Session I - Polytrauma / Pelvis / Post-Traumatic Reconstruction

Thurs., 10/10/13 Polytrauma/Pelvis/Post-Trauma, PAPER #31, 3:43 pm OTA 2013

Multiple Orthopaedic Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

Benjamin R. Childs, BS; Nickolas J. Nahm, MD; Timothy A. Moore, MD;
Heather A. Vallier, MD;
MetroHealth Medical Center, Cleveland, Ohio, USA

Purpose: The objective of this study is to compare the risk of performing orthopaedic procedures in the same setting as other procedures, with the risk of performing an orthopaedic procedure alone, in patients with unstable fractures and multiple system injury. We hypothesized that in resuscitated patients the complication rates would be no different, and that length of hospital stay would be shorter in patients undergoing multiple procedures.

Methods: Patients with high-energy, mechanically unstable fractures of the femur, pelvis, acetabulum, and spine and ISS >16 were prospectively identified over 30 months at a Level I trauma center. A standard protocol for resuscitation was followed to recommend definitive fixation of these fractures once a patient was hemodynamically stable and acidosis had improved to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥–5.5 mmol/L. Patient demographic, physiological, and laboratory data were collected, and musculoskeletal and other system injuries and treatment provided were recorded. Surgical duration, fluid, and blood product administration were included. Complications were adjudicated, including pneumonia, ARDS (acute respiratory distress syndrome, infections, DVT (deep vein thrombosis), PE (pulmontary embolism), sepsis, multiple organ failure, and death.

Results: 370 patients were included with fractures of the femur (n = 166), pelvis (n = 70), acetabulum (n = 57), and spine (n = 108). 147 (39.7%) underwent multiple procedures in the initial surgical setting, including definitive stabilization of the aforementioned fractures. Multiple procedure patients had significantly greater ISS (29.4 ± 12.3 vd 24.6 ± 10.2, P <0.01), more transfusions (8.86 ± 13.5 U vs 3.55 ± 5.7 U, P <0.01), greater estimated blood loss (773 ± 1370 mL vs 443 ± 555 mL, P <0.01), and longer surgical duration (4:22 ± 2:07 vs 2:41 ± 1:39, P <0.01). In spite of these differences, once adequate resuscitation was provided, no significant differences between groups with multiple versus single procedures were found in pulmonary complications (10.2% vs 14.8%, P = 0.50), pneumonia (7.48% vs 12.1%, P =0.15), infection (7.48% vs 8.52%, P = 0.72), sepsis (6.85% vs 5.38%, P = 0.56), mortality (3.40% vs 2.69%, P = 0.69), or overall complication rate (33.3% vs 30.0%, P = 0.50). Contrary to our hypothesis, multiple procedure patients had greater length of stay (12.4 ± 9.3 days vs 10.0 ± 9.0, P = 0.018) spending a mean of 1.41 additional days on the floor (5.97 ± 4.0 days vs 4.56 ± 4.3, P <0.01), although no more time in the ICU (6.38 ± 8.5 days vs 5.77 ± 9.3, P = 0.51).

Conclusion: Prior work has shown benefits of resuscitation in normalizing acidosis associated with severe trauma. A standardized protocol to measure the adequacy of resuscitation and to determine readiness for orthopaedic surgery results in an acceptable risk of complications. Multiple procedures did not increase the frequency of pulmonary or other complications versus patients who had a single procedure, despite greater ISS, more transfusions, and longer surgical duration in the multiple procedure group. Performing multiple procedures in the same setting likely reduces treatment expenses and risk associated with additional surgeries on other days. Additional study to characterize these two groups and to minimize risk will be helpful before making broad treatment recommendations.

Alphabetical Disclosure Listing

• 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.