Impact of the Method of Initial Stabilization for FemoralShaft Fractures in Patients With Multiple Injuries at Risk for
Complications (Borderline Patients)
Hans-Christoph Pape, MD, FACS,* Dieter Rixen, MD,† John Morley, MD,‡Elisabeth Ellingsen Husebye, MD,§ Michael Mueller, MD,¶ Clemens Dumont, MD,��
Andreas Gruner, MD,� Hans Joerg Oestern, MD,** Michael Bayeff-Filoff, MD,††Christina Garving,*** Dustin Pardini, PhD,‡‡ Martijn van Griensven, PhD,§§
Christian Krettek, MD, FRACS,¶¶ Peter Giannoudis, MD,‡ and the EPOFF study group
Objectives: The timing of definitive fixation for major fractures inpatients with multiple injuries is controversial. To address this gap,we randomized patients with blunt multiple injuries to either initialdefinitive stabilization of the femur shaft with an intramedullary nailor an external fixateur with later conversion to an intermedullary nailand documented the postoperative clinical condition.Methods: Multiply injured patients with femoral shaft fractureswere randomized to either initial (�24 hours) intramedullary fem-oral nailing or external fixation and later conversion to an intramed-ullary nail. Inclusion: New Injury Severity Score �16 points, or 3fractures and Abbreviated Injury Scale score �2 points and anotherinjury (Abbreviated Injury Scale score �2 points), and age 18 to 65years. Exclusion: patients in unstable or critical condition. Patients
were graded as stable or borderline (increased risk of systemiccomplications).Outcomes: Incidence of acute lung injuries.Results: Ten European Centers, 165 patients, mean age 32.7 � 11.7years. Group intramedullary nailing, n � 94; group external fixation,n � 71. Preoperatively, 121 patients were stable and 44 patientswere in borderline condition. After adjusting for differences in initialinjury severity between the 2 treatment groups, the odds of devel-oping acute lung injury were 6.69 times greater in borderlinepatients who underwent intramedullary nailing in comparison withthose who underwent external fixation, P � 0.05.Conclusion: Intramedullary stabilization of the femur fracture canaffect the outcome in patients with multiple injuries. In stablepatients, primary femoral nailing is associated with shorter ventila-tion time. In borderline patients, it is associated with a higherincidence of lung dysfunctions when compared with those whounderwent external fixation and later conversion to intermedullarynail. Therefore, the preoperative condition should be when decidingon the type of initial fixation to perform in patients with multipleblunt injuries.
(Ann Surg 2007;246: 491–501)
It is accepted that primary definitive stabilization of majorfractures in patients with blunt multiple injuries is advan-
tageous in terms of reduced ventilation time, shorter hospitalstay, and improved early mobilization of the patient.1
However, there is controversy in the orthopedic literatureas to whether all patients benefit from this approach. A certainsubset of patients, specifically those in severe shock or thosewho have additional severe head or chest injuries may be atincreased risk for complications after primary definitive stabili-zation of major fractures.2–5 It is still unclear whether initialtemporary stabilization of fractures by external fixation (damagecontrol orthopedics �DCO�4), or definitive stabilization of allmajor fractures should be performed in all cases.6–12
From the *Division of Trauma, Department of Orthopaedic Surgery, ‡‡De-partment of Psychiatry, University of Pittsburgh Medical Center, Pitts-burgh, Pennsylvania; †Department of Orthopaedics and Trauma Surgery,University of Witten, Herdecke, Germany; ‡Department of Trauma andOrthopaedics, St. James University Hospital, Leeds, United Kingdom;§Orthopaedic Centre, Ullevaal University Hospital, Oslo, Norway; ¶De-partment Trauma Surgery, University of Kiel, Germany; �Department ofTrauma, General Hospital, Braunschweig, Germany; **Department ofTrauma, Celle General Hospital, Celle, Germany; ††Department ofTrauma, General Hospital, Rosenheim, Germany; ***University of Pitts-burgh School of Medicine, Pittsburgh, Pennsylvania; §§Ludwig Boltz-mann Institute for Experimental and Clinical Traumatology, Vienna,Austria; ¶¶Department of Trauma, Hannover Medical School, Hannover,Germany; and ��Department of Trauma Surgery, Plastic and Reconstruc-tive Surgery, University of Gottingen, Gottingen, Germany.
Members of the European Polytrauma Study on the Management of FemurFractures (EPOFF) study group: A. Gruner, MD, Braunschweig, Germany;M. Wittke, MD, Celle, Germany; C. Dumont, Gottingen, Germany; K.Grimme, Hannover, Germany; M. Mueller, MD, Kiel, Germany; D. Rixen,MD, Cologne, Germany; J. Morley, MD, Leeds, United Kingdom; R.Stiletto, MD, Marburg, Germany; E. Ellingsen Husbye, MD, Oslo, Norway;and R. Bayeff-Filoff, MD, Rosenheim, Germany.
Supported by AO/ASIF (Grant No. AO/ASIF. 99 P65 and 03 P2).Reprints: Hans-Christoph Pape, MD, FACS, Director, Division of Trauma,
Department of Orthopaedic Surgery, University of Pittsburgh Medical Cen-ter 3471 Fifth Avenue Suite 1010, Pittsburgh, PA 15213. E-mail:[email protected].
Annals of Surgery • Volume 246, Number 3, September 2007 491
To date, any recommendations and guidelines de-scribed above have been based only on level II to III evi-dence. Currently, there are several prospective randomizedstudies dealing with fracture management in general,10,13,14
but no level I studies have investigated whether temporaryfracture fixation should be recommended for certain patientpopulations.15 This prospective, randomized, controlled anal-ysis therefore tests the hypothesis that initial temporary frac-ture stabilization is more advantageous than initial definitivestabilization for femoral shaft fractures in patients with moresevere injuries with regard to the development of systemiccomplications.
PATIENTS AND METHODS
SettingThis investigation was designed as a prospective, ran-
domized intervention trial in 10 level I trauma centers. Thestudy was carried out from January 1, 2000 to February28,2006.
SubjectsThe inclusion criteria consisted of multiple injuries
with a New Injury Severity Score (NISS) exceeding 16points. Alternatively, 3 extremity injuries with an Abbrevi-ated Injury Scale (AIS) score of 2 or more points in associ-ation with an injury of another body region with an AIS scoreof 2 or more points had to be present. Patients were requiredto have a long bone midshaft fracture of the lower extremityeligible for antegrade intramedullary (IM) fixation and bebetween 18 and 65 years old. In addition, the thoracic AISvalue had to be less than 4 points. The exclusion criteriaincluded previous polytrauma, body weight �250 lbs, openepiphyseal plates, and multiple premorbid conditions. Amongthese conditions were cardiac insufficiency, coronary insuf-ficiency, cardiac transplantation, pulmonary hypertension,emphysema, pulmonary disease requiring medical treatment,lung transplantation, previous acute respiratory distress syn-drome (ARDS), and previous malignancy. In addition, pa-tients were excluded if a critical clinical condition wasobserved during their emergency room treatment (patients inunstable or extremis condition,12 chest trauma AIS score �2points), a systolic blood pressure �90 mm Hg despite fluidtherapy, requirement of vasopressors, anuria, severe headtrauma requiring craniotomy or medication to lower intracra-nial pressure, intracranial pressure �25 mm Hg, core bodytemperature �32°C, and a platelet count �80,000/�L blood.
Operational DefinitionsThe severity of injury was graded on the basis of the
NISS.16 To facilitate comparison with other studies, the degreeof total severity of injury was also categorized by the InjurySeverity Score (ISS), calculated based on the AIS.17
The Revised Trauma Score (RTS) was calculated basedon the data obtained on arrival of the patient.18
Severe head injury was defined as morphologic evi-dence of cranial injury based on an initial computer tomog-raphy head scan. The initial neurologic state was evaluatedaccording to the Glasgow Coma Scale.19
Acute lung injury (ALI) was diagnosed when bilateraldiffuse infiltrates were present on the chest roentgenogram,pulmonary capillary wedge pressure was less than or equalto18 cm H2O, and the oxygenation ratio (PaO2/FiO2) waslower than 300.20
The severity of thoracic injuries was graded accordingto the admission chest roentgenogram, the chest roentgeno-gram at 1 day after admission, and the chest computedtomography, if available. Based on this information, thenumber of rib fractures was documented. Also, the incidencesof pneumothorax, hemothorax, pressure pneumothorax, andlung contusion were assessed.21,22
Systemic inflammatory response syndrome (SIRS) wasdefined as the presence of the following criteria: body tem-perature �38°C, heart rate greater than 90 bpm, respiratoryrate greater than 20/min or PaCO2 �32 mm Hg, and neutro-phil count greater than 12,000/mL or less than 4000/mL.Sepsis was diagnosed by a scoring system.23 Pneumonia wasdiagnosed if the body temperature was at least 38.5°C and if,in addition, 1 of the following criteria was met: infiltrate onchest roentgenogram in the absence of ARDS or positiveculture in bronchoalveolar lavage fluid. Multiple organ fail-ure (MOF) was diagnosed according to a scoring system,24
when at least 3 organs demonstrated a grade II dysfunction.The diagnosis of a fat embolism syndrome was made accord-ing to a scoring system.25
Standardization of Study ProtocolBefore the start of the study, all participating centers
met on several occasions to review the study criteria andprocedures, including the methods for randomization andfeasibility of the data collection techniques. A steering com-mittee was created for the overall organization of the study(H.C.P., K.G., and H.T.). An adjudication committee (K.G.and S.N.), reviewed patient eligibility. Data safety and mon-itoring was performed by means of regular meetings of thekey investigators (H.C.P., P.G., D.R., E.E.H., and M.M.). Allparticipating centers took part in biannual meetings duringwhich concerns regarding data collection, safety issues, andthe accuracy of the data were addressed. All participatingcenters were included in the authorship. Internal review boardapproval (no. 2019) was obtained by the coordinating centerand each local facility. Informed consent was obtained fromthe patient or the patient’s closest relative.
Subject Recruitment and RandomizationConsecutive patients with blunt multiple injuries in 10
centers were randomized to 2 treatment arms regarding themanagement of their femur fracture, as outlined below.
Planned Interventions and Their TimingPatients were randomly treated by either primary (�24
hours) intramedullary femoral nailing or by initial externalfixation, followed by secondary intramedullary nailing (dam-age control orthopedic surgery), as soon as the patient wasdeemed stable enough for surgery.
Pape et al Annals of Surgery • Volume 246, Number 3, September 2007
Distribution of Subgroups and Determinationof the Clinical Status
Further differentiation was made according to the pa-tient’s status. Four clinical categories for patient grading weredistinguished, as previously proposed (stable, borderline, un-stable, or in extremis).12,26 The clinical grading of the pa-tient’s status was performed in the emergency room by theattending physician. Treatment group differences were exam-ined separately in the stable and borderline patient groups.Patients in unstable and extremis condition were eliminatedfrom the study.
Endpoints of the study included the incidence of pul-monary complications (ALI).
Assignment and Blinding ProceduresA randomization list was generated by a computerized
system provided by the Department of Statistics. Random-ization was performed on an individual patient basis. Thesequence was numbered by a technical assistant uninvolvedin the study, and then printed and inserted into a sealedenvelope. Each center was provided with sequential enve-lopes containing 1 of the 2 treatment strategies. For allpatients who met the inclusion criteria, the sealed envelopethat contained the type of treatment was opened after com-pletion of the diagnostics and grading of the patient’s statusto account for the exclusion criteria. The sealed envelope wasopened by a physician in the emergency room who was notinvolved in the surgical care of the patient. The fracturestabilization was subsequently performed by the orthopedicsurgeon on call. All patients were assigned after completionof the primary survey according to 1 of the 2 treatment armsdescribed above, after all injuries had been categorized andthe inclusion criteria were met.
Stopping RulesThe treating attending physician was permitted to stop
the study and proceed with the fixation of the femoral fractureif the patient’s status was deemed inadequate to allow ran-domization. Causes included in the study protocol wereunexpected deterioration of the clinical status (hemorrhagicshock, development of uncontrollable bleeding etc) or unex-pectedly increased surgical time for fixation of the fracture(eg, diagnosis of vascular injury and limb ischemia).
Fracture classification was graded according to Ortho-pedic Trauma Organization of North America’s classificationsystem,27 and open fractures by a score.28
Primary surgery was defined as an operative interven-tion within 24 hours after trauma.
Technique of Surgery and PerioperativeDocumentation
Intramedullary instrumentation was performed in astandardized fashion, using an antegrade technique and usu-ally a piriformis fossa starting point. In some patients, un-reamed nailing was performed, based on the preference of thefacility and of the surgeon. External fixation was performedas a standardized procedure. There were no limitations re-garding the choice of implants. The perioperative assessment
included documentation of clinical and laboratory data toassess blood loss, coagulopathy, wound infection, and pneu-monia. Local (wound infection, compartment syndrome etc)and systemic complications (ALI, MOF, sepsis) were docu-mented. Pin tract infection was assessed using a scoringsystem.29
General TreatmentMultiple trauma patients were regularly submitted to
intubation and artificial ventilation. For patients included inthe study, lost volume was replaced with crystalloid orcolloid solutions; hypertonic solutions were not used. Patientsunderwent repeated arterial blood gas measurements andmeasurements of central venous pressures by insertion of acentral venous catheter.
Data Management and AnalysisAll data were collected in a data base designed for the
purpose of this study, based on Microsoft Office Accesssoftware.
Estimation of Required Sample SizeA power analysis was undertaken before the study.
According to this analysis, 150 patients were required todetect a significant difference in the primary outcome vari-ables (ALI and systemic complications) with a power of 80%at an a priori alpha level of 0.05.
Data AnalysisFirst, analyses were conducted to examine the relation
between treatment group (ie, external fixation vs. intramed-ullary nailing) and variables indexing patient demographiccharacteristics and initial injury severity. This was done todetermine whether the random assignment resulted in similarpatient characteristics across the 2 treatment groups. Indepen-dent sample t-tests were used to examine treatment groupdifferences for variables that approximated a Gaussian dis-tribution. For nonnormal indicators of injury severity Mann-Whitney U tests were performed. Pearson �2 tests wereperformed for binary indicators of injury severity, exceptwhen expected cell counts did not exceed 5 participants.When this occurred, Fisher exact test tests were used. Asimilar set of analyses were used to document that patientsclassified as being in stable condition exhibited more severeinitial injuries, a poorer clinical course, and more clinicalcomplications than patients in borderline condition.
Treatment group differences on postoperative courseand complications were examined using regression models.For postoperative course outcomes associated with the num-ber of hours patients spent in the intensive care unit (ICU)and on a ventilator, Cox regressions were used. Specifically,the difference between treatment groups was examined aftercontrolling for differences between the groups on initialinjury severity. A Cox regression is appropriate for predictingthe time until an event, such as release from the ICU orremoval from a ventilator, using 1 or more independentvariables. Group differences were quantified using the hazardratio (HR). For binary outcomes assessing complicationsduring the postoperative course (ie, pneumonia, ALI, ARDS,
Annals of Surgery • Volume 246, Number 3, September 2007 Initial Stabilization for Femoral Shaft Fractures
SIRS, SEPSIS MOF), logistic regressions were used. Again,the association between treatment group status and risk ofcomplications were examined after controlling for differencesbetween the groups on initial injury severity. Group differ-ences were quantified using the odds ratio (OR) in theseanalyses. For all regression models, robust standard errorswere used and P values �0.05 were considered statisticallysignificant. After analyzing treatment group differences onthese postoperative course outcomes for the entire sample,these regression models were rerun separately for patients instable condition and patients in borderline condition.
RESULTSNineteen patients were excluded after enrollment, 10
from the external fixation group and 9 from the intramedul-lary nailing group. All patients were excluded due to detec-tion of additional injuries in the emergency room. The pa-tients excluded from the external fixation and intramedullarynailing groups exhibited comparable injury severity. There-fore the analysis was considered to be by intention to treat. Atotal of 165 patients were included in the study. The stoppingrule was not used in any of these patients.
Overall, the mean age of the patients was 32.6 � 11.7years. There were 132 (80.0%) men and 33 women (20.0%).The mean ISS was 25.8 � 9.6 points, the mean NISS was29.0 � 9.7 points, and the mean RTS was 0.88 � 0.43 points.The mechanism of injury was a car accident in 116 (70.3%)cases, a motorcycle accident in 31 (18.8%), a fall in 4 (2.4%),suicide attempt in 4 (2.4%) and a pedestrian accident in 10cases (6.1%). Nineteen patients demonstrated bilateral fem-oral shaft fractures. There were 42 (25.5%) open fractures.Among these, 16 (9.6%) were grade 1 open fractures; 16(9.6%) were grade 2 open fractures and 10 (6.1%) were grade3 open fractures. Bilateral fractures were present in 9 patients(12.7%) in external fixation group, and in 10 patients (10.6%) inthe intramedullary nailing group. The amount of blood unitsadministered within the first 24 hours was 366.8 � 695.4 mL.
In terms of postoperative outcomes, the duration of theintensive care unit stay was 239.8 � 269.9 hours and theduration of ventilation 163.4 � 216.1 hour. Overall, 21% ofpatients developed pneumonia, 24% developed ALI, 36%were diagnosed with SIRS, 5% had MOF, and 13% experi-enced sepsis. There were no diagnoses of intraoperative fatembolism in patients undergoing a femoral nail, and no fatembolism syndrome diagnosed postoperatively. One patientdied 1 week after trauma from secondary cerebral herniation.
None of the patients who presented with open fracturesrequired coverage with a muscle flap, free flap or skin graftfor the femoral injury. One patient required a skin graft and1 patient required a muscle flap after an open tibia fracture.No osteomyelitis was observed. In the group submitted toexternal fixation, a crust was present in 19 (26.7%) patients,serous secretion in 5 (7.04%), inflammation and reddeningaround the screws in 17 (23.9%) and infection requiring localdebridement in 2 (2.8%) patients.
Of the 165 patients in the study, 71 (43.0%) wererandomized to the external fixation treatment group and 94(56.9%) were randomized to the intramedullary nailing treat-
ment group. Comparisons between the 2 groups on demo-graphic characteristics and initial injury severity are pre-sented in Table 1. Analyses indicated that patients in theexternal fixation group exhibited significantly higher RTSs,ISSs, and head trauma scores than patients undergoing initialintramedullary nailing of the femur. No other statisticallysignificant differences between the 2 groups in terms ofdemographic characteristics or initial injury severity werefound. For example, there was no difference in the number ofopen versus closed fractures across the 2 treatment groups,with 16 (22.5%) open fractures in the external fixation groupand 26 (27.7%) in the intramedullary nailing group. Therewere 6 (8.5%) grade 1 open fractures in the external fixationgroup and 10 (10.6%) in the intramedullary nailing group; 7(9.8%) grade 2 open fractures in the external fixation groupand 9 (9.6%) in intramedullary nailing group; 3 (4.2%) grade3 open fractures in the internal fixation group, and 7 (7.4%)in the intramedullary nailing group. Bilateral fractures werealso similar across the 2 groups, with 9 patients (12.7%) fromexternal fixation group and 10 patients (10.6%) from in-tramedullary nailing group experiencing bilateral fractures.
Comparisons between the 2 treatment groups on indicesof postoperative course and complications are present inTable 2. Because patients in the external fixation groupexhibited more severe injuries than patients the intramedul-lary nailing group as indicated by their higher RTS, NISS,and head trauma scores, these indices of injury severity werestatistically controlled for in regressions examining treatmentgroup differences on postoperative outcomes. Results indi-
TABLE 1. Treatment Group Differences on DemographicCharacteristics and Initial Injury Severity
cated that there were no significant differences between the 2treatment groups in terms of postoperative course and com-plications after accounting for group differences in initialinjury severity.
Analyses documenting differences between stable (n �121, 72.7%) and borderline (n � 44, 27.3%) patient groups in
terms of initial injury severity and postoperative outcomes arepresented in Table 3. These analyses validated the notion thatborderline patients have significantly worse injuries and post-operative outcomes than stable patients. In terms of initialinjury, borderline patients demonstrated higher scores on therevised trauma index, injury severity index, and head andthorax injury indices in comparison with stable patients.Borderline patients were also more likely to have a bilateralfemoral fracture, a hemothorax, and require a blood transfu-sion within 24 hours of admission in comparison with stablepatients. In terms of postoperative outcomes, borderline pa-tients spent more hours in the ICU and more hours onventilation in comparison stable patients. Borderline patientswere also more likely than stable patients to experienceclinical complications such as ALI, SIRS, sepsis, and MOF.
The final set of analyses examined the influence oftreatment group status on postoperative clinical course andcomplications separately for stable and borderline patients(Table 4). Again, regression analyses statistically controlledfor differences between the 2 treatment groups in terms ofinitial injury severity (ie, RTS, new injury severity index,head injury score) when examining group differences. Forpatients who presented in stable condition, those who under-went intramedullary nailing experienced a shorter duration ona ventilator in comparison with those in the external fixationcondition. In contrast, borderline patients that underwentinitial nailing of the femur had a higher incidence of ALI incomparison with those who underwent external fixation.After adjusting for initial injury severity, the odds of devel-oping ALI were 6.69 times greater in borderline patients whounderwent intramedullary nailing in comparison with thosewho underwent external fixation.
DISCUSSIONFor patients with severe injuries and those in uncertain
or critical condition, general surgeons modified their surgicaltreatment strategy for multiply injured patients more than adecade ago. A temporizing approach (damage control) wasdeveloped to focus on initial hemorrhage control only, fol-lowed by definitive care of the lesion once the patient had
TABLE 3. Differences Between Stable and BorderlinePatients on Initial Injury Severity, Clinical Course, andClinical Complications
Multiple organ failure (%) 5.0 5.0 OR � 1.05 0.21–5.23 0.953
Regression analyses represent the relation between treatment condition (0 � external fixation, 1 � intramedullary nailing) and each outcome aftercontrolling for initial treatment group differences on the revised trauma score, New Injury Severity Score, and AIS head score. Cox regression withrobust standard errors was used for outcomes involving hours until release from ICU and hours until taken off ventilator. Logistic regression withrobust standard errors was used for binary outcomes.
been stabilized. The clinical course of patients undergoing thetemporizing approach has been so convincing that a prospec-tive randomized study has not been required to achieve thesemanagement changes.30–36 In contrast, in the orthopedicliterature a longstanding controversy continues regardingwhether or not initial surgical stabilization of major extremityfractures should be definitive in all cases, or if in certainsubgroups, the surgical procedure creates a secondary insultand should be avoided.10,37 The available retrospective stud-ies have been criticized because of the long study period,38
the inclusion criteria, the injury severity, the inclusion ofisolated fractures,9,10,39 the distribution of additional injuries(chest trauma)40,41 or the fixation method.42 So far 3 prospec-tive randomized studies have investigated the effect of frac-ture fixation on the postoperative clinical course. Thesestudies examined the timing of fracture stabilization (tractionvs. surgery within or after 24 hours after injury),10 or theeffects of the operative procedure (reaming vs. nonreaming ofthe femoral canal) on the clinical course.13,14 To our knowl-edge, the present study is the first prospective randomizedtrial that investigates whether temporary or definitive initialfixation (external fixation vs. nailing) of the femoral shaftfracture is advantageous, in regard to the clinical condition.Despite the prospective randomized protocol, several limita-tions have to be considered in the current study.
First, because of the differences in injury severitiesbetween the 2 intervention groups (external fixation vs. in-tramedullary nailing), one may wonder whether selection biashas occurred. However, to minimize this risk, group assign-ment was determined by a numbered and sealed envelope,which was sent to the participating centers. Therefore, allinvestigators were unaware of which group a patient wouldbe assigned until consent was obtained and the patient wasfound appropriate for inclusion in the study. We thereforefeel that selection bias can be ruled out as a cause for thedifferences in injury severity described above. In this line, itis of note that uneven distributions are unavoidable despiteuse of a prospective randomized study design.43–45 In addi-
tion, this concern has been addressed by using a multivariateanalysis, which corrected for the differences in injury severityand distribution (eg, head injuries).
Second, most studies performed in single institu-tions1,6,9,10 have used ventilation time as an end point. Wechose not to do so because the protocols for weaning patientsoff the ventilator may have differed between the participatinginstitutions and standardization was not possible. In line withthis, none of the 3 previous prospective randomized stud-ies10,13,14 has included a protocol for weaning. Their maingroups demonstrated a similar variation in ventilation timesas the current investigation. In addition, ventilation time iswell known to be influenced by the presence of severe headtrauma.46,47 Although patients in the external fixation groupexhibited higher levels of head trauma than those who un-derwent intramedullary nailing, patients in stable conditionwho received external fixation had a longer duration on aventilator than those who received intramedullary nailing,even after controlling for differences in initial injury severity.As a result, external fixation should not be recommended forpatients in stable condition as it produced no added benefitsin terms of clinical complications, and seemed to delayclinical recovery. This finding confirms previous studies,namely Bone’s hallmark publication in that early fracturefixation in stable patients is beneficial.10
Third, criticism may arise because ALI was the mainend point and no further significant group differences in lifethreatening complications were detected apart from ALI.However, similar trends occurred in the other parameters andthese were associated with sustained changes in the ORs.Moreover, ALI is known as a distinct clinical complica-tion48,49 and has been used as a relevant and reliable end pointin numerous previous prospective investigations, and mayhave sustained clinical sequelae.50,51
Fourth, the sample size may be viewed as being toosmall. However, the current study overlooks 165 patientswith multiple injuries, among whom 44 were in uncertaincondition. In comparison, the previous largest prospective
TABLE 4. Treatment Group Differences in Clinical Course and Complications for Patients in Stable and Borderline Condition
Pneumonia 23.8% 6.5% OR � 0.40 0.11–1.50 0.176 38.9% 45.0% OR � 1.00 0.22–4.59 0.995
ALI 28.6% 12.9% OR � 0.39 0.14–1.08 0.170 16.7% 52.4% OR � 6.69 1.01–44.08 0.048
ARDS 9.5% 6.3% OR � 0.73 0.15–3.53 0.700 11.1% 16.7% OR � 2.01 0.13–31.91 0.618
SIRS 30.2% 30.8% OR � 1.49 0.62–3.57 0.367 50.0% 52.6% OR � 0.73 0.17–3.24 0.684
Sepsis 11.9% 6.3% OR � 0.60 0.15–2.36 0.469 11.1% 36.8% OR � 3.86 0.46–32.52 0.214
MOF 0.0% 0.0% 16.7% 22.2% OR � 0.78 0.13–4.75 0.791
Regression analyses represent the relation between treatment condition (0 � external fixation, 1 � intramedullary nailing) and each outcome after controlling for initial treatmentgroup differences on the revised trauma score, New Injury Severity Score, and AIS head score. Cox regression with robust standard errors was used for number of hours until releasefrom ICU and hours until taken off the ventilator. Logistic regression with robust standard errors was used for binary outcomes.
randomized publication summarized 83 patients with multi-ple injuries.10 Other prospective randomized studies had asmaller sample of patients with multiple injuries.13,14 Amongthe retrospective studies, Reynolds et al52 looked at theinfluence of chest trauma and summarized the data of 105multiply injured patients from a single institution over a 10year period. Among these, they compared 35 patients under-going early (�24 hours) nailing versus 13 patients undergo-ing nailing 24 to 48 hours after injury. They describe that theincidence of pulmonary complications was slightly higher inpatients who received an intramedullary nail �24 hours, butno significant difference was measured and the data were notcontrolled for injury severity or other variables, such as thepresence of head trauma.52 Most recently, the effect of failureto perform a damage control approach on mortality wasreported from a large data base. There were 64 patients whohad recognized errors in care that contributed to their death.In 5 of them (7%), these were associated with unduly longinitial operative procedures.53 Thus, in view of significantdifferences based on our multivariate analysis, we feel thatthe data set is solid despite a limited number of patients in theborderline subgroup.
Also, there is ample evidence that patients in uncertainand critical condition are at high risk for complications anddeath if they are submitted to inappropriate initial surgicalstrategies.6,7,9,14 Based on meetings with the participatingcenters and suggestions by the Institutional Review Boardcommittees, it was deemed unethical to randomize patientswith high ISSs and those at high risk of developing compli-cations due to their injury distribution. Finally, had theinclusion of patients with very severe injuries been per-formed, we would most likely have found more life threat-ening complications, but differentiating these complicationsinduced by the injuries and the effects of the initial surgerymight not have been possible.3,5,9,35,37,38
In contrast to the potential drawbacks discussed above,we have tried to control for several other variables that mightinterfere with the reliability of our data. Chest trauma is amajor risk factor for the development of pulmonary dysfunc-tion4,21 and was documented in detail, especially in regard topulmonary contusions.22,54 Bilateral pulmonary contusionswere documented separately, because they carry the highestrisk for the development of lung failure.55,56 The parametersthat were used in this study to quantify the degree of thoracicinjuries have previously been demonstrated to differentiatedifferent degrees of chest trauma appropriately.21,22
Only midshaft femoral fractures were studied, becauseit is well described that the pattern of the femoral fracture hasan influence on the clinical course by determining the pres-sure effects observed during intramedullary fixation.57–59
Previous authors excluded proximal fractures and fracturepatterns where an ipsilateral femoral neck or subtrochantericfracture was present,13 or provided even more specific inclu-sion criteria.14
Finally, the grading system12,26 for differentiating be-tween stable and borderline patients seems to have provideda reliable differentiation between a borderline and a stablecondition. Patients graded as borderline had a higher injury
severity and other parameters indicative that their status wassignificantly worse. These parameters were obtained beforeand independent of the surgical procedure (eg, hemoglobinvalue on admission, RTS). We therefore feel that the resultsof this study are more valid than the retrospective studiescited above that tried to determine the influence of fracturefixation of the femur and the degree of trauma on the clinicaloutcome. Our results demonstrate an association between asurgical intervention and the postoperative clinical course inpatients with multiple injuries. This seems to be related to thedistribution of injuries and severity of certain injury patterns.Specifically, the following key observations were made:
1. When the 2 treatment groups are compared, patients whounderwent initial external fixation were more severelyinjured and had a higher degree of head trauma. Aftercorrection for these differences in initial injury severity,the incidence of general complications was comparableacross the 2 treatment groups for the sample as a whole.
2. For stable patients, there was a longer duration of venti-lator care required for patients who underwent externalfixation in comparison with those who underwent in-tramedullary nailing, even after controlling for group dif-ferences in initial injury severity.
3. In patients whose condition was borderline, a higherincidence of ALI occurred in those patients who under-went initial fixation of the femur with an intramedullarynail. In comparison with patients in borderline conditionwho underwent external fixation, the odds of developingALI was over 6 times greater in borderline patients whounderwent intramedullary nailing.
Regarding the finding that overall there was a similarrate of complications when comparing the 2 methods oftreatment, one would expect that the higher injury severity inthe subjects that underwent external fixation is relevant forthe hospital course, and a higher incidence of complicationsin this group would be expected. In fact, a trend toward ahigher rate of pneumonia was observed. Because all otherAIS values were comparable, the higher ISS value is bestexplained by the higher degree of head trauma in the patientsthat underwent external fixation. The external fixation groupdemonstrated a trend toward longer duration of ventilationand of intensive care, which may also be related to the degreeof head injuries, which was sustained in 3 patients. Therelationship between head injury and an increased duration ofventilation and intensive care therapy has been extensivelydescribed and is outlined above.60 In addition, a higherdegree of hemorrhagic shock may have altered the clinicalcourse of head injured patients, because the effect of hemor-rhagic episodes on the clinical course of head injured patientshas been well reported.61,62
The second finding demonstrates that patients with anuncertain (borderline) condition have an increased incidenceof pulmonary complications if they undergo early definitivefixation of a femur fracture. The relevance of fracture fixationin regard to the pulmonary changes is supported by a com-parable incidence of bilateral lung contusions and otherparameters of chest trauma, including the AIS of the chest
Annals of Surgery • Volume 246, Number 3, September 2007 Initial Stabilization for Femoral Shaft Fractures
between the 2 treatment groups. It is noteworthy that a trendtoward higher injury severity and a worse trauma score onadmission was present in the group that underwent externalfixation, indicating that these patients were in potentiallyworse condition before having their femur stabilized with anexternal fixateur. In addition, the severity of head injuries washigher in the group randomized to external fixation. Theseparameters clearly put patients in the external fixateur groupat a higher risk of complications. Nevertheless, patientsstabilized with an external fixateur developed a significantlylower incidence of ALI than patients that underwent in-tramedullary nail fixation and there was no difference in theintensive care stay. After correction by multivariate analysis,the index groups differed again regarding their complicationrate. Given these considerations, it is very likely that in thissubgroup the impact of surgery has had an influence on thehospital course.
This finding is in agreement with data on the inflam-matory response, determined from a subset of these pa-tients.63 It is also supported by the results obtained from atrauma registry that proved the importance of the surgicalimpact on the posttraumatic course.38 Furthermore, a largeprospective cohort study has documented clinical benefits forpatients who undergo early external fixation followed byconversion to an intramedullary nail.9
One potential drawback to the DCO approach is thedevelopment of local infections due to prolonged externalfixation, deriving from the pin sites of Schanz screws.64,65
We have previously monitored patients in which the conver-sion from an external fixateur to an intramedullary device wasperformed. Patients had an increased risk for an infection ifthe application of the external fixateur was prolonged, ie,longer than 2 weeks after injury.66 In the current study, thetime to conversion from external fixation to intramedullaryfixation was 6 (range, 1–20) days. As in other studies,4,6 inselected patients the clinical condition did not improveenough to allow us to perform a timely conversion, but ingeneral this was achieved within the 2 week interval.
In summary, this study confirms that for multiply in-jured patients in a clinically stable condition, early intramed-ullary nailing of the femoral shaft fracture continues to be thegold standard for treatment. In contrast, a higher incidence ofsystemic complications is seen if intramedullary nail fixationis performed for immediate stabilization of the femur fracturein patients who present in a borderline clinical condition.Given this, we believe that the following recommendation isjustified: In patients who present with an unclear status, thetype of surgical procedure for fixation of a femoral shaftfracture should be carefully selected, according to the initialassessment of the clinical condition. In borderline patients, anexternal fixateur should be applied for temporizing purposes.
femur traction, and the pulmonary failure-septic state. Ann Surg. 1985;202:283–295.
2. Pape H-C, Regel G, Dwenger A, et al. Influence of thoracic trauma andprim. femoral nailing on the incidence of ARDS in multiple traumapatients. Injury. 1993;24:82–103.
3. Wudel JH, Morris JA, Yates K, et al. Massive transfusion: outcome in
blunt trauma patients. J Trauma. 1991;31:1–7.4. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to
intramedullary nailing for patients with multiple injuries and with femurfractures: damage control orthopaedics. J Trauma. 2000;48:613–623.
5. Freedland M, Wilson RF, Bender JS, et al. The management of flailchest injury: Factors affecting outcome. J Trauma. 1990;30:1460–1468.
6. Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of externalfixation to intramedullary nailing for fractures of the shaft of the femurin multiply injured patients. J Bone Joint Surg Am. 2000;82:781–788.
7. Giannoudis PV. Surgical priorities in damage control in polytrauma.J Bone Joint Surg Br. 2003;85:478–483.
8. Roberts CS, Pape HC, Jones AL, et al. Damage control orthopaedics:evolving concepts in the treatment of patients who have sustainedorthopaedic trauma. Instr Course Lect. 2005;54:447–462.
9. Taeger G, Ruchholtz S, Waydhas C, et al. Damage control orthopedicsin patients with multiple injuries is effective, time saving, and safe.J Trauma. 2005;59:409–417.
10. Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabiliza-tion of fractures. J Bone Joint Surg. 1989;71:336–339.
11. Bosse MJ, MacKenzie EJ, Riemer BL, et al. Adult respiratory distresssyndrome, pneumonia, and mortality following thoracic injury and afemoral fracture treated either with intramedullary nailing with reamingor with a plate. A comparative study. J Bone Joint Surg Am. 1997;79:799–809.
12. Pape H-C, Giannoudis P, Krettek C. The timing of fracture treatment inpolytrauma patients—relevance of damage control orthopaedic surgery.Am J Surg. 2002;183:622–629.
13. Anwar IA, Battistella F, Neimann R, et al. Femur fractures and lungcomplications—a prospective randomized study of reaming. Clin OrthRel Res. 2004;422:71–76.
14. Canadian Orthopaedic Trauma Society. Reamed versus unreamed in-tramedullary nailing of the femur: comparison of the rate of ARDS inmultiply injured patients. J Orthop Trauma. 2006;20:384–387.
15. Bhandari M, Giannoudis PV. Evidence-based medicine: what it is andwhat it is not. Injury. 2006;37:302–306.
16. Osler T, Baker SP, Long W. A modification of the injury severity scorethat both improves accuracy and simplifies scoring. J Trauma. 1997;43:922–926.
17. Baker SP, O’Neill B, Haddon W, et al. The injury severity score: Amethod for describing patients with multiple injuries and evaluatingemergency care. J Trauma. 1974;14:187–196.
18. Champion HR, Copes WS, Sacco WJ, et al. A revision of the TraumaScore. J Trauma. 1989;29:623–629.
19. Teasdale G, Jennett B. Assessment of coma and impaired consciousness,a practical scale. Lancet. 1974;13:81–84.
20. Bernard GR, Artigas A, Brigham KL, et al. The American-EuropeanConsensus Conference on ARDS. Definitions, mechanisms, relevantoutcomes, and clinical trial coordination. Am J Respir Crit Care Med.1994;149:818–824.
21. Tyburski JG, Collinge JD, Wilson RF, Eachempati R. Pulmonary con-tusions: Quantifying the lesions on chest x-ray films and the factorsaffecting prognosis. J Trauma. 1999;46:833–838.
22. Pape H-C, Remmers D, Rice J, et al. Appraisal of early evaluation ofblunt chest trauma: Development of a standardized score for clinicaldecision making. J Trauma. 2000;49:496–504.
23. Stevens LE. Gauging the severity of surgical sepsis. Arch Surg. 1983;118:1190–1192.
24. Moore FA, Moore EE, Pogetti R, et al. Gut bacterial translocation via theportal vein: a clinical perspective with major torso trauma. J Trauma.1991;31:629–638.
25. Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br.1970;52:732–736.
26. Pape HC, Giannoudis PV, Krettek C, et al. Timing of fixation of majorfractures in blunt polytrauma: role of conventional indicators in clinicaldecision making. J Orthop Trauma. 2005;19:551–562.
28. Gustilo RB, Mendoza RM, Williams DN. Problems in the managementof type III (severe) open fractures: a new classification of Type III openfractures. J Trauma. 1984;24:742–746.
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35. Moore EE, Burch JM, Franciose RJ, et al. Staged physiologic restorationand damage control surgery. World J Surg. 1998;22:1184–1191.
36. Hirshberg A, Walden R. Damage control for abdominal trauma. SurgClin North Am. 1997;77:813–820.
37. Rixen D, Grass G, Sauerland S, et al. Polytrauma Study Group of theGerman Trauma Society. Evaluation of criteria for temporary externalfixation in risk-adapted damage control orthopedic surgery of femurshaft fractures in multiple trauma patients. J Trauma. 2005;59:1375–1395.
38. Pape H-C, Hildebrand F, Pertschy S, et al. Changes in the managementof femoral shaft fractures in polytrauma patients: From early total careto damage control orthopaedic surgery. J Trauma. 2002;53:452–462.
39. Buckley R, De Groote R, Powell JP. A prospective randomized trialcomparing reamed versus unreamed intramedullary nailing of femoralshaft fractures: assessment of pulmonary dysfunction. In: Proceedings ofthe Annual Meeting of the Orthopaedic Trauma Association, Vancouver;1998:111–112.
40. Bone LB, Anders MJ, Rohrbacher BJ. Treatment of femoral fractures inthe multiply injured patient with thoracic injury. Clin Orthop Relat Res.1998;347:57–61.
41. Pape H-C, Auf’M’Kolck M, Paffrath T, et al. Primary intramedullaryfemur fixation in multiple trauma patients with associated lung contu-sion—a cause of posttraumatic ARDS? J Trauma. 1993;34:540–548.
42. Carlson DW. Femur fractures in chest-injured patients: is reamingcontraindicated? J Orthop Trauma. 1998;12:164–168.
43. Bono CM, Tornetta P. Errors in the design of orthopaedic studies. Injury.2006;37:355–360.
44. Ehrlich PF, Newman KD, Haase GM. Lessons learned from a failedmultiinstitutional randomized controlled study. J Pediatric Surg. 2002;37:431–436.
45. Bhandari M, Pape HC, Giannoudis PV. Issues in the planning andconduct of randomised trials. Injury. 2006;37:349–354.
46. Bakay L. Brain injuries in polytrauma. World J Surg. 1983;7:42–48.47. Siegel JH, Gens DR, Manatov T, et al. Effect of associated injuries and
blood volume replacement on death, rehabilitation needs, and disabilityin blunt traumatic brain injury. Crit Care Med. 1991;19:1252–1265.
48. Kou YR, Bien MY. Ventilatory management of acute lung injury byneurally adjusted ventilatory assist and positive end-expiratory pressure.Crit Care Med. 2006;34:3055–3056.
49. Vincent JL, Zambon M. Why do patients who have acute lung injury/acute respiratory distress syndrome die from multiple organ dysfunctionsyndrome? Implications for management. Clin Chest Med. 2006;27:725–731.
50. Avecillas JF, Freire AX, Arroliga AC. Clinical epidemiology of acutelung injury and acute respiratory distress syndrome: incidence, diagno-sis, and outcomes. Clin Chest Med. 2006;27:549–557.
51. Hough CL. Neuromuscular sequelae in survivors of acute lung injury.Clin Chest Med. 2006;27:691–703.
52. Reynolds MA, Richardson JD, Spain DA, et al. Is the timing of fracturefixation important for the patient with multiple trauma? Ann Surg.1995;222:470–478.
53. Gruen RL, Jurkovich GJ, McIntyre L, et al. Patterns of errors contrib-uting to trauma mortality: lessons learned from 2594 deaths. Ann Surg.2006;244:371–380.
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pulmonary contusion. J Trauma. 1986;26:695–697.57. Sturmer KM, Schuchardt W. Neue Aspekte der gedeckten Marknage-
lung und des Aufbohrens der Markhohle im Tierexperiment. Teil II: Derintramedullare Druck beim Aufbohren der Markhohle. Unfallheilkunde.1980;83:346–352.
58. Sturmer KM. Measurement of intramedullary pressure in an animalexperiment and propositions to reduce the pressure increase. Injury.1993;24(3):7–21.
59. Wenda K, Runkel M, Rudig L, et al. The effect of bone marrowembolization on the choice of procedure in the stabilization of femoralfractures. Orthopaede. 1995;24:151–163.
60. Giannoudis P, Veysi V, Pape H-C, et al. When should we operate onmajor fractures in patients with severe head injuries? Am J Surgery.2002;183:261–267.
61. Pietropaoli JA, Rodgers FB, Shackford SM, et al. The deleterious effectof intraoperative hypotension on outcome in patients with severe headinjuries. J Trauma. 1992;33:403–407.
62. Jaicks RR, Cohn SM, Moller BA. Early fixation may be deleterious afterhead injury. J Trauma. 1997;42:1–5.
63. Pape H-C, Grimme K, van Griensven M, et al. Impact of intramedullaryinstrumentation versus damage control for femoral fractures on immu-noinflammatory parameters in a prospective randomized analysis.J Trauma. 2003;55:1–7.
64. Tornetta P, DeMarco C. Intramedullary nailing after external fixator ofthe tibia. Bull Hosp Jt Dis. 1995;54:5–13.
65. Blachut PA, Meek RN, O’Brien PJ. External fixation and delayedintramedullary nailing of open fractures of the tibial shaft. A sequentialprotocol. J Bone Joint Surg Am. 1990;72:729–735.
66. Harwood PJ, Giannoudis PV, Probst C, et al. The risk of local infectivecomplications after damage control procedures for femoral shaft frac-ture. J Orthop Trauma. 2006;20:181–189.
DiscussionsDR. LEWIS M. FLINT, JR. (TAMPA, FLORIDA): My interest
in the role of fracture management in the total care of theinjured patient became sharply focused when I had the honorof working with the late Dr. John Border and the recentlydeceased Dr. Roger Seibel at the trauma center in Buffalo,New York.
The report that Dr. Pape lists as reference number 1in the bibliography of his paper is the published manu-script Border presented to the meeting of this Associationin 1985. The 1985 report recounted the results achieved byDr. Border’s team with the use of early definitive fixationof femur fractures as a means of reducing the risk ofpost-injury sepsis and pulmonary failure in the injuredpatient.
John Border felt that early control of all surgicallyrepairable injuries, including femur fractures, combined withaggressive protein based nutrition and early mobilization ofthe patient were keys to reducing the risk of these complica-tions. The elimination of prolonged femur traction and themobilization of the patient out of what John termed the“supine crucifixion position” were, he felt, critical compo-nents leading to the success of this approach. He restrictedthis approach to patients who would be able to get out of bed
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after fracture repair and his patients were clinically more likethose in your “stable” group.
Over time, trauma surgeons and trauma orthopedicsurgeons have extended this approach of early placement ofintramedullary nails in femur fractures to aggressively treatmore severely injured patients and complication rates haveincreased possibly due to the added inflammatory stimulus ofthe operation to fix the fracture to a patient whose inflamma-tory response is already primed. It is also possible that John’semphasis on nutrition and mobilization have not been appliedas he originally suggested.
These deteriorating outcomes led to the concept of“damage control orthopedics”, which is the concept understudy in this report. Using the damage control approach,patients receive fixation of the fracture using an externalframe followed by aggressive critical care to stabilize thepatient for a later definitive repair of the fracture with anintramedullary nail.
You have shown an increase in acute lung injury andsepsis as defined by the critical care community whenfemur fracture fixation with an intramedullary nail is usedin severely injured high-risk patients. In my view, how-ever, a major contribution that this report makes is that aseries of bedside assessments done early in the resuscita-tive phase can identify those high-risk patients, and thepatients best identified can be assigned to internal fixation.By whatever means the fracture is dealt with, these high-risk patients consume large amounts of resources and arecritically ill.
You have also shown, by identifying good risk patients,that there is a group of patients where intramedullary nailinggives better results than internal fixation. Because of the skillof your surgeons and excellent critical care, there were nodeaths in the high-risk patients. There were fewer days ofcritical care support required in the patients assigned tointernal fixation. These are important observations. I haveseveral questions.
I have some methodologic concerns. Did all centerscontribute patients equally? Your study involved 10 centersover 74 months. This would mean the center would, onaverage, enroll a patient about every 4 to 5 months. At mycenter, there are, on average, 5 early femur fracture repairswith an intramedullary nail and 7 external fixation proceduresfor femur fractures per month. Because of the volume out-come relationship that exists in trauma units, it would beuseful to know the contribution from each center and thedistribution of complications among centers. Could youplease address these issues?
Second, was the protocol for nutrition and mobilizationstandardized for the enrolled patients? Were these the samefor patients treated with intramedullary nails as well asexternal fixators? How many of each group reached nutri-tional and mobilization goals?
Finally, I believe most trauma surgeons would agree thatdamage control is a concept that seems to work and makesclinical sense. Does your study prove its value for high-riskpatients with femur fractures or is more data needed from othercenters in other countries to confirm this approach?
DR. HANS C. PAPE (PITTSBURGH, PENNSYLVANIA): First ofall, there is quite a difference in the organization of traumacare between Europe and the United States. First, there is nogeneral versus orthopedic surgeon in the European system.Second, recently orthopedic centers in Europe have beenobliged for financial reasons to treat fair numbers of electivetrauma cases due to the integration of the DRG system in theGerman reimbursement. Ever since I came to work in Pitts-burgh, my practice has changed and I am taking care of acutefractures only. In the wintertime when things get slower, I doa little bit more elective work in terms of non-unions andcorrective surgery of extremities. Also, I have learned that thecaseload and the general volume are higher in the UnitedStates than in Europe, which is due to the size of the capturearea. This may explain the higher patient numbers that youmentioned.
As far as the patient numbers in the centers are con-cerned, there were differences, of course. We looked specif-ically at whether variances of the complications depended onspecific centers. First of all, we investigated the complicationrate in the city hospitals versus the academic centers. Therewas no difference. We also looked at those who enrolledfewer versus more than 10 patients. And again, there was nodifference. The 2 centers who included the largest volumewere Hanover and Leeds. And these two did have a slightlyhigher complication rate, which was unexpected, but thenagain these 2 centers included patients with the highestinjury severity scores. In summary, I do believe that therewas no center specific complication rate that could haveflawed our results.
As far as the ICU treatment is concerned regardingexternal fixation versus IM nailing, the same protocol wasused and the patients were weaned off the ventilator when-ever possible. I am not aware of substantial differences innutritional status, but I have to admit that we did not focus onthat specifically.
As far as further study is concerned, there is a group of16 centers within the United States that is planning to performa study with larger patient numbers and which, to my mind,will hopefully add even more to our knowledge.
DR. CARL E. BREDENBERG (CAPE ELIZABETH, MAINE): Ihave 2 questions. The first is, in the group that initiallyunderwent external fixation, how long was it before theyunderwent definitive internal fixation? Historically, externalfixation was used as a prolonged and often the only treatment,and it is against that standard that early internal fixation wasshown to be preferable. Is this an example of what others
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have described as comparing early fixation versus very earlyfixation or perhaps early fixation versus too early fixation?My second question, was there evidence of fat embolizationconsequent to intramedullary nailing?
DR. HANS C. PAPE (PITTSBURGH, PENNSYLVANIA): As faras the conversion time is concerned, it certainly is an issue.Orthopedic surgeons are always concerned about intramed-ullary infection, so it is something that must be kept in mind.The conversion time in the stable patient group was 48 hoursand in the borderline patient group was about 5 days. Lastyear my group published a cohort study in the Journal ofOrthopaedic Trauma that looks at the infection rate afterexternal fixation in more than 150 patients. It appeared thatthe conversion must be performed within a week. Superficialinfection mainly occurred in patients in whom the conversiontook place after more than 14 days. But even in that subgroupthere were no deep infections. Nevertheless, I think we haveto look closely at this issue.
Also, another important issue to stress is to try andstabilize the patient as early as possible. The bottom lineshould be to avoid traction. To my mind it is better to have apatient with a relatively stable leg with an external fixator inthe ICU because you never know what will happen during theupcoming posttraumatic days. Even Dr. Border points outthat it is better to have a patient stabilized right away withwhatever method is available rather than not fixing him withan external fixator and leaving him in traction.
As far as the second question is concerned, we did lookspecifically at fat embolism. There was no identifiable patientin whom the deterioration was due solely to fat embolism inthat borderline group.
DR. H. GILL CRYER (LOS ANGELES, CALIFORNIA): I have acouple of questions.
First of all, the definition of acute lung injury as youdefined it was not clear to me. But the question I have for youis, what was the effect of that? If you developed acute lunginjury, how long did they require ventilator support?
The second question I have relates to the group in theexternal fixator group that developed acute lung injury. Werethere any of those that did not ever get definitive fixation asa result of developing ARDS and acute lung injury? Did anyof the patients in the external fixator group never get fixed;never get an intermedullary rod, because they developedacute lung injury or ARDS?
DR. HANS C. PAPE (PITTSBURGH, PENNSYLVANIA): Welooked at the issue of how the acute lung injury affects the
general course, and it appeared there was an increase in theventilation time of about 5 days. Three of the patients withacute lung injury or who developed ARDS in the ex fix grouphad acute lung injuries in the first place, and there was no caseof pulmonary worsening after external fixation.
All patients who had an external fixator were convertedto an intramedullary nail. For the stable patients the meanconversion time was 5 days, mainly due to chest trauma; forthe borderline group it was 16 days, mainly due to chest andhead trauma. I do believe that there may be an issue withpatients who are never converted from an external fixateur toan IM nail, but I believe that would be in the patient groupswho are more severely injured and in worse condition.
DR. JONATHAN R. HIATT (LOS ANGELES, CALIFORNIA): Myquestion relates to one of your first answers. In Europe, theorthopedic surgeon is often the traumatologist, and in theUnited States the general surgeon. Here in the United Stateswe have something of a crisis in specialty support of ourtrauma centers. In the past our group and others have pro-posed training for a general trauma surgeon who couldperform not only general surgical procedures but also some ofthe orthopedic and neurosurgical procedures for which welack support. Could you envision a day when the generalsurgeon might be able to do early fixation of these fractures?
DR. HANS C. PAPE (PITTSBURGH, PENNSYLVANIA): I thinkthat is a very political question. I personally find it helpful tohave a general surgeon who is in charge of the generalmanagement. In many European centers, the visceral surgeryis no longer done by the trauma surgeon. Instead, generalsurgeons open the abdomen and thoracic surgeons open thechest. When I was the senior attending in Hannover, Ger-many, we would meet in the emergency room with thegeneral surgeons if there was an abdominal trauma. Wewould also go to the CT scanner together, and then decidewho would do his or her procedures and in which sequence.
Since I came here �to the United States�, the situation isvery different. I am in the operating room fixing fractures allthe time. The general surgeon is the one who takes care of themanagement, so if I wanted to, I could stop thinking about thegeneral condition of the patient because someone else per-forms this function for me. Of course, I do think that it ishelpful to have somebody who has the whole picture andthinks about the stabilization of the extremity as well ashemorrhage control. After all, it is all about good communi-cation between the Departments.
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