Application Of Damage Control Orthopaedics Research Articles

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases.

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves. Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039). Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Management of Polytrauma Patient in a Limited Setting : A Case report

Polytrauma patients with multiple fractures present a significant challenge in limited resources settings. The application of damage control orthopedics (DCO) principles, including temporary stabilization, staged definitive fixation, and multidisciplinary collaboration, resulted in favorable outcomes for the patient. This case report describes the successful management of a polytrauma patient who sustained multiple injuries, including unstable pelvic fracture and fractures of the femur, radius, shoulder dislocation, and distal radio-ulnar joint dislocation. This report emphasizes the importance of timely intervention and resource optimization in limited settings.

Extremity injuries in the Sahelian conflict: lessons learned from a French Forward Surgical Team deployed in Gao, Mali.

This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali. A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included. During this period, 418 patients with a median age of 28years [range 23-31years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group. CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment.

Application of damage control orthopaedics in treatment of massive hemorrhage in severe traumatic fractures

This study is designed to investigate the clinical application value of the damage control orthopaedics (DCO) concept in guiding the treatment of severe traumatic fractures with massive hemorrhage. Using the introduction of the DCO concept in the hospital in June 2021 as the cut-off point, patients with severe traumatic fractures and major bleeding admitted in the two periods before the introduction of the DCO concept (January 2021~May 2021) and after the introduction of the DCO concept (June 2021~January 2022) were included as control group (n = 39) and observation group (n = 39), respectively. The control group was given conventional surgery and treatment, whereas the DCO group received treatment and surgery under the guidance of the DCO concept. The results of the intervention were compared between the two groups. The time from admission to definitive surgery was longer in the DCO group than that in the control group. Fewer suspended red blood cells, fresh frozen plasma and platelets were used in the DCO group compared to the control group. The total hospital stay was shorter and the rates of postoperative complications and mortality were lower in the DCO group than those in the control group. Patients were followed up for 6–8 months, with an average of (6.87 ± 1.15) months, and the results showed that the fracture healing rate in DCO group was higher than that in the control group. The concept of DCO could correctly guide the treatment of severe traumatic fractures complicated by massive hemorrhage, and improve the therapeutic safety, reduce the incidence of postoperative complications and mortality, and enhance the later fracture healing rate of patients.

Clinical efficacy of damage control orthopaedics in treatment of patients with severe traumatic brain injury combined with limb fracture

Objective: To explore the clinical efficacy of damage control orthopaedics in treatment of patients with severe traumatic brain injury combined with limb fracture. Methods: Total 149 patients with sTBI combined with limb fracture treated in Emergency Surgery Department of Shandong University Qilu Hospital from January, 2011 to December, 2018 were collected. Patients that were treated with immediate definitive fixation before March 31st, 2013 were included into the routine treatment group (group A, 47 cases), and that were treated with damage control orthopaedics (DCO) after April 1st, 2013 were included into the DCO group (group B, 102 cases). The clinical data during hospitalization and prognosis 3 months after injury was analyzed retrospectively. Then according to the risk of postoperative ICP increase, the two groups were divided into low risk subgroup and high risk subgroup. The postoperative ICP, length of stay and GOS score were statistically analyzed. Results: There were no statistically significant differences in sex, age, preoperative GCS score, imaging type of lesion and initial intraoperative ICP between the two groups. The postoperative ICP and incidence of coagulation dysfunction were significantly higher in group A [(17.1±4.6) mmHg, 29.8%] than that in group B[(15.0±4.3) mmHg, 13.7%] separately(P<0.05), and there was no significant difference of length of stay and GOS score between the two groups (P=0.475 and 0.097, respectively). As for the subgroup with low risk of postoperative ICP increase, there was no significant difference in postoperative ICP and GOS score between group A and B, and the length of stay of group B was significantly longer than that of group A (P<0.05). As for the subgroup with high risk of postoperative ICP increase, there was no significant difference in the length of stay between group A and B (P=0.667), and for group A the postoperative ICP was higher and GOS score was lower than that of group B (P<0.05). Conclusions: For patients with sTBI combined with limb fracture, the application of DCO should be based on the severity of traumatic brain injury. For patients with high risk of postoperative ICP increase, DCO can significantly improve the prognosis of patients.

Application of damage control orthopaedics in the management of type III open tibia fractures in a hilly region of North India

Application of damage control orthopaedics in the management of type III open tibia fractures in a hilly region of North India

Advances in the application of damage control orthopaedics in the fractures with severe multiple injuries

With the traffic accident, sudden disaster and safety accidents occur year after year, the injured patients often complicated with multiple injuries, how to maximize the treatment of the injury to improve the survival rate, is an important problem faced by orthopedic surgeons.In recent years, damage control orthopaedics (DCO) technology has been gradually developed, DCO aims to control the patients' primary injury, to prevent further deterioration of the disease, compared with the traditional treatment, it can effectively reduce the second strike and complications, is conducive to the recovery of patients.In this paper, the development of DCO concept, the theoretical basis of DCO, the adaptation of DCO, the implementation steps of DCO and the best time, the application of DCO in the treatment of severe multiple injuries and the prospect of DCO application are reviewed. Key words: Hospitals, osteopathic; Fracture; Severe multiple trauma; Research progress; Review

Application of damage control orthopedics to combat-related hand injuries

The purpose of this report was to analyze sequential management of patients with combat-related hand injuries in the Kabul International Airport Combat Support Hospital and to identify principles of hand damage control orthopedics (DCO). A retrospective study was conducted using the French Opex data system that included all the patients who received sequential treatment for combat-related hand injuries from 2009 to 2013. Demographics, mechanism, injury pattern, reasons for DCO application and surgical procedures performed during initial and definitive treatment were described. Forty-one patients were included: 14 French soldiers and 27 Afghan patients. Explosive devices were the most common injury mechanism. There were multiple reasons for DCO application in 20 cases. Debridement, skeletal fixation by pinning or splinting, and delayed primary closure were the main emergent procedures. Primary and secondary treatment data did not differ between French and Afghan patients. Although Afghan patients were fully treated on site, the time to secondary procedures was three time higher in this group because of intense operational activity during the period study. The functional outcome was only evaluated in French soldiers who were treated definitely in France. Hand DCO may be required in various situations encountered in both military and civilian settings: polytrauma; delayed transfer to hand specialist; complex high-energy injuries due to firearms or explosive devices. The basic elements of this specific surgical tactic are meticulous debridement, detailed wound assessment and temporary skin coverage.

Application of damage control orthopaedics in the treatment of severe polytrauma in Lushan earthquake rescue

Objective To report application of damage control orthopaedics in the hospital treatment of severe polytrauma patients after the earthquake at Yaan,Lushan,Sichuan,China.Methods A retrospective study was conducted to analyze the 22 severe polytrauma patients who had been treated from 20April to 2 May,2013 with damage control orthopaedics in our hospital.They were 13 men and 9 women,aged from 20 to 60 years (average,43.1 years).Their injury severity score (ISS) ranged from 17 to 41 points (average,25.8 points).There were 11 open limb fractures and l0 closed limb fractures.Results The patients received 38 operations,including 24 definite ones,13 temporary ones and one amputation.Nine patients were in the process of smooth rehabilitation after all the necessary definite operations,and 13 needed further operation.All the open injuries got closed at one stage except in one patient who had deep infection at the incision postoperation which had to be controlled by debridement and vacuum sealing drainage.No angulation deformity was observed by the postoperative radiographic evaluation,or no loosening or infection at the pin tracks of the external fixator was observed in all the 13 patients treated by external fixation.Conclusion Damage control orthopaedics can improve the cure rate of severe polytrauma patients in an earthquake rescue,decrease their mortality and facilitate later definite medical management. Key words: Earchquake; Wounds and injuries; Multiple trauma; Damage control

Application of damage control orthopedics in treatment of unstable pelvic fractures

Objective To investigate application and clinical results of damage control orthopedics (DCO) in treating unstable pelvic fractures combined with multiple trauma.Methods A retrospective analysis was done on the clinical data of 83 patients with unstable pelvic fractures combined with multiple trauma treated from 2007 to 2012.Among them,51 patients managed by DOC were designed to treatment group,including 37 males and 14 females,at age of average 36.5 years.According to Tile classification,there were 29 patients with type B and 22 patients with type C fractures.The injury severity score (ISS) averaged 31.2 points.The patients in treatment group received external fixation in the first stage,but definitive operation was performed only when their physical condition reached stable.The other 32 patients were classified as control group,including 23 males and 9 females,at age of average 38.2 years.According to Tile classification,there were 19 patients with type B and 13 patients with type C fractures.The ISS averaged 30.8 points.The patients in the control group underwent definitive operation in the first stage.Results In the treatment group,46 patients survived and five patients died,with postoperative complications in 10 patients.Only 43 patients in the treatment group were followed up,which showed excellence rate of 88％ in fracture reduction quality according to Lindahl criterion,with Majeed score of (84.1 ± 8.2) points.In the control group,23 patients survived and nine died,with postoperative complications in 11.Twenty-one patients in the control group received follow-up,which showed excellence rate of 91％ in fracture reduction quality according to Lindahl criterion,with Majeed score of (79.0 ± 9.8) points.Conclusion DCO is an effective and safe method in treatment of unstable pelvic fractures combined with multiple trauma,which improves survival rate,reduces complications and benefits postoperative functional restoration. Key words: Pelvis; Multiple trauma; Damage control orthopedics

Application of damage control orthopedics in treatment of severe multiple injuries combined with fractures

Objective To probe the feasibility, indications and efficacy of damage control orthopedics (DCO) in treating severe multiple injuries combined with fractures. Methods A retrospective analysis was done on the clinical data of 31 patients with severe multiple injuries combined with fractures treated by DCO from 1998 to 2008. Results Of all patients, 18 patients were combined with pelvic fractures and hemorrhage. Bilateralis hypogastric artery ligation was performed early in 17 patients and nonage pelvis external fixation was performed in 12. Eleven multiple trauma patients combined with femoral fractures received primary debridement and temporal external fixation for further definitive internal fixation. Two patients with spinal fractures combined with spinal cord compression received primary simple decompression. All patients received resuscitation in ICU for average 4.3 days (1-11 days). There was one death due to hemorrhagic shock. Conclusions DCO well conforms to pathophysiological character of the wounded. Early DCO and later integrated treatment are key to enhancement of the survival rate of the multiple trauma patients. Key words: Multiple trauma; Damage control orthopedics; Fractures

Training in the practical application of damage control and early total care operative philosophy – perceptions of UK orthopaedic specialist trainees

Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected. A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence. A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a 'floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar. Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.

Application of damage control orthopedics in 41 patients with severe multiple injuries

To probe the feasibility and efficacy of damage control orthopedics (DCO) in treating severe multiple injuries. A retrospective analysis was made on the clinical data of 41 patients (31 males and 10 females, aged 18-71 years, mean: 36.4) with multiple injuries admitted to our department and treated by DCO from January 1995 to December 2005. As a first-stage therapy, devascularization of internal iliac arteries was performed in 29 patients with pelvic fractures combined with massive bleeding, including ligation of bilateral internal iliac arteries in 21 patients and embolization of bilateral internal iliac arteries in 8. And early external fixation of pelvis was performed in 10 patients. Ten patients with severe multiple injuries combined with femoral fractures were managed with primary debridement and temporal external fixation and 2 patients with spinal fractures combined with spinal cord compression received simple laminectomy. Thirty-one patients received definite internal fixation after resuscitation in intensive care unit. The overall mortality rate was 12.1% (5/41) with an average injury severity score of 41.4. The main causes of death were hemorrhagic shock and associated injuries. Complications occurred in 7 patients including acute respiratory distress syndrome in 3 cases, thrombosis of right common iliac artery in 1, subphernic abscess in 2 and infection of deep wound in lower extremity in 1. After treatment, all the patients got cured. Prompt diagnosis and integrated treatment are keys to higher survival rate in patients with severe multiple injuries. In this condition, DCO is an effective and safe option.