Parkland Trauma Index of Mortality in Orthopaedic Trauma Patients: An Initial Report

OBJECTIVES

The extent and timing of surgery in severely injured patients remains an unsolved problem in orthopaedic trauma. Different laboratory values or scores have been used to try to predict mortality and estimate physiological reserve. The Parkland Trauma Index of Mortality (PTIM) has been validated as an electronic medical record-integrated algorithm to help with operative timing in trauma patients. The aim of this study was to report our initial experience with PTIM and how it relates to other scores.

METHODS

A retrospective chart review of level 1 and level 2 trauma patients admitted to our institution between December 2020 and November 2022 was conducted. Patients scored with PTIM with orthopaedic injuries were included in this study. Exclusion criteria were patients younger than 18 years.

RESULTS

Seven hundred seventy-four patients (246 female patients) with a median age of 40.5 (18-101) were included. Mortality was 3.1%. Patients in the PTIM high-risk category (≥0.5) had a 20% mortality rate. The median PTIM was 0.075 (0-0.89) and the median Injury Severity Score (ISS) was 9.0 (1-59). PTIM (P < 0.001) and ISS (P < 0.001) were significantly lower in surviving patients. PTIM was mentioned in 7.6% of cases, and in 1.7% of cases, providers indicated an action in response to the PTIM. PTIM and ISS were significantly higher in patients with documented PTIM.

CONCLUSION

PTIM is better at predicting mortality compared with ISS. Our low rate of PTIM documentation in provider notes highlights the challenges of implementing a new algorithm.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists?

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.

Early Total Care Versus Damage Control Orthopedics in Floating Knee Injury: Analysis of Radiological and Functional Outcomes

Introduction

Floating knee injury (FKI) occurs as a result of a high-velocity impact. We assessed the radiological and functional outcomes of FKIs treated by various fixation methods, by damage control orthopedics (DCO) or early total care (ETC).

Materials and methods

We investigated 46 patients with FKI who were operated on between January 2013 and January 2018 at the RL Jalappa Hospital and Research Center, Kolar, India. Functional assessments were evaluated using Karlström and Olerud’s criteria (KOC). Based on their treatments, the patients were divided into the damage control orthopedics group (n = 21) and the ETC group (n = 25). Statistical analyses were used to obtain and compare summary data.

Results

The data of 46 patients were collected. Fractures were classified using the modified Fraser’s classification. Five patients were not included in the final analysis because of death due to complications in the immediate postoperative period. In patients managed by DCO, after radiological union, the functional outcome was excellent in three cases, good in eight, fair in seven, and poor in two. The average time required for radiological union of the femur was 10.75 ± 1.482 months (P = 0.001); for tibia union, it was 10.25 ± 1.682 months (P = 0.011). The average range of knee flexion was 85°± 16.059° (P = 0.001), which was statistically significant. In patients managed by ETC, there were six cases with an excellent functional outcome, 13 with a good outcome, and two with a fair outcome. The average time required for radiological union of the femur was 9.29 ± 1.765 months (P = 0.006); for the tibia, it was 9.05 ± 1.161 months (P = 0.012). The average range of knee flexion was 100° ± 10.954° (P = 0.001), which was statistically significant. Fat embolism was noted in eight cases; four of these patients died due to multiorgan dysfunction. This was the major life-threatening complication in the early definitive fixation group. In the DCO group, only three cases had fat embolism, with one death due to multiorgan dysfunction. Early postoperative infection was a concern in the ETC group, evident in six cases.

Conclusion

The classification system for FKI needs further research, which must include multiple parameters. Fracture classification and patient selection are crucial considerations in deciding the best treatment for a particular fracture.

Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation

OBJECTIVES

We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5.

INTERVENTION

These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days).

MAIN OUTCOME MEASURES

Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications.

RESULTS

Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications.

CONCLUSIONS

Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications.

LEVEL OF EVIDENCE

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

Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

INTRODUCTION

Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles.

MATERIALS AND METHODS

This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression.

RESULTS

Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality.

DISCUSSION

Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients.

CONCLUSION

Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management.

LEVEL OF EVIDENCE

IV; retrospective study.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

Damage control surgery: current state and future directions

PURPOSE OF REVIEW

Damage control surgery (DCS) represents a staged surgical approach to the treatment of critically injured trauma patients. Originally described in the context of hepatic trauma and postinjury-induced coagulopathy, the indications for DCS have expanded to the management of extra abdominal trauma and to the management of nontraumatic acute abdominal emergencies. Despite being an accepted treatment algorithm, DCS is based on a limited evidence with current concerns of the variability in practice indications, rates and adverse outcomes in poorly selected patient cohorts.

RECENT FINDINGS

Recent efforts have attempted to synthesize evidence-based indication to guide clinical practice. Significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques.

SUMMARY

DCS remains an important treatment strategy in the management of specific patient cohorts. Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients.

The ABC and pain in trauma

Musculoskeletal trauma in the emergency setting is a challenge for orthopaedic surgeons. Life- and limb-threatening injuries of the extremities should be treated as soon as possible, since major musculoskeletal trauma can be the cause of significant bleeding. However, musculoskeletal trauma is often related to thoracic trauma. Management of the former should be performed only after patient's airway is maintained and breathing is secured with appropriate pain monitoring and management by expert anesthesiologists. This article discusses the association of musculoskeletal with thoracic trauma care and emphasizes on pain as a vital sign in trauma.

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.

Management of the Floating Knee in Polytrauma Patients

Ipsilateral fracture of the femur and tibia, or floating knee, is a rare injury that is found almost exclusively in polytrauma or high-energy trauma patients. It presents a combination of diaphyseal, metaphyseal and intra-articular fractures of the femur and tibia, with a high incidence of neurovascular, ligamentous and soft-tissue injuries. The functional outcome and, in some cases, the life, of such polytrauma patients depends largely on a correct therapeutic approach being taken. In general, the treatment decided upon will depend on the individual characteristics present, regarding aspects such as the patient’s general condition, the fracture line and the state of the soft tissues. The treatment provided may be the same as when single fractures are presented, but it is often necessary to consider whether certain techniques or surgical approaches may interfere with other lines of treatment. It is essential at all times to take into consideration the associated injuries and complications before deciding upon a treatment strategy. Ligamentous injuries play an important role in these injuries, much more so than when fractures occur singly. Therefore, these injuries require management by an experienced multidisciplinary team.

Influence of the timing of internal fixation of femur fractures during shock resuscitation on remote organ damage

BACKGROUND

Reamed intramedullary nailing is the gold standard for management of femur fractures. Nailing within 24 h is proven to reduce complications from ongoing bleeding, soft-tissue damage and pain. However, when combined with haemorrhagic shock, femur fracture and intramedullary nailing are associated with immune-mediated damage to remote organs. We studied whether delaying fracture fixation until resuscitation was succeeding would lead to a significant reduction in remote organ damage.

METHODS

Twenty male rabbits underwent closed femur fracture, haemorrhagic shock, resuscitation and either immediate nailing (group: ImmFix, n = 9), delayed nailing (group: DelFix, n = 8) or just splinting (group: NoFix, n = 3). Haemorrhagic shock was maintained for 60 min. Resuscitation was with shed blood and Hartmann's solution. Animals were euthanized 8 h after fixation; the lungs and small bowel were scored histologically by two pathologists.

RESULTS

Groups did not differ in weight, haemorrhage volume or magnitude of shock. At 8 h, there was no difference in end-organ damage between ImmFix and DelFix groups (11.3 ± 1.6 and 13.2 ± 1.6 versus 8.1 ± 1.3 and 12.9 ± 1.1, P = 0.26 between groups). However, the NoFix group had significantly greater end-organ damage when compared with the fixation at any time groups (17.3 ± 2.7 and 17.0 ± 3.3 versus 9.8 ± 1.1 and 13.1 ± 1, P = 0.01 between groups).

CONCLUSION

In this laboratory model, we have demonstrated that timely femur fracture fixation outweighs the potential harmful effects of surgery performed during haemorrhagic shock with simultaneous resuscitation. We have failed to demonstrate a difference between immediate and delayed fixation during resuscitation.

Do parameters used to clear noncritically injured polytrauma patients for extremity surgery predict complications?

BACKGROUND

In multiply injured patients, definitive stabilization of major fractures is performed whenever feasible, depending on the clinical condition.

QUESTIONS/PURPOSES

We therefore asked whether (1) any preoperative indicators predict major complications after major extremity surgery; (2) perioperative routine parameters other than those indicative of hemorrhagic shock predict postoperative complications; and (3) any postoperative clinical findings can predict major complications in the further course of the patient.

METHODS

We prospectively followed patients with femoral midshaft fracture, Injury Severity Score (ISS) > 16 points, or three fractures and Abbreviated Injury Scale (AIS) ≥ 2 points and another injury (AIS ≥ 2 points), and age 18 to 65 years. We recorded multiple clinical parameters. End points were pneumonia, sepsis, acute respiratory distress syndrome, acute lung injury, and multiple organ failure.

RESULTS

Forty-three of 165 patients developed complications. (1) Patients with complications had a decreased initial Glasgow Coma Scale and tended to have a lower ISS. (2) None of the assessed perioperative parameters was able to sufficiently predict postoperative complications. (3) The presence of a lung contusion and ventilation > 48 hours were associated with complications in the further course.

CONCLUSIONS

In stable multiply injured patients, none of the individual routine clinical parameters was able to predict complications. Severe head and thoracic injuries seem to be important drivers for the development postoperative complications.

Advances and future directions for management of trauma patients with musculoskeletal injuries

Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.