Concept Of Damage Control Orthopedics Research Articles

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.

Damage Control Orthopaedics in Spinal Trauma

There has been a shift in the management of the polytrauma patients from early total care to damage control orthopaedics (DCO), whereby patients with borderline hemodynamic stability may be temporized with the use of external fixators, traction, or splinting with delayed osteosynthesis of fractures. Recently, there has been an increasing trend toward a middle ground approach of Early Appropriate Care for polytrauma patients. The concepts of DCO for the spine are less clear, and the management of trauma patients with combined pelvic ring and spinal fractures or patients with noncontiguous spinal injuries present unique challenges to the surgeon in prioritization of patient needs. This review outlines the concept of DCO and Early Appropriate Care in the spine, prioritizing patient needs from the emergency department to the operating room. Concepts include the timing of surgery, minimally invasive versus open techniques, and the prioritization of spinal injuries in the setting of other orthopaedic and nonorthopaedic injuries. Contiguous and noncontiguous spinal injuries are considered in construct planning, and the principles are discussed.

There Is No Role for Damage Control Orthopedics Within the Golden Hour.

Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour." The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour. Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified. Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality.The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.

Surgical treatment strategies in pediatric trauma patients: ETC vs. DCO-an analysis of 316 pediatric trauma patients from the TraumaRegister DGU®.

External fixation within the damage control concept in unstable multiple trauma patients is widely accepted. Literature about its usage in the pediatric trauma population, however, is rare. The aim of the present study was to elucidate the factors associated with the application of external fixation in the severely injured child. Patients with severe trauma aged 0-54years documented in the TraumaRegister DGU® were included in this study. Demographic data, pattern of injury, injury severity, use of the damage control orthopedics (DCO) or early total care (ETC) concept, duration of mechanical ventilation, intensive care stay, and total hospital stay as well as the occurrence of complications and mortality were evaluated. Statistical evaluation was performed using SPSS (Version 21.0.0) using Chi square tests and linear regression models. While injury severity was comparable between children and adults, type of accident and injury patterns showed significant differences, Overall, the majority of surgical fracture stabilization in AISExtremity ≥ 3 injuries followed the DCO concept in adults (60.3%) and the ETC protocol in children (49.4%). Conservative treatment was chosen for only 11.6% of all children and 9.6% of all adults. An increasing injury severity, AISExtremity ≥ 3 and AISExtremity ≥ 3 in ≥ 2 body regions, and a more advanced age were found to be independent factors in the use of the DCO concept in children. Use of external fixation increases with age and plays a minor role in the very young trauma population. However, this does not produce a difference in outcome between children and adults.

Kirschner wire combined with external fixator for open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics

Objective To report the clinical efficacy of Kirschner wire combined with external fixator in the treatment of open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics. Methods A case series study was done on the clinical data of 15 open comminuted distal tibiofibular fractures which had been treated with kirschner wire combined with external fixation from January 2015 to August 2018 at Department of Orthopedics, Affiliated Hospital to Logistics College of Chinese People's Armed Police. They were 12 men and 3 women, aged from 27 to 62 years (mean, 46.5 years). By the Gustilo classification, there were one case of type Ⅰ, 4 cases of type Ⅱ, 7 cases of type ⅢA, 2 cases of type ⅢB and one case of type ⅢC. All the patients were treated with emergency debridement, tibial fixation using external fixator and fibular fixation using kirschner wire, followed by vacuum sealing drainage(VSD). Effective anti-inflammatory and other comprehensive treatments were given postoperatively. Regular follow-up was conducted to observe fracture healing and complications like osteomyelitis and bone disconnection. At the final follow-up, the American Orthopaedic Foot Ankle Society (AOFAS) ankle-hindfoot scale was used to evaluate the ankle function. Results All the patients were followed up for 12 to 18 months (mean, 12.8 months). Primary bone union was achieved in 13 cases (86.7%), delayed healing observed in one case (6.7%) and bone nonunion in one case (6.7%). No osteomyelitis occurred. By the AOFAS ankle-hindfoot scale, the ankle function was rated as excellent in 9 cases, as good in 4, as fair in one and as poor in one. Conclusions For patients with open comminuted distal tibiofibular fracture, treatment should be conducted according to the concept of damage control orthopaedics. After early thorough debridement, the tibia should be fixated using external fixator and the fibula using kirschner wire, followed by VSD, leading to economical cost and satisfactory clinical efficacy. Key words: Tibial fractures; Fibular fractures; External fixators; Bone nail; Damage control orthopaedics

Damage Control Orthopedics

Purpose of Review This review focuses on the concept of damage control orthopedics (DCO), the staged procedure to prevent the multiple injury patients from additional unnecessary trauma by postponable extensive surgery.

The application of multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in patients with pelvic fracture

Objective To discuss the safety and the application of the self-designed multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in pelvic fracture patients. Methods The MIPHF was subjected to pressure test and quality inspection. From September 2016 to June 2017, 61 pelvic-fracture patients were treated with our self-designed MIPHF as pre-hospital first-aid care according to the concept of damage control orthopedics (DCO) (MIPHF group). The control group consisted of 69 pelvic-fracture patients who had not received pre-hospital first-aid care with the self-designed MIPHF from December 2015 to August 2016. There were no statistically significant differences between the two groups in gender, age, types of pelvic fracture, and preoperative injure severity score (ISS). The study compared the two groups for the case fatality rate, volume of blood transfused during surgeries, early complication rates, fracture reduction (Matta standards), and long-term efficacy (Cole scores). Results The pressure test showed that the MIPHF had a good fixation effect on the pelvis. And the quality inspection showed that the material used for the MIPHF was in line with national standards and the safety was guaranteed. The MIPHF group had 1 death (1.6%) and the control group had 8 deaths (11.6%), which was a significant difference (χ2=4.979, P=0.026). All survival patients in both groups were followed up. The MIPHF group (61 cases) received 3.0 to 18.0 months follow-up, with an average of 9.0 months. And the control group (69 cases) had 18.0 to 30.0 months follow-up, with an average of 21.9 months. In the MIPHF group, 23 cases were treated conservatively, and 37 cases were treated with surgery. Among them, 3 cases were fixed with external fixator, 20 cases with anterior open reduction and internal fixation, 9 cases with posterior open reduction and internal fixation, and 5 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 20 days after injury, with an average of 4.1 days. The volume of blood transfused in the MIPHF group during surgery was 200 to 1500 ml, with an average of 628.6 ml. In the control group, 27 patients were treated conservatively, and 42 patients were treated with surgery. Among them, 2 cases were fixed with external fixator, 24 cases with anterior open reduction and internal fixation, 10 cases with posterior open reduction and internal fixation, and 6 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 15 days after injury, with an average of 3.1 days. The volume of blood transfused in the control group during surgery was 200 to 4000 ml, with an average of 1 707.1 ml. There was a significant difference between the two groups in intraoperative blood transfusion(Z=-2.330, P=0.020). The MIPHF group had 10 (16.4%) cases of early serious complications and the control group had 22 (31.9%) cases, which had a significant difference (χ2=4.187, P=0.041). According to the criteria proposed by Matta et al., the good rate of results for treating fractures was 82.0% in the MIPHF group and 60.9% in the control group, which got a significant difference (χ2=6.967, P=0.008). The MIPHF group and the control group also differed significantly in their mean long-term Cole scores (27.2±4.0 versus 25.1±5.6, t=2.457, P=0.015). Conclusion MIPHF, which reflects the DCO concept, may be recommended as pre-hospital first-aid care for patients with pelvic fracture because it can lessen bleeding and prevent secondary pelvic injury, thus reduce case fatality rate and the incidence of complications. It can also improve the success rate of treating pelvic fracture, which will positively affect long-term outcomes. Key words: Pelvis; Fractures, bone; External fixators; First aid

Role of Negative Pressure Therapy as Damage Control in Soft Tissue Reconstruction for Open Tibial Fractures.

The concept of damage control orthopaedics (DCO) is a strategy that focuses on managing orthopaedic injuries in polytrauma patients who are in an unstable physiological state. The concept of DCO is an extension of damage control surgery or damage limitation surgery (DCS/DLS). Recently, it has become clear that certain patients, following extensive soft tissue trauma, could benefit from the idea of DCS. In the management of severe lower extremity trauma with exposed fracture sites, aggressive early wound excision debridement, early internal fixation, and vascularized wound coverage within a few days after trauma were proposed. A negative-pressure dressing can be easily and rapidly applied to obtain a temporary closure between surgical stages. While negative pressure wound therapy (NPWT) has clear indications in the management of chronic wounds, its applications in the acute setting in victims of polytrauma are uneven. We conducted a review of the current clinical literature to evaluate the role of NPWT in this field, which points out that the negative pressure, applied immediately after the first debridement, seems to be an optimal bridge to the final reconstruction up to 7 days.

Influence on coagulation function and the therapy effect of damage control orthopaedics for unstable pelvic fractures and multiple fractures of extremities

To retrospectively explore the effects of damage control orthopaedics concept on coagulation and curative effects in unstable pelvic fractures and multiple fractures of limbs. From March 2014 to December 2015, 40 patients with unstable pelvic fractures and limbs multiple fractures in treatment group included 22 males and 18 females with an average age of (39.00±4.12) years old were treated with the damage control orthopaedics concept, the ISS score was (25.36±10.81) on average;Other 40 patients with the same trauma in conventional group included 25 males and 15 females with an average age of (38.00±3.24) years old were treated with conventional method from January 2012 to January 2014 served as control, the average ISS score was 26.56±11.44. Matta criteria and Majeed function standard were used respectively to evaluate the fracture reduction and therapeutic effects postoperatively. Coagulation function on the 7th day postoperatively was compared between two groups. All patients were followed up for 6 to 24 months. According to Matta criteria, the fracture reduction of the treatment group and the conventional group were (7.38±5.09) mm and (10.11±6.53) mm, respectively (P<0.05). Majeed functional results of the treatment group and the conventional group were (86.12±6.84) points and (77.53±8.30) points, respectively (P<0.05). On the 7th day after surgery, PT, APTT, TT of the treatment group were significantly higher than that of the control group;and Fib of the treatment group was also significantly lower than that of the conventional group(P<0.05). The concept of damage control orthopaedics could effectively improve coagulation function of the patients with unstable pelvic fractures and limbs multiple fractures, thus are beneficial to the functional recovery as well as improve the curative effect postoperatively.

Damage control orthopedics in a patient with polytrauma complicated with thyroid storm

The concept of damage control orthopaedics (DCO) especially in a polytrauma patient compounded with other medical conditions being vigorously advocated by orthopaedic trauma surgeons. Presenting a case of a polytrauma patient with thyroid storm. The decision on DCO in this patient being discussed. The decision about the timing of surgery should be based on the patients’ condition as a whole. Careful planning and definition of priorities in each individual patient is essential. This holistic approach will see that patient safety care improves.

The influence of coagulation and inflammation research on the improvement of polytrauma care.

Treatment guidelines and management principles of polytrauma patients are largely derived from experience, supplemented by the results of few clinical studies. Their clinical impact on survival outcome is rarely scientifically evaluated. Hence, research algorithms need to be developed which enable a rapid and profound reevaluation of the current treatment strategies in polytrauma care and which provide a solid basis for the assessment of future treatment options. Such new concepts might include a more individualized approach and a better identification of operative windows for early definitive care. Since polytrauma results in a complex physiological and immunological disorder, which is additionally influenced by multiple confounding variables, it is challenging to establish such novel algorithms by clinical research only. In this regard, the well defined parameters in valid basic science models can provide a solid base for evaluating current concepts and investigating future treatment options. Here we have analyzed the contribution of basic science to well-established concepts in polytrauma care, such as the management of trauma induced coagulopathy or the damage control orthopedics concept. Many of these ideas moved from previous basic science activities to clinical studies but in many cases the direct effects of basic science on clinical trials or even clinical management strategies often remain elusive. Nevertheless, the knowledge which is created on a daily basis by basic science studies acts as an invaluable data pool, which can be accessed and combined for the clinical researcher to develop and address clinically relevant questions, providing them with a comprehensive pool of information to carefully plan and conduct their clinical trials. This may then subsequently lead to the development of new management principles for polytrauma patients.

Overdistraction of the Fracture Eases Reduction in Delayed Femoral Nailing: Results of Intraoperative Force Measurements

(Initial) primary external fixation of femoral shaft fractures followed by secondary intramedullary nailing is a concept of damage control orthopedics. We hypothesized that external fixation with overdistraction of the fracture might reduce reduction forces and shorten reduction time during the secondary nailing. An experimental study on seven patients with eight fractures of the femoral shaft was conducted. Intraoperative reduction forces were determined in all patients using a load cell. The amount of distraction was measured on the latest radiographs before nailing. The reduction time was recorded as an indirect indicator of the intricacy of reposition. Reduction forces and reduction times were compared between those fractures fixed with shortening (Group A) and those fixed in distraction (Group B). Three femurs showed some shortening and five femurs showed some distraction within the fracture. The maximum measured distraction force along the shaft axis was 396 N. On average the maximal force was 336 N (+/- 51.9 N) in Group A and 200 N (+/- 43.1 N) in Group B. This difference is statistically significant (p = 0.007). The average reduction time was 28.3 minutes (+/- 21.8 minutes) in Group A and 5.8 minutes (+/- 4.0 minutes) in Group B. This difference shows a trend toward significance (p = 0.056). Fracture shortening leads to higher restraining forces and consequently prolonged reduction time in delayed nailing. Overdistraction should be performed as soon as possible under careful soft-tissue monitoring.

„Damage Control Orthopedics“

In the management of patients with multiple injuries, the concept of damage control orthopedics (DCO) is still a matter of controversy. Thus, the clinical value of DCO remains unclear and should be evaluated on an evidence-based level by a review of the current literature. The work of various authors has demonstrated an association between injury severity and the clinical immuno-inflammatory response and its prognostic relevance regarding organ dysfunction or organ failure and clinical outcome. Research data published by the authors and other investigators have clearly demonstrated an additional inflammatory response caused by surgical trauma which is significantly higher after primary intramedullary fracture treatment than after external fracture stabilization. In contrast, a generally minor inflammatory response seems to be associated with intramedullary nailing for secondary conversion osteosynthesis. Three retrospective cohort studies have shown a reduction of organ dysfunction and an improvement of survival with the DCO approach. Simultaneously, it was demonstrated that primary external fracture fixation and secondary conversion to definite osteosynthesis is not associated with an increased rate of local or systemic complications. The advocates of DCO claim that patients with multiple injuries including severe brain and chest injuries as well as those with an unstable cardiopulmonary or circulatory condition are at high risk of developing a severe systemic immuno-inflammatory reaction during early total fracture care. Therefore, they recommend primary minimally invasive external fracture stabilization in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization of the patient in intensive care.

Damage Control Orthopaedics

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Damage control in orthopaedic trauma

The last century has seen great strides in the care of the polytrauma patient. Prior to the 1950s, routine operative stabilization of long bone fractures was not performed. With the advent of modern methods of fracture fixation the philosophy of early total care arrived and all fractures were operatively fixed at an early stage. Further understanding of the inflammatory response in trauma has now led to the concept of damage control orthopaedics. The aim of this review is to highlight this philosophy and its use in the polytrauma patient.

Damage control: extremities

The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last five decades, various strategies of fracture treatment in the multiply injured patient have evolved. The various new methodologies remain controversial. In the beginning, early surgical fracture treatment of long bone fractures after multiple trauma was not routinely advocated. It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations. The introduction of standardised, definitive surgical protocols, led to the concept of early total care (ETC) in the 1980s. This concept was subsequently applied universally, in all patient groups, regardless of injury severity and distribution. Later, it became apparent that certain patients did not appear to benefit from ETC. Indeed, extended operative procedures, during the early phase of multiple trauma recovery, were associated with adverse outcome. This applied for patients with significant thoracic, abdominal and head injuries and those with high injury severity scores (ISS). In response, the concept of damage control orthopaedics (DCO) was developed in the 1990s. DCO methodology is characterised by primary, rapid, temporary fracture stabilization. Secondary definitive management follows, once the acute phase of systemic recovery has passed. We explore the processes underlying the systemic biological impact of fracture fixation, the evolution of operative treatment strategies for major fractures in polytrauma and the current trends toward staged management of these patients.