Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: Damage control orthopedic surgery

Abstract

In the treatment of polytrauma patients, multiple studies have shown how the timing and the type of the initial surgery of long bone fractures influence the incidence of systemic complications. Database analyses documented that unduly long surgical procedures undertaken early after trauma increase the risk of acute respiratory distress syndrom (ARDS), especially when femoral shaft fractures are stabilized. Animal research and prospective clinical studies also support the fact that the type of stabilization of a femoral shaft fracture may influence the systemic response to trauma. Reamed intramedullary reaming and nailing for a femoral shaft fracture is associated with an increased risk of pulmonary fat embolization from the medullary canal. This can result in pulmonary compromise if certain cofactors are also present. Modified reamers have been developed to reduce this side effect. The mediating effects are immunologic changes, varying according to the magnitude of the surgical procedure. Pro-inflammatory markers (e.g., Interleukins) may be used to assess the inflammatory response to injury as well as the magnitude of surgery and the systemic impact induced by surgery. Serum levels of such markers can be used clinically to tailor the amount of surgery that is performed to the clinical condition of the patient. The potentially negative impact of excessive surgery in high-risk patients can be avoided by using a new grading system for the assessment of the clinical status of the injured patient. Most recently, a large prospective randomized multicenter study has documented that this grading system is effective for identifying these borderline patients, and that in the borderline patient a staged surgical approach, such as temporary femoral stabilization with an external fixator, reduces the incidence of systemic complications. This work has changed the surgical management of multiply injured patients toward an approach that is tailored to the clinical condition of the patient, as indicated by well-defined clinical parameters as well as objective measurements of serum cytokine levels. ß

Early surgery increases mitochondrial DNA release and lung injury in a model of elderly hip fracture and chronic obstructive pulmonary disease

“…Damage control orthopedics (DCO) is an approach that contains and stabilizes orthopedic injuries to enable improvement of the patient's overall physiology (21,27,28). Its purpose is to avoid worsening of the patient's condition by the ʻsecond hitʼ of a major orthopedic procedure and to delay definitive fracture repair until a time when the overall condition of the patient is optimized (28).…”

“…Its purpose is to avoid worsening of the patient's condition by the ʻsecond hitʼ of a major orthopedic procedure and to delay definitive fracture repair until a time when the overall condition of the patient is optimized (28). DCO has been suggested for the management of femoral shaft fractures in severely injured patients because patients were unable to tolerate the burden of early determinative surgery (21,29). A clinical study investigated the type and timing of surgery and demonstrated that improvements in the clinical status coincided with a less sustained inflammatory response if DCO was followed (30).…”

“…PMNs exert damaging effects through the release of proteolytic enzymes, reactive oxygen species and vasoactive substances when they have migrated into the lung tissue (21). According to the manufacturer's protocol, the level of MPO was measured using ABC ELISA (custom kit, R&D Systems, Inc. Minneapolis, MN, USA).…”

Preperitoneal Pelvic Packing: How and When

“…Minimizing compressive stabilization will limit the risk of pressure sores and nerve injuries that have been reported with such devices. More definitive yet expeditious stabilization with external fixation of the pelvic fracture can be performed in the operating room [5,21,30,[32][33][34]. Concurrent resuscitation of the patient during fracture stabilization is critical.…”

Damage control in thoracic and lumbar unstable fractures in polytrauma. Systematic review

“…6 In the field of orthopedics, these concepts have been well understood for the management of long bone and pelvic fractures in polytraumatized patients. 7 In the case of isolated spinal fractures, the treatment regimen has been adequately defined and standardized; however, the optimum time, and the best type of fixation to use in unstable thoracolumbar fractures in polytraumatized patients, are still controversial. 8 At present, the management of unstable thoracic and lumbar fractures consists mainly of: 1) deferred fixation after the associated lesions have been resolved or 2) a more aggressive approach called "early total care" via invasive anterior approaches, corpectomy, and anterior fusion based more on purely mechanical aspects than on the physiopathology of the traumatized patient.…”