Damage Control Orthopedics Research Articles

Seat belt syndrome

Seat belt syndrome is a term used collectively for all injuries associated with the use of seat belts during motor vehicular accident. It usually presents with seat belt sign with associated intra-abdominal, thoracic, pelvic and spinal injuries. A 42-year-old male presented to our hospital 15 h after a head-on collision with an oncoming vehicle. He was the driver of a saloon car and was seatbelted at the time of the accident. He sustained multiple injuries which included blunt abdominal injury, multiple rib fractures and right femoral fracture. Examination revealed the seat belt sign on both anterior chest and abdominal walls and progressive abdominal distension with right femoral fracture. Chest, brain and abdominal computed tomography scans confirmed the diagnosis. He subsequently had an exploratory laparotomy and damage control orthopaedics in which an external fixator was applied to the right femur and a locked intramedullary nail thereafter. He recuperated and discharged home 26 days after the accident. Patients who present with a seat belt sign on the anterior chest or abdominal wall following a motor vehicle accident should be managed with a high index of suspicion for seat belt syndrome. Thus, the presence of any of the injuries mentioned should warrant a search for other associated injuries. With increase in the compliance of seat belt use amongst car users in Nigeria, there will be a rise in seat belt syndrome, There is need to create more awareness about seatbelt syndrome and a classification system would help to know its severity.

Sequential management of tibial fractures using a temporary unicortical external fixator.

Introduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation.Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® − Orthofix®) followed by an early conversion to intramedullary nailing.Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with “fixator in place” in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications.Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.

Are large fracture trials really possible? What we have learned from the randomized controlled damage control study?

Although they are considered the 'gold standard' of evidence-based medicine, randomized controlled trials are still a rarity in orthopedic surgery. In the management of patients with multiple trauma, there is a current trend toward 'damage control orthopedics', but to date, there is no proof of the superiority of this concept in terms of evidence-based medicine. The purpose of this article is to present unexpected difficulties we encountered in successfully completing our randomized controlled trial and to discuss the problematic differences between theoretically planning a trial and real-life practical experience of implementing the plan, with attention to published strategies. The multicenter randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients (DCO study) was designed to determine whether 'risk adapted damage control orthopedics' of femoral shaft fractures is advantageous when treating multiple trauma patients. We compared our methods of study planning and realization point by point with published methods for conducting such trials. The study was methodically planned. We met the most prerequisites for successfully completing a large fracture trial, but experienced unexpected difficulties. After 2.5 years, the Deutsche Forschungsgemeinschaft suspended the financing because of low recruitment. The reasons were multifactorial. We believe it is much more difficult to perform a large fracture trial in reality than to plan it in theory. Even the theoretically best designed trial can prove unsuccessful in its implementation. The question remains: are large fracture trials even possible? Hopefully YES! Current Controlled Trials ISRCTN10321620. Date assigned: 09/02/2007. Level I.

Gestione delle fratture acetabolari

Acetabular fractures are rare injuries which involve a heavy burden in terms of complications and long-term disability. The management of these fractures is challenging and it should be performed in Hospitals specialised in pelvic trauma. Initial management should follow Damage Control Orthopaedics principles and the definitive treatment should be performed with the patient under stable clinical conditions. In young patients, reduction and internal fixation is a safe treatment with satisfactory functional results and good hip survival. In elderly patients, acute total hip arthroplasty could be the right acute fracture management and is related with satisfactory clinical results.

Damage Control Orthopedics in Mangled Limb and Open Fractures

Damage Control Orthopedics in Mangled Limb and Open Fractures

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.

Damage control surgery \u2013 experiences from a level I trauma center

BackgroundThere is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The aim of this study was to determine parameters influencing the choice of treatment in clinical routine (DCO, ETC, or EF) in femoral or tibial shaft fractures in combination with multi-system-trauma, severe soft tissue damage or both.MethodsData of 236 patients with 280 fractures of long bones of the lower extremities treated at a level I trauma center were analysed. Clinical parameters on arrival (age, sex [m/f], ISS, fracture site [femur/tibia], soft tissue damage [closed or open fractures according to the Gustilo-Anderson classification], pulmonary injury [yes/no]) were collected and analysed whether they influence the choice of upcoming treatment (DCO/ETC/EF).ResultsOur findings showed that high ISS and severe soft tissue damage (grade III) significantly correlated with DCO. High ISS, old age, female sex and fracture site (tibia) correlated with EF. This group of sole use of external fixation had highest rate of complications, 69% were associated with at least one complication.ConclusionSeverely injured patients are treated significantly more often with DCO or EF. The presence of higher ISS (≥16) and of type III open fractures increased the use of DCO. However, ISS, fracture-site, patient’s age, type III open fractures or sex (female) increased the use of EF compared to ETC.

Damage control orthopaedics

Emergency procedures aimed at rapid reduction and fixation and spanning of periarticular fractures has been termed “damage control orthopaedics”. In severely injured patients, early definitive fixation of fractures may not be appropriate. Recent studies showed that in multiple trauma, DCO is the best option for management of patients who are unstable and in extremis. The paper presents a case of such a control in a 34-year-old patient who sustained polytrauma on 20.10.2016. Primary medical care was conducted at a local hospital. Ten hours after the injury, the patient was transported to the Bari-Ilizarov orthopaedic centre for further management. On admission, he was in a traumatic shock. Radiographic study showed a comminuted fracture of the left femur, medial condylar fracture of the ipsilateral femur, comminuted fractures of both bones of the shin, left wrist sprain, and contusion of the head. Osteosynthesis of the left femoral shaft was performed with a Kuntscher nail and additionally with the Ilizarov fixator. When patient’s condition stabilized on the next day, osteosynthesis of the tibia was performed with the Ilizarov apparatus and the wrist was fixed with a plaster cast.

Robot-assisted surgery guided by damage control orthopaedics for pelvic fractures in polytrauma patients: preliminary results of 26 patients

Objective To evaluate the safety and efficiency of robot assisted surgery guided by damage control orthopaedics(DCO) in polytraumatised patients with pelvic ring injuries. Methods A retrospective review of the pelvic fracture database was performed. Twenty-six patients who had sustained a pelvic fracture from September 2012 to December 2015 were suitable for robot-assisted minimally invasive internal fixation. They were 17 men and 9 women, aged from 23 to 58 years (average, 42.6 years). Their Injury Severity Score(ISS) ranged from 20 to 31 points (average, 21.3 years). According to Tile classification, 6 cases were type B2, 3 type B3, 9 type C2 and 8 type C3. Guided by DCO, the vital signs were stabilized by all means and the fractures treated by simple and temporary external fixation before the pelvic and other fractures were managed by the robot-assisted minimally invasive internal fixation. Demographics, times to operating room (TOR), time from acute stabilization to late definitive internal fixation (TAL), time for bone union, type of robot-assisted surgery for major fractures, length of stay (LOS), postoperative complications and mortality were recorded. The outcomes of the pelvis were evaluated at the final follow-up according to the Matta criteria. Results Of the 26 patients, robot-navigated percutaneous screwing was conducted with 23 sacroiliac screws in 19, with 9 ramus pubicus screws in 9, with 6 supraacetabular screws in 4, and with 4 both-column screws in 2 cases. TOR averaged 2.7 times, TAL 5.9 days, LOS at ICU 2.1 days, ICU ad-mission rate 46.2% (12 of 26), hospital LOS 7.3 days, and time for pelvic bone union 79.0 days. None patients had postoperative complications related to the pelvic fracture and no one died. According to the Matta criteria at the final follow-ups, 8 cases were excellent, 11 good, 5 fair and 2 poor, yielding an excellent and good rate of 73.1%. Conclusion Robot-navigated minimally invasive surgery plus DCO is effective, time saving and safe treatment for polytraumatised patients with pelvic ring injuries. Key words: Pelvis; Fractures, bone; Robotics; Surgical procedures, minimally invasive

Il politraumatizzato portato a guarigione con FE

The treatment of polytrauma patients has been largely debated in the last decades. The main issue has been if an immediate definitive treatment (Early Total Care, ETC) is always indicated; actually, a staged, minimally invasive approach (Damage Control Orthopaedics, DCO) should be preferred considering the potential reduction of surgical time, bleeding and inflammatory response. External fixation is the preferred method of temporary fixation in polytrauma patients; however, in selected cases, it could become the definitive treatment, especially when fracture reduction is maintained and the priority is to promote adequate wound healing and tissue coverage.

RISK FACTORS OF FRACTURE NONUNION IN POLYTRAUMA

Aim. To carry out literature analysis devoted to pathological mechanisms of delayed union and nonunion of limb fractures and the influence of various osteosynthesis strategies on bone healing in polytrauma. The risk of bone fractures nonunion in polytrauma increases with high-energy complex comminuted and open fractures with severe injuries of soft tissues and bones, bruised lung, shock and severe massive blood loss. The development of a systemic inflammatory response affects local immune responses in the fracture zone to the early inflammatory phase of bone healing and disrupts subsequent osteogenesis and angiogenesis processes. Early stable-functional osteosynthesis using minimally invasive techniques creates optimal conditions for bone healing. When following the tactics of the stepwise treatment of Damage Control Orthopedics, the risk of infectious complications and fracture nonunion increases with the duration of treatment in the apparatus of external fixation. Conclusion. In polytrauma a violation of consolidation of bone fractures of the extremities occurs more often than in isolated trauma. Risk factors of fracture nonunion in polytrauma are the severity of bone and soft tissue damage, shock, acute blood loss and systemic inflammatory response, as well as unjustified delay in the final stable fixation of long bones fragments or using traumatic methods of their early osteosynthesis without taking into account the severity of the condition of the injured.

“The swinging pendulum” – the evolution of (Orthopaedic) trauma care. (An explanation of the controversies & analysis of the evidence.)

Serious trauma affects 48 000 individuals each year in England, of whom 20 000 have an injury severity score greater than 15. Annual mortality rates are reported at 5400, and 3000 for all those admitted to hospital.Orthopaedic surgery accounts for over 50% of major trauma operating, and has seen changes in trends with time, from ‘Early Total Care’ (ETC) in the 80's, to ‘Damage Control Orthopaedics’ (DCO) at the turn of the century, and now ‘Early Appropriate Care’ (EAC). These changes have been driven predominantly by an enhanced understanding of the individuals' physiological response to trauma. Timing of surgery for the more severely injured is best guided by physiological parameters with the goal of providing definitive stabilisation of the axial skeleton or long bones within 36 hours provided there has been an adequate physiological response to trauma and resuscitation, otherwise damage control is sought.The introduction of major trauma networks in England in 2012, each with a major trauma centre, has seen a new multidisciplinary approach to trauma management. The result of which has been an improvement in complication profiles, reduced hospital stays with reduced use of resources, and an overall reduction in mortality rates by between 15 and 20%.

Damage Control Orthopaedics

Emergency procedures aimed at rapid reduction and fixation and spanning of periarticular fractures has been termed “damage control orthopaedics”. In severely injured patients, early definitive fixation of fractures may not be appropriate. Recent studies showed that in multiple trauma, DCO is the best option for management of patients who are unstable and in extremis. The paper presents a case of such a control in a 34-year-old patient who sustained polytrauma on 20.10.2016. Primary medical care was conducted at a local hospital. Ten hours after the injury, the patient was transported to the Bari-Ilizarov orthopaedic centre for further management. On admission, he was in a traumatic shock. Radiographic study showed a comminuted fracture of the left femur, medial condylar fracture of the ipsilateral femur, comminuted fractures of both bones of the shin, left wrist sprain, and contusion of the head. Osteosynthesis of the left femoral shaft was performed with a Kuntscher nail and additionally with the Ilizarov fixator. When patient’s condition stabilized on the next day, osteosynthesis of the tibia was performed with the Ilizarov apparatus and the wrist was fixed with a plaster cast.

NEW TECHNOLOGIES IN TREATMENT OF FRACTURES OF THE UPPER EXTREMITIES IN PATIENTS WITH SEVERE MULTIPLE AND POLYTRAUMA

A comparative analysis of treatment results of fractures of long bones of the upper extremities was made in 172 victims with severe polytrauma. The traditional strategy of treatment was used in the first group. The new technologies such as prognostic tactics, method of Damage control orthopedics and low-invasive osteosynthesis developed by the authors were applied in the second group. The application of new technologies allowed doctors to improve the immediate and long-term results of surgery. The rate of lethality decreased in 1,6 times, incidence of complications reduced in 1,4 times. Hospital stay shortened in 2 times: for victims with favorable prognosis — on 7 days; for patients with unfavorable prognosis — on 13 days. The long-term results were studied in 154 (89,5%) patients. The common duration of treatment reduced on 30 days and the quantity of good results increased on 18,6%. The number of patients with vocational rehabilitation increased from 82,3 to 90,7%.

Damage Control Orthopedics in Multitrauma Patients: A Pediatric Case Presentation and Literature Review

Introduction: A multiple long-bone shaft fracture is associated with developing systemic complications and increased morbidity and mortality. Optimal timing for surgery of polytrauma patients according to damage control orthopedics principles is crucial. Case Presentation: We present a 5-year-old boy referred after a pedestrian car accident with right femoral shaft fractures, a left distal femur fracture, and a left tibial fracture. The patient was classified as a borderline state according to the orthopedic trauma team and was managed accordingly. Conclusions: An article review is presented that signifies the potential benefits of delays in operativemultitrauma fracture fixation, particularly for patients in a borderline state.

The strategy for the surgical treatment of femoral fractures in polytrauma

The review describes peculiarities of the choice of time and methods of osteosynthesis offemur fractures of different localization in patients with multiple injuries in accordance with modern concepts of treatment of severe multiple and associated lesions. Analysis of domestic and foreign literature shows that earlyfixation of the femur in case of polytrauma can reduce the mortality rate associated with complications and improve the functional outcome. Terms of osteosynthesis of the femur in polytrauma should be chosen taking into account the severity of the injury, the patient's condition, and the period of traumatic disease. The procedure of osteosynthesis must not be a threat to the clinical condition. The choice of the method for fixation of the femur depends of fracture type and location, the presence of fractures in the adjacent and remote segments. The minimally invasive techniques of osteosynthesis of the femur and staged surgical treatment of the victims in an unstable state should be chosen for the treatment of multiple injury in accordance with the concept of «Damage Control Orthopedics».

Damage Control Orthopedics Management as Vital Procedure in Elderly Patients with Femoral Neck Fractures Complicated with Chronic Renal Failure: A Retrospective Cohort Study.

BackgroundChronic renal failure (CRF) predisposes to hip fractures in elderly patients, with high subsequent mortality. Selection and timing of the surgical procedure of such patients is a serious challenge. Many clinicians believe in earlier surgery as preferable and providing better outcomes. Damage control orthopedics (DCO) aids to adjust and optimize the overall condition of patients.MethodsIn 32 patients with femoral neck fractures complicated with CRF, we evaluated how the timing of the surgery determines the mortality rates if the DCO approach is applied. Preoperative ASA grading, POSSUM score, P-POSSUM score and DCO were carried out. Based on the assessment, timing of the surgery was ascertained.ResultsOf a total of 32 patients, twenty-nine patients were accepted for either early (< 48 hours; n = 18) or delayed (3–10 days; n = 10) surgery. Hip arthroplasty (total hip arthroplasty and hemiarthroplasty) was the principal surgery option. All patients survived operation and were followed up postoperatively with the average time of 30 days. Postoperative complications tended to occur at higher rates in the early vs. delayed surgery group (7/18 vs. 5/10). During follow up, a total of 3 patients died in both groups (2/18 in the early surgery and 1/10 in the delayed surgery group), mostly from multi-organ failures and acute respiratory distress syndrome. There was no significant difference in complication rates and Harris hip score between both groups.ConclusionIn patients with femoral neck fracture complicated with CRF, delaying the surgery for several days does not increase the incidence of postoperative adverse events.

Diagnostik und Versorgungsstrategien beim polytraumatisierten Patienten

Severe trauma is still one of the leading causes of death worldwide. The initial treatment and diagnostics are of immense importance in polytraumatized patients. The initial approach mainly focuses on the advanced trauma life support (ATLS) concept. This includes the identification of life-threatening conditions and application of life-saving interventions. Depending on the physiological condition of the patient, the surgical treatment strategies of early total care (ETC) or damage control orthopedics (DCO) can be chosen. Appropriate surgical management can reduce the incidence of associated delayed systemic complications. This review summarizes the most commonly used definitions of polytrauma (including the Berlin polytrauma definition) and classification systems of severely injured patients. Moreover, the recently introduced treatment strategy of the safe definitive surgery concept for severely injured patients is also discussed in this article.

Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients.

BackgroundLong bone fractures, particularly of the femur, are common in multiple-trauma patients, but their optimal management has not yet been determined. Although a trend exists toward the concept of “damage control orthopedics” (DCO), current literature is inconclusive. Thus, a need exists for a more specific controlled clinical study. The primary objective of this study was to clarify whether a risk-adapted procedure for treating femoral fractures, as opposed to an early definitive treatment strategy, leads to an improved outcome (morbidity and mortality).Methods/DesignThe study was designed as a randomized controlled multicenter study. Multiple-trauma patients with femur shaft fractures and a calculated probability of death of 20 to 60 % were randomized to either temporary fracture fixation with external fixation and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective was to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score.ResultsThirty-four patients were randomized to two groups of 17 patients each. Both groups were comparable regarding sex, age, injury severity score, Glasgow Coma Scale, prothrombin time, base excess, calculated probability of death, and other physiologic variables. The maximum SOFA score was comparable (nonsignificant) between the groups. Regarding the secondary endpoints, the patients with external fixation required a significantly longer ventilation period (p = 0.049) and stayed on the intensive care significantly longer (p = 0.037), whereas the in-hospital length of stay was balanced for both groups. Unfortunately, the study had to be terminated prior to reaching the anticipated sample size because of unexpected low patient recruitment.ConclusionsThus, the results of this randomized study reflect the ambivalence in the literature. No advantage of the damage control concept could be detected in the treatment of femur fractures in multiple-trauma patients. The necessity for scientific evaluation of this clinically relevant question remains.Trial registrationCurrent Controlled Trials ISRCTN10321620Date assigned: 9 February 2007.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1162-2) contains supplementary material, which is available to authorized users.

History of Pelvi-Acetabular Fracture Treatment

Acetabular Fractures were treated conservatively before 1960. Robert Judet in 1960 started to treat displaced Acetabular Fractures Surgically. In the modern world of fast moving vehicular traffic, the Pelvic Fractures are the third most common cause of death in Motor Vehicle accidents. The associated injuries to the abdomen, chest, CNS and long bones as well as hemodynamic instability is frequently present Implementation of the ATLS protocol has helped in the early management of such patients but even during the ”golden hour” further decisions need to be taken regarding the surgical management (temporary or definitive) in order to improve survival rates in such patients. Acetabular Fixation can be delayed for a week after the index injury managing the life threatening injuries first. However they may have to be fixed as a damage control orthopedics when the Hemorrhage of pelvis fracture itself is a cause of the shock. Keywords: Acetabulum Fractures, Pelvis Fracture, treatment.