The influence of the method of initial stabilization of traumatic femoral shaft fractures on postoperative morbidity and mortality - a retrospective study.

BACKGROUND: The last 20 years have been dedicated to extensive research regarding the pathophysiology of trauma and the consequences of interventions that follow. Several theories have been proposed in terms of what causative factors are associated with poor outcome in polytrauma patients. Once the "two event model" was accepted, it became clear that patients although initially resuscitated, but in a vulnerable condition, have a high risk that a secondary aggression (for example, surgical interventions) would precipitate a state of hyperinflammation and early multiple organ dysfunction syndrome (MODS). The aim of this retrospective study was the analysis of the "second hit" phenomenon, meaning the alterations that occur in patients having femoral shaft stabilization surgery after major trauma.

METHODS: This is a retrospective study of severe polytrauma patients with femoral shaft fractures admitted to the intensive care unit of the Emergency clinical Hospital of Bucharest and treated from an orthopaedic point of view by either Damage Control Orthopaedics (DCO) or Early Total Care (ETC) principles. All patients had femoral shaft stabilization in the first 24 hours. Using patients files we recorded the following data: 30 day mortality, development of acute respiratory distress syndrome (ARDS) and MODS, local infectious complications (LIC), intensive care unit length of stay (ICU LOS), days of mechanical ventilation (MV), units of red blood cells units/48 h (RBC). We decided to analyze results in three groups - DCO group with shock on admission, DCO group without shock and ETC group.

RESULTS: We observed significantly higher mortality in the DCO shock group (25%) compared with the other two groups (ETC - 9.4%; DCO without shock - 6.7%; p = 0.042/0.015). Similar results for: ICU LOS (16.29 ± 6.7 versus 9.92 ± 4.7 and 10 ± 3.9; p = 0.001/0.002), days of MV (10.29 ± 5.7 versus 6.83 ± 4.7 and 6.8 ± 3.4; p = 0.007/0.04), units of RBC/48 h (15.04 ± 4.3 versus 8.08 ± 4.3 and 7.33 ± 1.5; p = 0.007/0.04). Although not statistically significant, MODS and ARDS incidences were higher in the DCO shock group: MODS (41.7% versus 22.6% and 20%; p = 0.08/0.17), ARDS (29.2% versus 17% and 20%; p = 0.22/0.53). These results correlate with a higher trauma score in these patients, more serious lesions requiring several damage control procedures. In the other two groups (DCO without shock and ETC) all outcomes were similar. Local septic complications were higher, as expected, in all patients with external fixation and we observed a very low incidence in the ETC group (8.3% - DCO shock group versus 1.9% - ETC group and 6.7% - DCO no shock group; p = 0.18/0.009).

CONCLUSIONS: In patients who are not in a very severe condition (shock), the choice for femoral shaft stabilization by intramedullary nailing represents a safe option. We did not observe any differences in outcomes by comparing ETC and DCO types of procedures in these relatively stable patients.