How risky is early intramedullary nailing of femoral fractures in polytraumatized patients?

When is the best time to fix fractures?

The best time to operate on a fracture is governed in part by the nature of the fracture itself. It is also influenced by the premorbid condition of the patient and by the degree that associated injuries have disrupted normal processes. It is likely that some patients have a period of increased physiological risk for intervention, during which a second insult will result in further harm. The picture is not yet fully clear but relates to variations in the inflammatory response to trauma. One consistent lesson appears to resonate throughout the published literature. The most predictable risk factor for iatrogenic physiological disturbance is transfer to the operating theatre before adequate resuscitation of the patient has taken place.

Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury: A meta-analysis

Early intramedullary nailing (IMN) within the first 24 hours for multiply injured patients with femoral fracture and concomitant severe chest injury is still controversial. This review aimed to investigate the association between early IMN and pulmonary complications in such patients. We searched the literature up to Jan 2016 in the main electronic databases (PubMed, Web of Science, Cochrane library databases) to identify eligible studies. Data were extracted and analyzed using a Mantel-Haenszel method with random-effects model to estimate pooled odds ratio (OR) and 95% confidence intervals (CIs). Seven retrospective cohort studies were identified eventually. The pooled estimates demonstrated that the application of early IMN did not significantly increase the risk of adult respiratory distress syndrome (ARDS) (OR, 0.65; 95% CI: 0.38-1.13), mortality (OR, 0.79; 95% CI: 0.43-1.47), pneumonia (OR, 0.92; 95% CI: 0.55-1.54), multiple organ failure (MOF) (OR, 0.87; 95% CI: 0.45-1.71) and pulmonary embolism (OR, 1.81; 95% CI: 0.28-11.83). In subgroup analysis according to the type of IMN (reamed or undreamed), we did not find any significant difference either. Our results indicated that early IMN of femoral shaft fracture was not associated with increased rates of pulmonary complications in severe chest-injured patients.

Three-dimensional finite element analysis and comparison of a new intramedullary fixation with interlocking intramedullary nail

This study was set to introduce a new intramedullary fixation, explore its biomechanical properties, and provide guidance for further biomechanical experiments. With the help of CT scans and finite element modeling software, finite element model was established for a new intramedullary fixation and intramedullary nailing of femoral shaft fractures in a volunteer adult. By finite element analysis software ANSYS 10.0, we conducted 235-2,100 N axial load, 200-1,000 N bending loads and 2-15 Nm torsional loading, respectively, and analyzed maximum stress distribution, size, and displacement of the fracture fragments of the femur and intramedullary nail. During the loading process, the maximum stress of our new intramedullary fixation were within the normal range, and the displacement of the fracture fragments was less than 1 mm. Our new intramedullary fixation exhibited mechanical reliability and unique advantages of anti-rotation, which provides effective supports during fracture recovery.

Two variants of fat embolism syndrome evolving in a young patient with multiple fractures

Fat embolism syndrome (FES) is a continuum of fat emboli. Variants of FES: acute fulminant form and classic FES are postulated to represent two different pathomechanisms. Acute fulminant FES occurs during the first 24 h. It is attributed to massive mechanical blockage pulmonary vasculature by the fat emboli. The classic FES typically has a latency period of 24-36 h manifestation of respiratory failure and other signs of fat embolism. Progression of asymptomatic fat embolism with FES frequently represents inadequate treatment of hypovolaemic shock. We present a rare case of two variants of FES evolving in a patient with multiple fractures to emphasis the importance of adequate and appropriate treatment of shock in preventing the development of FES. Since supportive therapy which is a ventilatory support remains as the treatment of FES, it is appropriate to treat FES in the intensive care unit setting.

Protocol for a randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients

Background

Fractures of the long bones and femur fractures in particular are common in multiple trauma patients, but the optimal management of femur fractures in these patients is not yet resolved. Although there is a trend towards the concept of "Damage Control Orthopedics" (DCO) in the management of multiple trauma patients with long bone fractures as reflected by a significant increase in primary external fixation of femur fractures, current literature is insufficient. Thus, in the era of "evidence-based medicine", there is the need for a more specific, clarifying trial.

Methods/Design

The trial is designed as a randomized controlled open-label multicenter study. Multiple trauma patients with femur shaft fractures and a calculated probability of death between 20 and 60% will be randomized to either temporary fracture fixation with fixateur externe and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective is to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score.

Discussion

The Damage Control Study is the first to evaluate the risk adapted damage control orthopedic surgery concept of femur shaft fractures in multiple trauma patients in a randomized controlled design. The trial investigates the differences in clinical outcome of two currently accepted different ways of treating multiple trauma patients with femoral shaft fractures. This study will help to answer the question whether the "early total care" or the „damage control” concept is associated with better outcome.

Trial registration

Current Controlled Trials ISRCTN10321620

Bone marrow fat in the circulation: clinical entities and pathophysiological mechanisms

Fat embolism (FE) and fat embolism syndrome (FES) are controversial topics, particularly regarding their clinical relevance and their independency as a clinical syndrome. FE describes the presence of fat globules within the microcirculation. FES on the other hand, is a clinical syndrome characterized by the presence of FE with the manifestation of an identifiable clinical pattern of signs and symptoms. Both experimental and clinical studies have demonstrated the occurrence and the possible harmful effects of FE. For instance, FE involving the lungs can result in adult respiratory distress syndrome (ARDS). The effects of FE are certainly mechanical, leading to capillary congestion, but are also highly likely to be of a proinflammatory and prothrombotic nature. The demarcation of FES against ARDS is mainly demonstrated by the single organ involvement of ARDS, exclusively influencing the lungs, whereas FES has a multiorgan effect with pulmonary, skin and, neurological manifestations. This article is a review of the pathophysiological mechanisms of FE and the clinical occurrence and influence of FE and FES.

Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society

BACKGROUND

Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database.

METHODS

A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept.

RESULTS

Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death.

CONCLUSIONS

Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.

Rinsing-Suction Reamer Attenuates Intramedullary Pressure Increase and Fat Intravasation in a Sheep Model

BACKGROUND

Reamed intramedullary nailing causes an increase of intramedullary pressure. A new rinsing-suction reamer (RSR) can reduce this problem, and it was evaluated in animal experiments in comparison with the AO reamer (AOR) to see its effects on intramedullary pressure and fat intravasation.

METHODS

Reamed intramedullary nailing was performed in 14 sheep using the RSR or AOR. The following parameters were evaluated: intramedullary pressure, hemodynamics, blood tests, lung histology, and radiographs of the femur that was operated on.

RESULTS

Intramedullary pressure during reaming was significantly (p < 0.001) lower with RSR (9 mm, 34 mm Hg; 9.5 mm, 4 mm Hg; 10 mm, 1 mm Hg) than AOR (9 mm, 750 mm Hg; 9.5 mm, 292 mm Hg; 10 mm, 138 mm Hg). There was a significantly (p < 0.05) higher increase of pulmonary resistance in AOR (from 144 +/- 84 dyne x s x cm to 391 +/- 169 dyne x s x cm) than in RSR (from 137 +/- 51 dyne x s x cm to 258 +/- 105 dyne x s x cm) after nailing and less intravenous fat measured in RSR (0.9; AOR, 2.9; p < 0.05) at all stages of reaming, at nail insertion (RSR, 0.3; AOR, 2.7; p < 0.05), and 30 seconds after nail insertion (RSR, 0.2; AOR, 1.1; p < 0.05) proved by the Gurd test. Pco2 increased (p < 0.05) in AOR (AOR, 36 +/- 5 vs. 40 +/- 7 mm Hg; RSR, 33 +/- 4 vs. 32 +/- 3 mm Hg) and pH dropped significantly (AOR, 7.49 +/- 0.06 vs. 7.45 +/- 0.05; RSR, 7.53 +/- 0.04 vs. 7.54 +/- 0.04; p < 0.05). Semiquantitative histologic analysis proved a significant higher pulmonary fat load in AOR (13.1 +/- 13.4) versus RSR (3.9 +/- 1.5, p = 0.00002).

CONCLUSION

Because we found only a minimal increase of the pulmonary arterial pressure as a sign of pulmonary embolism, we conclude that by using the RSR, the systemic side effects caused by intravasation of medullary content during reaming could be reduced as far as possible.