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Damage Control In Trauma Orthopedic Surgery T...

In summary, the concept of DCO is far from being universally accepted and validated, and the cornerstone of major trauma survival continues to be the control of bleeding and the inflammatory response. Although in the case of major bleeding, blood haemoglobin concentration sensitivity may be very low, this is a key variable, together with blood pressure, to be taken into account when rapid treatment decisions must be taken.

damage control in trauma orthopedic surgery t...

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Low molecular weight heparin (LMWH) seems to be the drug of choice for AP[124], although the evidence in this respect remains insufficient. In a study carried out with 743 high-risk polytraumatised patients, in whom the AP was carried out with LMWH, the treatment was started once the patients were haemodynamically stable and the bleeding was under control. For patients with intracranial haemorrhage or spinal trauma, the AP was started when, according to the CT study, the intracranial haemorrhage was inactive. In patients with epidural analgesia, the AP with LMWH was started after removal of the epidural catheter. These patients were given a dose of 5000 units, once daily, administered by subcutaneous injection, and the AP was continued until the patient could walk independently. This treatment was maintained under the same regimen, even when the patient required further surgical treatment. The study concluded that this daily regimen with LMWH provided similar levels of safety and efficacy to those reported in previous studies when LMWH was given twice a day. In addition, the once-daily regimen, regardless of the need for further invasive procedures, obtained better results in terms of compliance[125]. Although recent attempts have been made to improve these results by dosing LMWH adjusted for thromboelastography, conclusive data have not yet been obtained[126].

The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.

The development of the ETC was made possible by the progressive improvement of osteosynthesis techniques and trauma resuscitation, involving better cardiorespiratory monitoring and the ability to perform prolonged artificial ventilation. In the late 80s, Bone et al. further strengthened this movement with their prospective study, showing the basic role of early surgery. Multi-injured patients treated with ETC appeared to have less pulmonary complications, reduced length of intensive care unit (ICU) and hospital stay (LOS), compared to patients with delayed surgery [8].

The next step is based on identification of factors that discourage immediate surgery and lead to selection for DCO. The choice of treatment depends on patient age and comorbidities. The mortality rate is higher in elderly patients [23]. Diabetic patients are subjected to peripheral vascular deficiency and increased risk of limb ischemia following high-energy fracture. Obesity is significantly associated with an increased mortality [24]. Consequently, similar anatomical injuries may lead to different outcomes, based on preexisting patient conditions. Useful prognostic factors for grading the patient clinical status and addressing treatment remain controversial. The first criteria ascertaining the suitability of blunt trauma patients for orthopedic surgery were published in 1978. The authors recommended the use of systolic blood pressure, heart rate, central venous pressure, and hematocrit for basic evaluation. In addition, cardiac index, pulmonary arterial pressure, coagulation status, and acid-base balance were found to be of value during the early period after trauma [25]. Improved knowledge of the pathophysiological mechanisms of trauma allowed identification of four significant clinical factors. Three of them correspond to the so-called lethal triad: hypothermia, coagulopathy, and acidosis [26]. Hypothermia begins at the traumatic insult and is thereafter exacerbated by hypoperfusion, prolonged exposure, and inactivity. Studies have shown that up to 21% of trauma patients are hypothermic at presentation; this figure increases to 46% when patients leave the operating room [27]. Coagulopathy is caused by multiple factors including dilution due to aggressive fluid resuscitation, hypothermia, acidosis, and calcium levels, which have all been shown to affect both the intrinsic and extrinsic clotting cascades. Acidosis is often the result of hemorrhage and shock [11]. Soft tissue injuries are the fourth parameter and may affect the extremities, lung, abdomen, and pelvis.

The poor prognosis of pelvic fractures is related to the high incidence of hemorrhagic shock, due to the anatomical proximity of arteries and veins. Fracture and vascular injury can cause the formation of hematoma in the pelvis and retroperitoneum. This space can hold up to 4 liters of blood before the pressure within the hematoma dabs further hemorrhage [45]. In most of the cases (90%), the bleeding originates from venous disruption or from cancellous bone, while bleeding is due to an arterial injury in only 10% of cases. The mortality of polytrauma patients with pelvic fracture and unstable hemodynamics has been reported to be as high as 50% in one series [46]. Early mortality is usually secondary to uncontrolled hemorrhage, whereas late mortality is due to associated injuries and sepsis-induced MODS. With advances in resuscitation, the mortality directly related to pelvic trauma is most likely closer to 7% [44].

In the absence of a clear extrapelvic bleeding (that could explain the hemodynamic instability), the orthopedic surgeon should assume that the cause of the shock is a retroperitoneal hematoma related to the pelvic fracture. At this point, every effort should be aimed at stabilization of the fracture in order to reduce the volume of the open pelvic ring and to dab the venous bleeding. A method that has proved useful over the years is wrapping of the pelvis. This method consists in binding the pelvis with a commercial device, such as the TPOD, or with a sheet, which allows to reduce pelvic volume. This application is rapidly accomplished, is free from side effects, and is usually able to effectively staunch vein bleeding [49]; these patients can then be safely subjected to total-body CT scan. Pelvic binders have largely replaced external fixation and pelvic C-clamp as the best initial means of controlling the hemorrhage associated with unstable fractures of pelvis [50]. In spite of the fact that pelvic external fixation can be rapidly applied, reduces the pelvic volume, and provides temporary fracture stabilization, this fixation is located in front of the patient, while pelvic ring instability is predominantly posterior. By compressing the front, external fixation may widen the posterior pelvis and worsen the problem [51]. The pelvic C-clamp also allows rapid reduction and stabilization of the posterior pelvic ring, through the positioning of two nails in the coccyx and sacroiliac joint. This device does not prevent operators' access to the abdomen but can be burdened with neurological complications, particularly in the presence of sacral fractures [48].

Before deciding the type and timing of surgery, efforts must be focused on optimizing ventilatory and hemodynamic parameters and normalizing lactate levels, by means of an adequate resuscitation strategy. The tumultuous progress in the field of molecular biology and genetics is likely to guide future treatment protocols, as suggested by the discovery of a close relationship between blood inflammatory marker levels and the risk of posttraumatic complications.

Background: Long 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/design: The 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.

Conclusions: Thus, 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.

There 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.

Data 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). 041b061a72

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