Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society

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.

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.

A global perspective on gun violence injuries

INTRODUCTION AND DEFINITIONS

Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.

PRE-HOSPITAL CARE

There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.

ACUTE TREATMENT

Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.

DEFINITIVE CARE

The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.

RESOURCES AND ETHICS

There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes

Background: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. Methods: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12–24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). Results: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). Conclusion: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

[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.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey

OBJECTIVES

The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO.

BACKGROUND

The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO).

METHODS

Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process.

RESULTS

Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery".

CONCLUSION

This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

The polytrauma patient: Current concepts and evolving care

Principles of care in the polytraumatized patient have continued to evolve with advancements in technology. Although hemorrhage has remained a primary cause of morbidity and mortality in acute trauma, emerging strategies that can be applied pre-medical facility as well as in-hospital have continued to improve care. Exo-vascular modalities, including the use of devices to address torso hemorrhage and areas not amenable to traditional tourniquets, have revolutionized prehospital treatment. Endovascular advancements including the resuscitative endovascular balloon occlusion of the aorta (REBOA), have led to dramatic improvements in systolic blood pressure, although not without their own unique complications. Although novel treatment options have continued to emerge, so too have concepts regarding optimal time frames for intervention. Though prior care has focused on Injury Severity Score (ISS) as a marker to determine timing of intervention, current consensus contends that unnecessary delays in fracture care should be avoided, while respecting the complex physiology of certain patient groups that may remain at increased risk for complications. Thromboelastography (TEG) has been one technique that focuses on the unique pathophysiology of each patient, providing guidance for resuscitation in addition to providing information in recognizing the at-risk patient for venous thromboembolism. Negative pressure wound therapy (NPWT) has emerged as a therapeutic adjuvant for select trauma patients with significant soft tissue defects and open wounds. With significant advancements in medical technology and improved understanding of patient physiology, the optimal approach to the polytrauma patient continues to evolve.

Surgical strategy for femoral shaft fractures in severely injured patients: A 13-year experience from a tertiary trauma centre

BACKGROUND

The treatment strategy of femoral shaft fractures in polytraumatised patients has evolved over the years and led to improved outcomes for these patients. However, there is still controversy regarding the optimal treatment strategy and surgical care can differ markedly from one country to another. We investigate the surgical treatment strategy (Early Definitive Care (EDC) or Damage Control Orthopaedics (DCO)) implemented in the care of severely injured patients with femoral shaft fractures treated at a single tertiary trauma centre in southern Finland and factors affecting decision making.

METHODS

The Helsinki Trauma Registry (HTR) was used retrospectively to identify severely injured patients (New Injury Severity Score [NISS] ≥ 16) treated from 2006 through to 2018 with concomitant femoral shaft fractures. Patients <16 years old, with isolated head injuries, dead on arrival and those admitted >24 h following the injury were excluded. Based on their initial surgical management strategy, femoral fracture patients were divided into EDC and DCO groups and compared.

RESULTS

Compared to other trauma-registry patients, those with femoral shaft fractures are younger (30.9 ± 15.9 vs. 47.0 ± 19.7, p<0.001) and more often injured in road traffic accidents (64.1% vs. 34.4%, p<0.001). The majority (78%) of included patients underwent EDC. Patients who underwent DCO were significantly more severely injured (NISS: 40.1 ± 11.5 vs. 27.8 ± 10.1, p<0.001) with longer lengths of stay in ICU (15.4 ± 9.8 vs. 7.5 ± 6.1 days, p<0.001) and in hospital (29.9 ± 29.6 vs. 13.7 ± 11.4 days, p<0.001) than patients treated with EDC. Decision making was based primarily on injury related factors, while non-injury related factors may have contributed to choosing a DCO approach in a small number of cases.

CONCLUSION

Early definitive care is the prevailing treatment strategy in severely injured femoral shaft fracture patients treated at a tertiary trauma centre. Patients treated with DCO strategy are more severely injured particularly having sustained worse intracranial and thoracic injuries. In addition to injury related factors, treatment strategy decision making was influenced by non-injury related factors in only a minority of cases.

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.

Strategies for the treatment of femoral fractures in severely injured patients: trends in over two decades from the TraumaRegister DGU®

Purpose

Treatment strategies for femoral fracture stabilisation are well known to have a significant impact on the patient’s outcome. Therefore, the optimal choices for both the type of initial fracture stabilisation (external fixation/EF, early total care/ETC, conservative treatment/TC) and the best time point for conversion from temporary to definitive fixation are challenging factors.

Patients

Patients aged ≥ 16 years with moderate and severe trauma documented in the TraumaRegister DGU^® between 2002 and 2018 were retrospectively analysed. Demographics, ISS, surgical treatment strategy (ETC vs. EF vs. TC), time for conversion to definitive care, complication (MOF, sepsis) and survival rates were analysed.

Results

In total, 13,091 trauma patients were included. EF patients more often sustained high-energy trauma (car: 43.1 vs. 29.5%, p < 0.001), were younger (40.6 vs. 48.1 years, p < 0.001), were more severely injured (ISS 25.4 vs. 19.1 pts., p < 0.001), and had higher sepsis (11.8 vs. 5.4%, p < 0.001) and MOF rates (33.1 vs. 16.0%, p < 0.001) compared to ETC patients. A shift from ETC to EF was observed. The time until conversion decreased for femoral fractures from 9 to 8 days within the observation period. Sepsis incidences decreased in EF (20.3 to 12.3%, p < 0.001) and ETC (9.1–4.8%, p < 0.001) patients.

Conclusions

Our results show the changes in the surgical treatment of severely injured patients with femur fractures over a period of almost two decades caused by the introduction of modern surgical strategies (e.g., Safe Definitive Surgery). It remains unclear which subgroups of trauma patients benefit most from these strategies.

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the "first hit"). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the "second hit" and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality. The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the "Safe Definitive Surgery" (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.

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.

Risk factors of non-union in intramedullary stabilized diaphyseal long bone fractures: identifying the role of fracture stabilization strategies and concomitant injuries

Purpose

Concomitant chest injury is known to negatively affect bone metabolism and fracture healing, whereas traumatic brain injury (TBI) appears to have positive effects on bone metabolism. Osteogenesis can also be influenced by the timing of fracture stabilization. We aimed to identify how chest injuries, TBI and fracture stabilization strategy influences the incidence of non-union.

Methods

Patients with long bone fractures of the lower extremities who had been treated between 2004 and 2014 were retrospectively analysed. Non-union was defined as fracture healing not occurring in the expected time period and in which neither progression of healing nor successful union is expected without intervention. Diverse clinical and radiological parameters were statistically analysed using the Statistical Package for the Social Sciences (SPSS).

Results

The total number of operations before consolidation was an independent predictor (odds ratio [OR] = 6.416, p < 0.001) for the development of non-union in patients with long bone fractures. More specifically, patients treated according to the damage control orthopaedics (DCO) principle had a significantly higher risk of developing a non-union than patients treated according to the early total care (ETC) principle (OR = 7.878, p = 0.005). Concomitant chest injury and TBI could not be identified as influencing factors for non-union development.

Conclusion

Our results indicate that the number of operations performed in patients with long bone fractures should be kept as low as possible and that the indication for and the timing of DCO treatment should be meticulously noted to minimize the risk of non-union development.

Damage control orthopaedics: State of the art

Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.

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.

Are large fracture trials really possible? What we have learned from the randomized controlled damage control study?

PURPOSE

Although they are considered the 'gold standard' of evidence-based medicine, randomized controlled trials are still a rarity in orthopedic surgery. In the management of patients with multiple trauma, there is a current trend toward 'damage control orthopedics', but to date, there is no proof of the superiority of this concept in terms of evidence-based medicine. The purpose of this article is to present unexpected difficulties we encountered in successfully completing our randomized controlled trial and to discuss the problematic differences between theoretically planning a trial and real-life practical experience of implementing the plan, with attention to published strategies.

METHODS

The multicenter randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients (DCO study) was designed to determine whether 'risk adapted damage control orthopedics' of femoral shaft fractures is advantageous when treating multiple trauma patients. We compared our methods of study planning and realization point by point with published methods for conducting such trials.

RESULTS

The study was methodically planned. We met the most prerequisites for successfully completing a large fracture trial, but experienced unexpected difficulties. After 2.5 years, the Deutsche Forschungsgemeinschaft suspended the financing because of low recruitment. The reasons were multifactorial.

CONCLUSIONS

We believe it is much more difficult to perform a large fracture trial in reality than to plan it in theory. Even the theoretically best designed trial can prove unsuccessful in its implementation. The question remains: are large fracture trials even possible? Hopefully YES!

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10321620. Date assigned: 09/02/2007.

LEVEL OF EVIDENCE

Level I.

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.

Retrospective comparison of postoperative infection and bone union between late and immediate intramedullary nailing of Gustilo grades I, II, and IIIA open tibial shaft fractures

Background

The optimal method of skeletal stabilization is still controversial. Therefore, we examined the clinical outcomes associated with late (L) versus immediate intramedullary nailing (IMN).

Methods

This was a retrospective comparative study of trauma registry data from an emergency medical care center (university hospital). We examined 85 open tibial shaft fractures (85 patients) treated with L or immediate (I) IMN from January 2004 to December 2010. The L and I groups comprised 37 (33 men, 4 women) and 48 (44 men, 4 women) patients, respectively. The postoperative infection rate, time to bone union, and delayed union/non-union were evaluated.

Results

The mean ages at the time of trauma in the L and I groups were 41.8 (18-79) and 42.0 (18-71) years, respectively; the mean follow-up periods were 15.0 (6-39) and 18.3 (8-36) months, respectively. A higher rate of postoperative infection was found in the L group than in the I group (p=0.004). Superficial/deep infection developed at a higher rate in the L group than in the I group (p=0.042 and 0.045, respectively). Among patients with Gustilo grade IIIA fractures, postoperative infection occurred at a higher rate in the L group than in the I group (p=0.008). However, the delayed union rate, non-union rate, and time to bone union were not significantly different between the groups.

Conclusions

Gustilo grade IIIA fractures had a high infection rate, which is likely due to various factors, including pin-site infection after external fixation. We think that I IMN is safer than L IMN, and it should be the treatment of choice.

Level of evidence

Retrospective comparative study, level III.

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.

[Using data from registries like the TraumaRegister DGU(®) for effectiveness evaluations]

In some situations like a rare disease or an emergency intervention, a randomized controlled trial is rather difficult or even impossible to conduct. In these cases, the use of observational studies or registries for the assessment of effectiveness is discussed. Results from registries, however, are subject to the same methodological limitations as any non-randomized comparison. Specifically, the comparability of selected patient groups is not ensured. Using three examples from the TraumaRegister DGU(®), a nationwide registry for severely injured patients in Germany, the advantages as well as the risks of outcome evaluation with registry data will be discussed: 1) whole-body computed tomography in the early in-hospital phase, 2) pre-hospital volume resuscitation, and 3) surgical treatment according to the principle of damage control. The most important prerequisite for any successful outcome evaluation using registry data is the documentation and availability of so-called confounding variables (prognostic factors), the absence of an accepted standard treatment, i.e., both interventions are routinely applied in similar situations, and, finally, the use of sophisticated statistical methods for multivariate adjustment of results.

Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients

Background

Long bone fractures, particularly of the femur, are common in multiple-trauma patients, but their optimal management has not yet been determined. Although a trend exists toward the concept of “damage control orthopedics” (DCO), current literature is inconclusive. Thus, a need exists for a more specific controlled clinical study. The primary objective of this study was to clarify whether a risk-adapted procedure for treating femoral fractures, as opposed to an early definitive treatment strategy, leads to an improved outcome (morbidity and mortality).

Methods/Design

The study was designed as a randomized controlled multicenter study. Multiple-trauma patients with femur shaft fractures and a calculated probability of death of 20 to 60 % were randomized to either temporary fracture fixation with external fixation and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective was to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score.

Results

Thirty-four patients were randomized to two groups of 17 patients each. Both groups were comparable regarding sex, age, injury severity score, Glasgow Coma Scale, prothrombin time, base excess, calculated probability of death, and other physiologic variables. The maximum SOFA score was comparable (nonsignificant) between the groups. Regarding the secondary endpoints, the patients with external fixation required a significantly longer ventilation period (p = 0.049) and stayed on the intensive care significantly longer (p = 0.037), whereas the in-hospital length of stay was balanced for both groups. Unfortunately, the study had to be terminated prior to reaching the anticipated sample size because of unexpected low patient recruitment.

Conclusions

Thus, the results of this randomized study reflect the ambivalence in the literature. No advantage of the damage control concept could be detected in the treatment of femur fractures in multiple-trauma patients. The necessity for scientific evaluation of this clinically relevant question remains.

Trial registration

Current Controlled Trials ISRCTN10321620

Date assigned: 9 February 2007.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1162-2) contains supplementary material, which is available to authorized users.

Early and late intramedullary nailing of femur fracture: A single center experience

Background:

Femur fracture (FF) is a common injury, and intramedullary nailing (IMN) is the standard surgical fixation. However, the time of intervention remains controversial. We aimed to describe the reamed IMN (rIMN) timing and hospital outcomes in trauma patients presenting with FF.

Materials and Methods:

A retrospective analysis was conducted for all patients admitted with FF and they underwent fixation at level 1 trauma unit between January 2010 and January 2012. Patients were divided into Group I with early rIMN (<12 h) and Group II with late rIMN (≥12 h). Patients’ demographics, clinical presentations, mechanism of injury, pulmonary complications, organ failure, length of stay, and mortality were described.

Results:

A total of 307 eligible patients with FF were identified (156 patients in Group I and 151 patients in Group II). Patients in Group II were older (36 ± 18 vs. 29 ± 9; P = 0.001) and had higher rate of polytrauma (35% vs. 18%, P = 0.001), head injury (5% vs. 12%, P = 0.68) and bilateral FF (10.7% vs. 5.1%; P = 0.07) in comparison to Group I. Group II had longer stay in Intensive Care Unit (7 [1–56] vs. 2 [1–17] days; P = 0.009) and hospital (13 [2–236] vs. 9 [1–367]; P = 0.001). There were no significant differences in outcomes between the two groups in terms of sepsis, renal failure, fat embolism, adult respiratory distress syndrome and death.

Conclusions:

Based on this analysis, we believe that early rIMN is safe in appropriately selected cases. In patients with traumatic FFs, early rIMN is associated with low hospital complications and shorter hospital stay. The rate of pulmonary complications is almost the same in the early and late group. Further prospective randomized studies with large sample size would be ideal using the information garnered from the present study.

Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients

OBJECTIVES

We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation.

DESIGN

Prospective.

SETTING

Level 1 trauma center.

INTERVENTION

Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis.

MAIN OUTCOME MEASUREMENTS

Three hundred five consecutive skeletally mature patients with Injury Severity Score ≥ 16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded.

RESULTS

Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation.

CONCLUSIONS

Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.

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.

Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion

External fixation has become an important tool in orthopedic surgery. Technology has improved the design and material as well as the construct of the fixator. As most patients are converted from external fixation to definite stabilization during later clinical course, prevention of complications such as infection is of high importance. Based on the current literature, principles of temporary external fixation were summarized. We focused on minimizing the risk of infection and introduce a standardized algorithm how to proceed when converting from external to internal fixation, which also was examined for effectiveness.

Extremity War Injuries IX: Reducing Disability Within the Military

Extremity War Injury Symposium IX focused on reducing disability within the military, centering on cartilage defects, amputations, and spinal cord injury. Many areas of upper and lower extremity trauma and disability were discussed, including segmental nerve injuries, upper extremity allotransplantation, and the importance of patient-reported functional outcomes compared with the traditionally reported measures. Strategic planning addressed progression toward clinical solutions by setting clear objectives and goals and outlining pathways to address the "translation gap" that often prevents bridging of basic science to clinical application.

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.

Strategies for comparative analyses of registry data

The present paper is a description and summary of methods used in non-randomised cohort data where the comparability of the study groups usually is not granted. Such study groups are formed by a diagnostic or therapeutic intervention, or by other characteristics of the patient or the treatment environment. This is a typical situation in the analysis of registry data. The methods are presented together with an illustrative example of whole-body computed tomography in the early phase of treatment of severe trauma cases. The following approaches are considered: (i) unadjusted direct comparisons; (ii) parallelisation; (iii) subgroup analysis; (iv) matched-pairs analysis; (v) outcome adjustment; and (vi) propensity score analysis. All these approaches have in common that they try to separate, or limit, the influence of confounding variables, which are unevenly distributed among the study groups, but also influence the outcome of interest. They differ in the number of confounders being considered, as well as the number of patients regarded. The more sophisticated the approach, the more effectively such confounding factors could be reduced. However, any method used for the reduction of bias depends on the quality and completeness of recorded confounders. Factors which are difficult or even impossible to be measured could thus not be adjusted for. This is a general limitation of retrospective analyses of cohort data.

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

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.

Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care

OBJECTIVES

The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications.

DESIGN

Statistical modeling based on retrospective database.

SETTING

Level 1 trauma center.

PATIENTS

A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures.

INTERVENTION

All fractures were treated surgically.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated.

RESULTS

Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis.

CONCLUSIONS

Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.

Surgical strategies in polytraumatized patients with femoral shaft fractures - comparing a German and an Australian level I trauma centre

BACKGROUND

Femoral shaft fractures are one of the most common injuries in multiple trauma patients. Due to their prognostic relevance, there is an ongoing controversial discussion as to the optimal treatment strategy in terms of Damage Control Orthopaedics (DCO) and Early Total Care (ETC). We aimed to describe the differences in fracture management and clinical outcome of multiple trauma patients with concomitant femoral shaft fractures treated at a German and an Australian level I trauma centre using the same inclusion criteria.

METHODS

Polytraumatized patients (ISS ≥ 16) with a femoral shaft fracture aged ≥ 16 years treated at a German and an Australian trauma centre between 2003 and 2007 were included. According to ETC and DCO management principles, we evaluated demographic parameters as well as posttraumatic complications and clinical outcome.

RESULTS

Seventy-three patients were treated at the German and 134 patients at the Australian trauma centre. DCO was performed in case of increased injury severity in both hospitals. Prolonged mechanical ventilation time, and length of ICU and hospital stay were demonstrated in DCO treatment regardless of the trauma centre. No differences concerning posttraumatic complications and survival were found between both centres. Survival of patients after DCO was similar to those managed using ETC despite a greater severity of injury and lower probability of survival. There was no difference in the incidence of ARDS. DCO was, however, associated with a greatly increased length of time on mechanical ventilation and length of stay in the ICU.

CONCLUSION

We found no differences concerning patient demographics or clinical outcomes in terms of incidence of ARDS, MODS, or mortality. As such, we propose that comparability between German and Australian trauma populations is justified. Despite a higher ISS in the DCO group, there were no differences in posttraumatic complications and survival depending on ETC or DCO treatment. Further research is required to confirm whether this is the case with other countries, too.

Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course

OBJECTIVES

We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

1005 skeletally mature patients with Injury Severity Score (ISS) ≥18 with pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) fractures. Chest (n = 447), abdomen (n = 328), and head (n = 155) injuries were present.

INTERVENTION

Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433.

MAIN OUTCOME MEASUREMENTS

Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death.

RESULTS

Days in intensive care unit (ICU) and total hospital stay were lower with early fixation (5.1 ± 8.8 vs. 8.4 ± 11.1 ICU days (P = 0.006); 10.5 ± 9.8 versus 14.3 ± 11.4 total days (P = 0.001), after adjusting for ISS and age. Fewer complications (24.0% vs. 35.8%, P = 0.040), ARDS (1.7% vs. 5.3%, P = 0.048), pneumonia (8.6% vs. 15.2%, P = 0.070), and sepsis (1.7% vs. 5.3%, P = 0.054) occurred with early versus delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS.

CONCLUSIONS

Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future.

LEVEL OF EVIDENCE

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

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

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.

[S3 guideline on treatment of polytrauma/severe injuries. Initial surgical phase: significance--possibilities--difficulties?]

There is no universal, generally established strategy for polytrauma management in Germany until now. The new S3 guideline on polytrauma patient care is the first high-level evidence-based compendium consented to by all major medical societies in Germany. This report emphasises all new guideline recommendations concerning the early operative care of multiply injured patients. With regard to the available evidence in the literature this report shows that the assessment of key recommendations is often difficult due to a lack of data. For guideline explanations with the highest grade of recommendation however it can be assumed that there is no alternative and that these will be implemented nationwide. This study also shows that the absolute and relative number of recommendations and the corresponding grade of recommendation do not correlate with the frequency and severity of injuries in an average polytrauma patient. It will now become a major challenge in German trauma care to incorporate all S3 guideline recommendations into the local treatment algorithms. Regional trauma networks could play a key role in this crucial task.

The treatment of patients with severe and multiple traumatic injuries

BACKGROUND

The care of severely and multiply injured patients is an interdisciplinary challenge. The only existing German-language guideline up to now has been the S1-guideline issued in 2002 by the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU). In this article, we present a new, comprehensive, evidence and consensus based S3-guideline for the treatment of severely and multiply injured patients in the pre-hospital and early in-hospital phases which has been developed with the aim of structural and procedural quality optimization. Its implementation should lower these patients' mortality and improve their quality of life.

METHODS

The guideline was developed by a panel consisting of 18 delegates from 11 specialty societies under the lead of the DGU, with designated coordinators for each of three phases of treatment: the pre-hospital phase, the emergency-room phase, and the emergency surgery phase. The key questions to be answered were determined by vote, and then the relevant literature (in English and German, 1995-2010) was systematically searched and evaluated. Key recommendations with explanatory texts were formulated and agreed upon in a nominal group process (NGP) with five consensus conferences and three further Delphi rounds.

RESULTS

264 recommendations were issued: 66 for the pre-hospital phase, 102 for the emergency-room phase, and 96 for the emergency surgery phase. The three phases were subcategorized according to organizational and anatomical considerations. Topics of major emphasis were, in the pre-hospital phase, the establishment and implementation of correct priorities for treatment; in the emergency-room phase, the creation of clear structures and processes; and, in the emergency surgery phase, the avoidance of secondary injury (i.e., the principle of damage control).

CONCLUSION

This guideline can only improve outcomes if it is implemented in routine practice. Aside from the guideline itself, the DGU trauma network (www.dgu-traumanetzwerk.de) has issued a set of directions as an aid to its implementation.

The timing of definitive fixation for major fractures in polytrauma--a matched-pair comparison between a US and European level I centres: analysis of current fracture management practice in polytrauma

PURPOSE

Early definitive stabilisation is usually the treatment of choice for major fractures in polytrauma patients. Modifications may be made when patients are in critical condition, or when associated injuries dictate the timing of surgery. The current study investigates whether the timing of fracture treatment is different in different trauma systems.

MATERIALS AND METHODS

Consecutive patients treated a Level I trauma centre were documented (Group US) and a matched-pair group was gathered from the German Trauma Registry (Group GTR).

INCLUSION CRITERIA

New Injury Severity Score (NISS)>16, >2 major fractures and >1 organ/soft tissue injury. The timing and type of surgery for major fractures was recorded, as were major complications.

RESULTS

114 patients were included, n=57 Group US (35.1% F, 64.9% M, mean age: 44.1 yrs±16.49, mean NISS: 27.4±8.65, mean ICU stay: 10±7.49) and n=57 Group GTR (36.8% F, 63.1% M, mean age: 41.2 yrs±15.35, mean NISS: 29.4±6.88, mean ICU stay: 15.6±18.25). 44 (57.1%) out of 77 fractures in Group US received primary definitive fracture fixation compared to 61 (65.5%) out of 93 fractures in Group GTR (n.s.). The average duration until definitive treatment was comparable in all major extremity fractures (pelvis: 5 days±2.8 Group US, 7.1 days±9.6 Group GTR (n.s.), femur: 7.9 days±8.3 Group US, 5.5 days±7.9 (n.s.), tibia: 6.2 days±5.6 Group US, 6.2 days±9.1 Group GTR (n.s.), humerus: 5 days±3.7 Group US, 6.6 days±6.1 Group GTR (n.s.), radius: 6 days±4.7 Group US, 6.1 days±8.7 Group GTR (n.s.).

CONCLUSION

The current matched-pair analysis demonstrates that the timing of initial definitive fixation of major fractures is comparable between the US and Europe. Certain fractures are stabilised internally in a staged fashion regardless the trauma system, thus discounting previous apparent contradictions.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]

INTRODUCTION

Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC).

PATIENTS AND METHODS

In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects.

RESULTS

In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group.

CONCLUSION

From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Damage Control Resuscitation: From Emergency Department to the Operating Room

Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the Non DCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters ( P = 0.0001), more FFP: 1.8 versus 0.5 ( P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg ( P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters ( P = 0.0001) and more FFP: 15.1 versus 6.2 ( P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.

Treatment strategies for intramedullary nailing of femoral shaft fractures

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).

[Early or delayed peripheral surgery in patients with severe head injury?]

Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".

[Coagulation management in the treatment of multiple trauma]

In recent years a new understanding of trauma-associated hemorrhaging and trauma-induced coagulopathy has been achieved. This coagulopathy is multifactorial with the predominant mechanisms being tissue trauma, shock and hypoperfusion which can lead to hyperfibrinolysis by activation of the endothelium. Routinely tested coagulation parameters, such as prothrombin time and partial thromboplastin time, are frequently employed for decision making but remain problematic as they do not give any information on clot stability, lysis or platelet function. Thrombelastometry seems to be a useful alternative. A pro-active anticipatory approach is required for a successful outcome to be achieved as rescue correction is more difficult than prevention. While the pathophysiological conception of causal relationship of the mentioned therapeutic options is conclusive, an evidence-based validation by randomized controlled studies is mostly lacking. The emergency and anesthesiological concept of damage control resuscitation consists of limiting volume therapy with crystalloids and colloids to reach a mean arterial pressure > or =65 mmHg (higher for head injuries), active (re-)warming management, the prevention of a pH< or =7.2 and a base excess (BE) < or =-6 mmol/l. The early and sufficient application of hemostatic drugs is essential. Because erythrocytes play a substantial role in the coagulation process, hemoglobin (Hb) values of around 6. 2 mmol/l (10 g/dl) and/or a hematocrit of 30% should be strived for when massive non-arrested hemorrhaging occurs. After severe multiple trauma a fibrinogen deficit develops and must be adequately compensated. If coagulation therapy is carried out using fresh frozen plasma sufficient quantities (20-30 ml/kgBW) must be administered to correspondingly raise the coagulation factors. Prothrombin complex concentrates can be helpful to optimize thrombin generation during severe hemorrhaging. Because hyperfibrinolysis occurs more often than previously assumed during severe trauma, an anti-fibrinolytic therapy should be used especially for patients with an instable circulation. The platelet count should not go below 100,000/microl when hemorrhaging occurs after multiple trauma. For thrombocytopathic patients with diffuse bleeding desmopressin (DDAVP) is a therapeutic option and the "off label" use of recombinant activated factor VIIa (rFVIIa) remains an option for individual situations with stringent indications and when the above named measures to optimize the coagulation situation have been taken.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Femur shaft fracture fixation in head-injured patients: when is the right time?

The ideal timing and modality of femur shaft fracture fixation in head-injured patients remains a topic of debate. Several groups advocate the immediate definitive fixation of femur fractures ("early total care"), whereas others support the concept of "damage control orthopaedics" with temporary fracture fixation by means of external fixation and staged, planned conversion to internal fixation. The present review was designed to address this unresolved controversy by outlining the underlying immunopathophysiology of traumatic brain injury and providing clinical recommendations on the timing of femur shaft fracture fixation in patients with severe head injuries.