Thurs., 10/18/07 Polytrauma, Paper #8, 2:21 pm OTA-2007
Early Intramedullary Femoral Fixation versus External Fixation in Polytrauma Patients at Risk for Systemic Complications: A Prospective Randomized Controlled Multicenter Study
Hans-Christoph Pape, MD1 (n); Dieter Rixen, MD2 (n); Elisabeth Ellingsen Husbye, MD3 (n); Michael Mueller, MD4 (n); Clemens Dumont, MD5 (n); Christian Krettek, MD6 (n);
Peter Giannoudis, MD7 (n); Peter Epoff, MD8 (n);
1University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
2University of Witten Herdecke, Witten, North Rhine-Westphalia, Germany;
3University of Oslo, Oslo, Norway;
4University of Kiel, Kiel, Germany;
5University of Göttingen, Göttingen, Germany;
6University of Hannover, Hannover, Germany;
7University of Leeds, Leeds, United Kingdom;
8Olso, Kiel, Rosenheim, Marburg
Objectives: The timing of definitive fixation for major fractures in polytrauma patients is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixator and documented the postoperative clinical condition.
Methods: Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion criteria were new injury severity score (NISS) >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 excluded patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications). Outcomes were the incidence of acute lung injuries.
Results: From 10 European centers, we had 165 patients with a mean age of 32.7 ± 11.7 years. The intramedullary nailing group was n = 94; the external fixation group, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity across the two treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison to those who underwent external fixation (P <.05).
Conclusion: Intramedullary stabilization of the femur fracture in borderline patients is associated with a higher incidence of lung dysfunction following primary nailing when compared with external fixation. Therefore, the preoperative condition should be considered for the decision making regarding the type of initial fixation for femoral fractures in patients with blunt multiple injuries.
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