Sat., 10/16/10 Polytrauma & Femur, Paper #65, 10:06 am OTA-2010
The Effect of Intramedullary Nailing on Cognitive Impairment following Multiple Trauma without Intracranial Hemorrhage
Justin E. Richards, MD; Oscar D. Guillamondegui, MD; E. Wesley Ely, MD;
James C. Jackson, PsyD; Kristin Archer-Swygert, PhD; William T. Obremskey, MD, MPH;
Vanderbilt University Medical Center, Nashville, Tennessee, USA
Purpose: The primary purpose of this study is to evaluate the prevalence of cognitive deficit at 12 months postinjury in a cohort of patients who sustained multiple trauma without intracranial hemorrhage (ICH) and had fractures treated with intramedullary nailing (IMN). A secondary purpose is to determine whether IMN is a predictor of cognitive deficit at 12 months from initial injury. We hypothesize that long-term cognitive deficits are more likely in patients treated with IMN.
Methods: 173 patients with multiple trauma (injury severity score [ISS] >15) who presented to a Level 1 trauma center from July 2006 to July 2007 were enrolled in this study. Of these patients, 108 were evaluated 12 months after hospital discharge with a comprehensive battery of neuropsychological tests. Cognitive impairment was defined as having 2 neuropsychological test scores 1.5 standard deviations (SD) below the mean or 1 neuropsychological test score 2 SD below the mean. Medical records for each patient evaluated at 1 year were reviewed, demographic data were noted, and ISS was obtained. Operative data was recorded with respect to operative intervention and stratified by treatment with IMN or without IMN. Timing of fracture fixation (<24 hours or >24 hours), initial 24-hour blood requirements, and presence of intraoperative hypoxia (SpO2 <90%) or hypotension (systolic blood pressure <90 mm Hg) were documented.
Results: 59 patients (55%) demonstrated cognitive impairment at 12-month follow-up, with 3 (5.5%) of these patients having pre-existing impairment. There were 18 patients (OTA classification 32 and 42) who underwent IMN. 14 patients (78%) with IMN had cognitive deficit at follow-up. A significant difference in cognitive impairment was identified among patients treated with a reamed intramedullary device and those who were not treated with IMN (78% vs 50%, P = 0.03). A multiple variable logistic regression analysis found that IMN (odds ratio [OR], 3.0; P = 0.08) and having less than a high school education had a moderate effect on cognitive impairment (OR, 3.4; P = 0.07) after adjusting for ISS, ventilator days, and open fracture. Interaction between IMN and timing of fixation with regard to outcome was not found to be statistically significant (P = 0.08)
Conclusions: Fracture fixation with a reamed intramedullary nail is moderately associated with cognitive impairment in this cohort of multiple trauma patients without ICH at 1 year postinjury. The potential clinical neurocognitive consequences of intramedullary reaming cannot be ignored. To date, there are little data evaluating long-bone fracture fixation with IMN and the association with long-term cognitive impairment. Rare events of cerebral fat embolism have been reported but the etiology and risk factors are unknown.
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• 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.