Thurs., 10/16/08 Tibia/Polytrauma, Paper #9, 4:02 pm OTA-2008
Comparison of Multiple Trauma Patients Undergoing either Early Total Care or Damage Control Orthopedics in a German Level I Trauma Center: Patients’ Characteristics and Effects on the Clinical Course
Frank Hildebrand, MD (n); Michael Frink, MD (n); Hagen Andruszkow, MD (n);
Christian Probst, MD (a-Grant by H & S Re Insurance Company, Grant from Medartis, Basel,
Switzerland); Christian Zeckey, MD (n); Christian Krettek, MD (a-AO Foundation);
Trauma Department, Hannover Medical School, Hannover, Germany
Purpose: There has been a move away from early total care (ETC) in patients with severe, multiple injuries to damage control orthopaedics (DCO) in an attempt to reduce the physiologic insult resulting from operative treatment after trauma. For femoral shaft fracture, this entails initial external fixation and subsequent conversion to an intramedullary nail. We sought to compare the populations of multiple trauma patients undergoing either of the concepts (DCO vs ETC) and link this to the consequences for their clinical course in a German Level 1 trauma center.
Methods: In a retrospective study, multiple trauma patients (Injury Severity Score [ISS] >16, trauma between 2003 and 2007) with femoral shaft fractures were split into two groups with either primary intramedullary nailing (ETC) or primary external fixation and secondary conversion to intramedullary nailing (DCO). Demographic and clinical data (injury severity and distribution, ventilation time, time in ICU, total hospital stay, transfusion requirements) as well as posttraumatic complications (adult respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS) according to the Marshall Score) of both groups were documented. Furthermore, the calculated probability of survival (TRISS and APACHE II) was compared to the survival. For statistical analysis, we used analysis of variance, Student t test, and rank-sum test. Values were considered significant at P <0.05.
Results: 77 patients were included in this study. There was an increasing use of the DCO concept over the observation period (2004: 52.6% vs 2007: 67.9%). The ISS of the DCO group was significantly higher compared to the ETC group (36.5 ± 4.3 vs. 25.1 ± 3.1). None of the patients with an ISS >40 was treated after the ETC concept. The Abbreviated Injury Scale (AIS)–head (2.6 ± 0.3 vs 0.8 ± 0.2) and the AIS–chest (3.6 ± 0.2 vs 2.6 ± 0.2) were significantly higher in DCO patients, whereas all other body regions were equally injured. All patients with an ISS <25 survived after trauma (72.2% ETC treatment). Comparison of the AIS and the body temperature at admission revealed no significant differences between the DCO and ETC group. In these patients, DCO treatment resulted in a significantly longer ventilation time (12.1 ± 2.2 vs 3.0 ± 1.0 days) and time in ICU (16.0 ± 2.2 vs 1.0 ± 0.5 days). In patients with an ISS of 25 to 39 (63.3% DCO treatment), the DCO group demonstrated a significantly higher AIS)–head compared to the ETC group. Although the AIS–chest also tended to be higher in the DCO group (3.7 ± 0.4 vs 3.1 ± 0.2), ARDS incidence was slightly lower in these patients compared to ETC patients (DCO 23.4% vs ETC 25.0%). Time of ventilation was comparable between the two groups (DCO 10.5 ± 3.0 vs ETC 9.0 ± 3.5 days). All ETC-treated patients survived (calculated survival probability: TRISS 89.9%. APACHE 90.5%). One patient in the DCO group died due to his severe brain injury (calculated survival probability of DCO group: TRISS 81.2%, APACHE 85.3%).
Conclusion: ETC seems to be advantageous in terms of reduced ventilation time and time in ICU in patients with a low ISS. However, in patients with more severe injuries, DCO exerts beneficial effects with a reduction of pulmonary complications. Therefore, the preoperative condition should be carefully evaluated before the decision on the type of initial fixation is made in multiple trauma patients.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.