There were no significant differences in complications when comparing normal-weight patients with overweight and obese patients. Systemic complications occurred in 23% of morbidly obese and 9% of normal-weight patients [odds ratio (OR) = 3.15, P = 0.013]. Morbid obesity increased odds of adult respiratory distress syndrome (OR = 35.38, P = 0.019) and sepsis (OR = 6.49, P = 0.0015). Overall, morbidly obese patients with a femoral fracture had a mortality rate of 10%, but a subset of polytraumatized patients (Injury Severity Score > 17) had a mortality rate of 20%. Morbid obesity significantly increased the odds of mortality (OR = 46.77, P = 0.01). Body mass index was found to be an independent predictor of adult respiratory distress syndrome, sepsis, and death.

CONCLUSIONS

Morbid obesity is a significant risk factor for systemic complications in patients with closed femoral shaft fractures, especially in polytraumatized patients. Patients and their families need to be counseled regarding the high risk of morbidity and mortality.

LEVEL OF EVIDENCE

Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Role of Damage Control Orthopedics and Early Total Care in the Multiple Injured Trauma Patients

The care of multiply injured patients with orthopedic injuries has evolved from prolonged periods in traction to early total care (ETC). ETC is advantageous in ease of nursing care and aiding patient recovery. However, concerns have been raised that this ‘second hit’ of surgery places these severely injured patients at risk of excessive inflammatory responses that can lead to systemic inflammatory response syndrome (SIRS). Damage control was initially used in abdominal trauma but has been adapted for use in orthopedics. The mainstay of treatment involves external fixation of long bone and pelvic fractures which acts to defer definitive fixation until physiologic stability is restored. The indications for implementing each approach are not clear and this article provides a narrative review of the topic.

[Emergency room management : in the era of the White Paper, S3 guidelines, Advanced Trauma Life Support® and TraumaNetwork DGU® of the German Society of Trauma Surgery]

Die Behandlung Schwerverletzter ist – wie auch die Verletzungsschwere und -kombination – oftmals hoch komplex und lässt nur wenig Spielraum für Verzögerungen, Dissens oder gar Fehler. Um diese auf ein Minimum zu reduzieren sind – neben optimalen apparativen und strukturellen Voraussetzungen – auch eingespielte Schockraumteams notwendig, die nach festen, allen Teammitgliedern bekannten und auch von allen Teilnehmern konsentierten Algorithmen interdisziplinär zusammenarbeiten. Das Weißbuch „Schwerverletztenversorgung“ der Deutschen Gesellschaft für Unfallchirurgie (DGU) und die kürzlich erschienenen S3-Leitlinie bieten hier evidenzbasierte Vorgaben der strukturellen, apparativen, organisatorischen und personellen Voraussetzungen.

Does perioperative systemic infection or fever increase surgical infection risks after internal fixation of femur and tibia fractures in an intensive care polytrauma unit?

BACKGROUND

We hypothesized that internal fixation procedures performed on trauma intensive care unit (ICU) patients with systemic infections, some also febrile, would be at increased risk for deep infection.

METHODS

A total of 128 patients (mean age, 37.4 years; mean Injury Severity Score [ISS], 34.7) admitted to the ICU with 179 femur or tibia fractures developed systemic infections. Systemic infections included sepsis, pneumonia, urinary tract infections, abdominal infections, and wound infections remote to the fracture. Of the fractures, 33 open and 146 closed underwent 150 intramedullary and 29 plate fixation procedures. Data were gathered regarding antibiotic use, systemic infection timing in relation to the date of fixation, and whether fever (>38.2°C) was present within 24 hours of fixation. Patients were followed up for a mean of 491 days.

RESULTS

Twenty-eight procedures were performed a mean of 4.7 days after the diagnosis of a systemic infection, and 151 were performed a mean of 9.3 days before the diagnosis. Forty-five procedures were performed in patients who were febrile within 24 hours. Of the 179 procedures, 10 (5.6%) developed a deep infection. Four patients' implant infection was potentially hematogenously seeded with the same organism as their systemic infection. Neither the timing of the systemic infection in relation to the fixation procedure nor the presence of fever within 24 hours of fixation, days of preoperative antibiotics, location of the fracture, type of fixation (intramedullary nail vs. plate fixation), or type of systemic infection was significantly associated with the development of an infection. The only significant risk factor for developing an orthopedic infection was an open fracture (p < 0.001).

CONCLUSION

Internal fixation performed in ICU patients with fever or in close conjunction to the diagnosis of systemic infection led to a 5.6% infection rate, which compares favorably with historic infection rates for fixation of open or closed tibia and femur fractures.

LEVEL OF EVIDENCE

Therapeutic, level IV.

The imbalance between regulatory and IL-17-secreting CD4⁺T cells in multiple-trauma rat

BACKGROUND

It has been well recognised that a deficit of numbers and function of CD4(+)CD25(+)Foxp3(+)cells (Treg) is attributed to the development of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue; however, there are controversial data regarding the suppressive effect of Treg cells on the T-cell response in auto-immune diseases. Additionally, interleukin-17 (IL-17)-producing cells (Th17) have a pro-inflammatory role. The balance between Th17 and Treg may be essential for maintaining immune homeostasis and has long been thought as one of the important factors in the development/prevention of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue, but their role in multiple trauma remains unclear.

OBJECTIVE

This study aims to investigate whether an imbalance of Treg and Th17 effector cells is characteristic of rats suffering from multiple trauma.

METHODS AND SUBJECTIVE

Sixty Sprague-Dawley (SD) rats were randomly divided into three groups. The control group (n=20, group I) no received procedures (normal). The sham group (n=20, group II) only received anaesthesia, cannulation and observation. The bilateral femoral shaft fractures with haemorrhagic shock groups (n=20, group III). Rats in groups II and III were killed at the end of 4h after models were established. Peripheral blood samples were collected for assessment of Treg cells, Th17 cells and cytokines (IL-17, IL-6, IL-2, transforming growth factor beta (TGF-β)) and intestine tissue was collected for intestine histological analysis.

RESULTS

We observed decreased Treg/Th17 ratios in CD4(+)T cells in rats with multiple trauma and a strong inverse correlation with disease activity (intestinal histological scores).

CONCLUSION

We suggest a role for immune imbalance in the pathogenesis and development of multiple trauma. The alteration of the index of Treg/Th17 cells likely indicates the therapeutic response and progress in the clinic.