Presented by Intern Huang, Yu-Hao

Background Primary fracture fixation in the early stage has been found to significantly reduce the incidence of pulmonary complications and organ failure and to improve survival. However, operative trauma in Early total care (ETC) may be associated with posttraumatic systemic complications.

The strategy of damage control surgery (DCS) described by Rotondo et al. focusing on the treatment of life-threatening injuries has been adopted by many trauma centers. Evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis Time savings, effectiveness, and safety.

Hypotheses were analyzed prospectively: (1) External fracture fixation significantly reduces primary operation time (magnitude of time savings) and blood loss. (2) External fracture fixation does not increase local complications. (3) The quality of definite osteosynthesis is not impaired by previous external fracture fixation.

PATIENTS AND METHODS Prospective controlled, 1,070 patients, Injury Severity Score (ISS) of 20.7, Level I trauma center, 3.5-year period. ISS >15, survival of more than 24 hours, and without interhospital transfer was included. All patients with major fractures (femur, tibia, and complete pelvic ring fractures, humeral fractures not suitable for conservative treatment), external fixation was performed (DCO).

TRISS was calculated for patients requiring DCO(DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h- ETC).

Data collected Duration of all primary operative interventions Time spent between admission to the ER and the ICU Fracture fixations Blood loss >100 mL The time required for the management of soft- tissue injury in open fractures and for DCS for other site, documented separately The latter time intervals to the duration of definite osteosyntheses was possible The end point of the analysis was fracture consolidation or death of the patient.

RESULTS All injuries were caused by blunt trauma. Tx group :75 patients with multiple injuries with additional orthopedic injuries. Control group :334 patients with multiple injuries. Overall injury severity (ISS) showed a comparable level.

Damage Control Orthopedics Required a mean of 33.8 minutes per fracture including the time needed for soft-tissue management in the 27.4% that were open fractures. Operation time: closed fractures (average 29 minutes  open fractures (average 47 minutes) Blood loss averaged mL for external fixation with soft-tissue management. Virtually no blood loss was observed for external fixation alone.

Six patients developed seven complications (8%) caused by external fixation.

13 patients died before conversion. (significantly older, a lower initial hemoglobin concentration) No differences were detected in the time spent in primary operations and overall treatment time until admission to the ICU.

Conversion (h-ETC) Further data

All shaft fractures were treated with unreamed intramedullary nailing. Joint neighboring or affecting fractures weremanaged by open reduction and internal fixation or combined measures.

Blood loss per fracture was 271 mL and differed highly significantly (p<0.001) from the observed blood loss during DCO. Total blood loss per patient was also significantly different (p<0.001) between h-ETC (472.6 mL) and DCO (194.3 mL). Blood loss attributed to DCO is caused by primary soft-tissue management, whereas this parameter was not considered in the calculation of blood loss for h-ETC.

Differences in operation/treatment times were equally large when comparing DCO and h-ETC per fracture. DCO required 34 minutes and h-ETC required minutes more than four times as much. Although DCO was performed within 1 hour (62.9 minutes), h-ETC lasted almost 4 hours (232 minutes; p <0.001). Accordingly, DCO plus DCS (120.4 minutes) was also significantly shorter when compared with h-ETC plus DCS.

Complications Ten complications (9.8%) related to osteosynthesis needing operative intervention were found after conversion.

Outcome In the Tx group, the expected mortality using the TRISS methodology was 39.3%. The actually observed mortality was 20% which was significantly lower than the expected mortality (p<0.001). Comparison of expected (29.5%) and observed mortality (24.3%)in the control group revealed similar significant results (p<0.01).

DISCUSSION Although the necessity of early fracture fixation for reduction of pulmonary failure and other complications in the severely injured is undoubtedly accepted in the early care of these patients, it remains controversial whether a two-staged strategy with primary external fracture fixation (DCO) or ETC with definite ORIF should be performed. The concept of damage control surgery for penetrating trauma is adopted by many trauma centers for immediate external stabilization of long bone fractures (DCO)in patients with multiple injuries. In our study, a consecutive series of patients with DCO was prospectively evaluated to study the hypotheses delineated in the Introduction.

External Fracture Fixation Significantly Reduces Primary Operation Time External Fracture Fixation Significantly Reduces Primary Operation Time Primary operation time using DCO is short and offers a minimal loss of blood (Fig. 1). Our data indicate that DCO (33 minutes per fracture) required only 25% of the operation time that would have been required for h-ETC (133 minutes per fracture). ETC would have resulted in at least a similar blood loss as in conversion osteosynthesis.  With almost 500 mL per patient, it potentially impairs homeostasis and induces hypoxemia in severely injured patients.

With DCO and DCS, all procedures are finished within 2 hours on average  using h-ETC for fracture management would require almost 5 hours on average. Pape et al.  that initial surgery exceeding 6 hours is critical for prognosis. h-ETC would have caused a delayed (6 hours) admission to the ICU for almost 80% of the patients.

External Fracture Fixation Does Not Increase Complications External Fracture Fixation Does Not Increase Complications The low incidence of DCO-related complications in our cohort (5.1%) is comparable to the results of Antich et al’s retrospective studies on infection rates from 2.5% to 6% and complete fracture healing in 97.5% when external fixation was secondarily replaced by intramedullary nailing. Scalea et al.13 found a low rate of local complications (4.6%) in 43 severely injured patients initially treated with external fixation and secondary conversion compared with our data.

Quality of Definite Osteosynthesis Is Not Impaired by Previous External Stabilization Quality of Definite Osteosynthesis Is Not Impaired by Previous External Stabilization Prolonged operation time and blood loss in early traumatic hemorrhagic shock present an additional trauma that is not calculable because of the absence of predictive parameters. In the DCO group the reduction in observed mortality of 20% versus the predicted rate of 39.3% (improvement of 19.3%) was considerably higher than in the controls (24.3% vs. 29.5%).  indirectly hints at an improved survival

CONCLUSION Although the current study is limited by the lack of a control group with ETC in a randomized design, the study clearly demonstrates the enormous time savings and reduction of blood loss during initial treatment if patients with multiple injuries are treated according to DCO. This indicates that a smaller operative trauma (duration of surgery, blood loss) is inflicted on these patients. The TRISS data suggest a potential advantage of DCO with respect to survival, although this has to be further substantiated by other studies.

Our study shows that complication rates strictly associated with DCO are low  definite osteosynthesis appears not to be impaired by previous external fixation. DCO is a safe strategy in severely injured patients with multiple injuries who are too critically ill for ETC and for those patients who cannot be safely assigned to the clinical pathway of early total care.

Thanks for your attention!!