Session IX - Femur
Sat, 10/9/04 Femur, Paper #51, 4:16 pm
Damage Control in Femoral Shaft Fractures: Risk of Local Infection?
Purpose: In polytrauma patients with femoral shaft fractures, damage control orthopaedics (DCO) entails primary external fixation and subsequent conversion to an intramedullary device (IMN). Sub-clinical contamination of external fixator pin sites is relatively common, and it is argued that a DCO approach may risk subsequent local infective complications. We aimed to determine the rate of wound infection after use of DCO procedures and primary IMN for femoral fracture stabilization in severely injured patients.
Methods: An evaluation of a prospective patient database of patients treated in our institution between 1996 and 2002 was performed. Inclusion criteria were femoral shaft fracture, New Injury Severity Score (NISS) 20 points or more, age more than 16, and survival more than 2 weeks. Two groups, damage control (DCO) and early total care (ETC) (1 nail), were formed. Contamination was defined as positive culture from the wound or fixator-pin sites without clinical signs of infection. Superficial infection was a combination of positive bacterial swabs and local or systemic signs of infection. Deep infection was defined as any case requiring surgical intervention, with a sub-group requiring removal of femoral metal work (ROMW) also defined.
Results: 173 patients met the criteria for inclusion, with 192 fractures (19 bilateral). The mean follow-up was 19 months.
Table 1 - Patient demographics by treatment and timing of exchange procedure (*P <0.05)
| Group | N | Age | Sex male | Mean NISS | Open # |
Gd 3 Open | Delay 1° proc |
Duration 1° proc | ICU Stay |
Died | Non Union |
| ETC | 81 | 33.3 | 60 |
25 |
23 |
1 |
4.4h |
175 m |
9.9 d |
1 |
6 (8%) |
| DCO | 111 | 32.3 | 73 |
36* |
33 |
12* |
3.6h |
94 m* |
23 d* |
8 |
2 (2%) |
| <7 d | 31 | 31.2 | 21 |
31.2 |
9 |
1 |
3.7h |
103 m |
10.6 d | 0 |
- |
| 7-14 d | 28 | 31.5 | 19 |
33.2 |
10 |
4 |
3.8h |
104 m |
22.1 d | 0 |
- |
| >14 d | 53 | 32.6 | 33 |
40.3* |
13 |
6 |
3.6h |
94 m |
29.1 d | 8* |
- |
Table 2 - Infective complications by treatment group and timing of exchange procedure (*P <0.05)
| Group | N | Timing IMN (d) |
Contamination | Superficial | Deep | ROMW | Any infection | |||||
| ETC | 81 | <1 |
3 |
3.7% |
5 |
6.1% | 3 | 3.7% | 2 | 2.5% | 9 | 11.1% |
| DCO | 111 | 14.1 |
14* |
12.6% |
4 | 3.6% | 6 | 5.4% | 2 | 1.8% | 12 | 10.8% |
| <7d | 31 | 4.3 |
1 |
3.2% |
1 | 3.2% | 3 |
9.6% | 0 |
0% |
4 |
12.9% |
| 7-14 d | 28 | 11.1 |
1 |
3.6% |
0 | 0% | 2 | 7.1% | 2 | 7.1% | 4 | 14.2% |
| >14 d | 53 | 23.8 |
12* |
22.6% |
3 | 5.6% | 1 | 1.9% | 0 | 0% | 4 | 7.6% |
Patients in the DCO group were more severely injured than those undergoing
primary intramedullary nailing. There were also more severe (Grade 3 A,
B or C) local soft tissue injuries in this group. Ninety-eight of the 111
DCO patients underwent subsequent IMN. The others either died after the
initial 2-week period without conversion being appropriate, or it was elected
to complete treatment with external fixation due to local or systemic complications.
The mean time of exchange of an external fixation to a nail was 14.1 days.
Although contamination rates were higher in the DCO group, there was no excess of infective complications. Contamination increased significantly in patients who underwent conversion to IMN after 14 days. Grade 3 open injury was significantly associated with infection irrespective of treatment.
Conclusion/Significance: The results of this study demonstrate that infection rates after DCO for femoral fractures are not significantly different than those observed after primary IMN. The overall risk of deep infection in the DCO group did not show any correlation with the timing of converting the external fixator to a nail. The risk of contamination was higher in patients when the exchange nailing was performed after a period of 2 weeks.