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Hans-Christoph Pape

Damage control orthopedics: a response

In issue 1/06 of AO Dialogue, Robert Meek and Peter OBrien from Vancouver, Canada again raised the question of whether or not damage control orthopedic surgery is the best strategy to adopt for patients with multiple orthopedic injuries. The article was based on the John Border Memorial lecture given by Robert Meek at the annual meeting of the Orthopaedic Trauma Association in 2005. During this lecture, Meek presented recalculations of raw data from a 2002 publication of mine, which described management changes for polytrauma patients undertaken in my previous institution [1]. These recalculations were wrong and misleading. I therefore wrote an explanatory letter which appeared in the winter issue of the OTA newsletter. Additionally, the same information was published in March 2006 [2]. I was therefore surprised to find a reiteration of these accusations in the AO Dialogue, published after my explanatory letters, but without any reference to these responses. Since the readers of AO Dialogue may not have the chance to research the original data, please find the information below: In the publication from 2002 [1], we reported management changes in Germany regarding the treatment of major fractures over a period of almost 20 years. The manuscript is a description of the management changes performed at Hannover Medical School under the guidance of Harold Tscherne, and was written in honor of his retirement after 30 years of leadership. It was not designed to prove the value of DCO. Patients who were treated during the latest time period (DCO era, 1993-2000 in the paper) developed less ARDS when treated by initial external fixation (DCO) and secondary nailing compared with those treated by initial intramedullary nailing (ETC). This was shown by means of an odds ratio of ARDS and by comparison of the ARDS incidence between the subgroups. The patient selection supporting the data is as follows: In the group who received intramedullary nails (ETC), patients were excluded if the nail was inserted in a retrograde fashion. Retrograde nailing is a special entity and is used for distal fractures, bilateral fractures or floating knee injuries. Also, the exclusion of these patients is important because the systemic and pulmonary effects of retrograde nailing are poorly described. The ARDS incidence in patients who had antegrade nails (n=99 out of 110 in the DCO era) was 15.1%, as indicated in the abstract (15 out of 99 patients). It is important to note that table VII has been designed to illustrate the general reduction in the rate of complication over time, rather than portray a relationship between the complication rate and the method of fracture management. In the group with initial external fixation (DCO), we excluded those patients in whom the indication for the external fixateur was based on the severity of head injury only (ie was unrelated to other orthopedic injuries): 14 patients with head injuries received an external fixateur. In 13 of these cases, the timing of the definitive surgery did not depend

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Reported incidence of ARDS and odds ratio regarding the development of ARDS in the publication from 2002 (Abstract and Discussion)
Treatment ARDS incidence reported ARDS incidence reported Relative percentage (0dds ratio) of ARDS External fixation IM nailing Table 1 DCO era 9.1% 15.1% ETC era 97.4% 54.6% DCO era 22.1% 26.4%

on the influence of the orthopedic surgeon, but was delayed because of the severity of head injury. In one patient receiving an external fixateur, the control head CT showed an improvement of the head injury. This resulted in conversion to an intramedullary nail the following day, thus leaving 55 out of 68 patients for evaluation. In these, the ARDS incidence was 9.1% (5 out of 55), as indicated in the abstract. The reported data on the difference of ARDS incidence during the DCO era are as follows: ( Table 1). Robert Meek recalculated the data from Table VII in the 2002 article, which describes the general improvements in the rates of complications in all patients over time. He then used all available patients for a given time period as the denominator for his recalculations. In contrast, we excluded patients with severe head trauma and those with retrograde nails. The table below lists the comparison between the reported (Pape) and recalculated (Meek) data of ARDS incidences and the denominators used ( Table 2). I agree that the publication from 2002 could have been clearer had we included the inclusion criteria as a separate table. However, there is no need to reconsider our conclusions from the 2002 publication. Also, one may wonder whether it is

rational to question a broad concept based solely on the criticism of a single publication. Moreover, as pointed out in the comment in the AO dialogue by Trentz, other centers have also changed their management strategy over the last decade. As listed in Table 3 , reports on DCO have been present throughout the world in recent years [314]. Dr Meek and Dr OBrien state that the idea of the patient being too sick to operate is not a new one. While this may be true, I do not think that returning to an old concept of fixing every fracture in every patient is the right course of action. Moreover, I believe that one must take into account the effect of the system of trauma care, as it differs throughout the world. Specifically, there are striking differences in organization which may contribute to the confusion that arises from the interpretation of study data from Europe and study data from Canada and North America: In the North American/Canadian system, the management of the polytrauma patient is not handled by the orthopedic surgeon. A general surgeon inspects the patient in the ED, performs the clinical examination and then consults the orthopedic surgeon for

Comparison of data based on denominators used in our publication in 2002 and the ones used for recalculating the raw data by Robert Meek
ARDS Incidence ARDS Incidence

Treatment of femur fractures Ex fixation IM nailing Table 2

Papes data (denominators used ) 9.1% (5/55) no ex fix for head trauma 15.1% (15/99) no retrograde nails

Recalculated data (Meek) (denominators: all patients) 22.1% (15/68) all patients 26.4% (29/110) all patients

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fractures of the pelvis and the extremities. The general surgeon weighs the general injury severity and decides which surgical procedures can be undertaken. He does or does not clear the patient for surgery to be undertaken by the orthopedic surgeon ( Fig 1). Due to these differences in organization of the trauma system, it is not surprising that general surgeons rather than orthopedic surgeons were the first to report the benefits of a limited surgery approach in the severely injured. Over the last decade, the idea of limiting surgery in view of a life threatening condition has become common practice in the general surgery community [1521]. The important question to be asked is the following: What happens to a patient who is not cleared for definitive stabilization of his fractures? Does he receive traction? Will the fractures be stabilized by a cast? Does any one of these patients receive an external fixateur? Are the patients included in the study only those who have been cleared for surgery by the general surgeon? If so, absolutely no discussion would be necessary, since throughout the world these patients would appear to be treated in a similar fashion. The same issue has been addressed in a previous publication by Ziran et al. Common to all studies, including the present one, is the inherent difficulty of determining the effects of delays in fixation. Because trauma centers reporting such studies have favored early fixation in those with multiple injuries, patients who are not stabilized within 48 to 72 hours tend to be delayed for reasons pertaining to their physiologic condition. These patients tend to be more severely injured and therefore may not be comparable with those whose condition allows early fixation [22].

Care of femoral shaft fractures in Germany (Rixen et al; data from the German Trauma registry)
Polytrauma patients with femur shaft fractures Osteosynthesis <24 hours External fixation Nailing Plating Table 4 1465 1465 47.0% 41.1% 11.9%

Author

Country

Reference

Scalea and Nowotarski John and Ertel Labeu and van Erbs Rixen and Bouillon Olson Taeger and Nast Kolb Giannoudis Roberts Prior and Reilly Nast Kolb Roise Keel and Trentz Table 3

USA Germany Belgium Germany USA Germany Great Britain USA USA Germany Norway Switzerland

(1,2) (3) (4) (15) (5) (6) (9) (10) (11) (11) (12) (13)

In contrast to the North American/Canadian system, the orthopedic trauma surgeon in Switzerland, Germany and the UK performs many of the tasks of the general surgeon. In most institutions, the surgeon examines, evaluates, and manages the patient in the emergency room. He/she then collects the injury data and the physiologic parameters and categorizes the patient accordingly. He/she determines the priority of the different injuries, determines the timing of surgery, and proceeds with fracture stabilization him/herself as part of the resuscitation protocol. According to the established treatment protocols in most European trauma centers, long bone fractures undergo immediate intramedullary nailing if the overall cardiopulmonary condition allows it. In polytraumatized patients who have an unstable cardiopulmonary condition, it is advised that long bone fractures are stabilized with an external fixateur. This approach has recently been described in detail by two studies: 1. Taeger et al report a prospective survey of polytrauma patients submitted to a damage control approach. They convincingly report a low incidence of ARDS and multiple organ failure, when following this approach [8]. 2. Rixen et al describe the reality of fracture care in Germany and includes data from 1,465 polytrauma patients. It is interesting to note that this report from the German Trauma Registry clearly documents that all patients had their femur fractures stabilized within 24 hours [23]. ( Table 4). There was no patient in whom traction was performed or a cast was applied for temporary stabilization. This may elucidate how different the trauma systems affect the question of timing. I believe that future studies comparing the outcome in the treatment of major fractures should include these issues and that the number of patients who underwent no fracture stabilization should be documented. I would like to thank the AO for the opportunity to add my comments to the discussion. Moreover, I would like to thank the AO for its ongoing funding and support which has enabled us to investigate many urgent questions regarding this topic.

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Canada/USA General surgeon Attending general surgeon admits patient manages diagnostics evaluates physiologic parameters consults ortho trauma General surgeon operates on truncal injuries decides if patient is cleared for fracture fixation by orthopedic surgeon Anesthesia General Surgery ICU Figure 1

Rescue

Switzerland/Germany/UK Orthopedic trauma surgeon Attending orthopedic surgeon expects patient manages diagnostics weighs physiologic parameters takes patient to OR for fracture care Orthopedic trauma surgeon decides on management/timing of injuries and performs surgery

Emergency room

Operating room Timing of fracture fixation

ICU

Anesthesia Orthopedic trauma surgery

Organization of patient management in different trauma systems

Bibliography
1 Pape HC, Hildebrand F, Pertschy S et al (2002) Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma; 53(3): 452 462. 2 Pape HC (2006) Confusion regarding method of patient selection. J Trauma; Mar; 60(3):6856. 3 Scalea TM, Boswell SA, Scott JD et al (2000) External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopaedics. J Trauma; 48:613623. 4 Nowotarski PJ, Turen CH, Brumback RJ et al (2000) Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am; 82:781788. 5 John T, Ertel W (2005) Pelvic injuries in the polytraumatized patient. Orthopade ; 34:91730. 6 Labeeu F, Pasuch M, Toussaint P et al (1996) External fixation in war traumatology. J Trauma; 40:S2237. 7 Olson S (2004) Pulmonary aspects of treatment of long bone fractures in the polytrauma patient. CORR ; 422: 6670. 8 Taeger G, Ruchholtz S, Waydhas C et al (2005) Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma; 59:40917. 9 Giannoudis PV (2003) Surgical priorities in damage control in polytrauma. J Bone Joint Surg Br ; 85:47883. 10 Roberts CS, Pape HC, Jones AL et al (2005) Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect.; 54:44762. 11 Pryor JP, Reilly PM (2004) Initial care of the patient with blunt polytrauma. Clin Orthop Relat Res ; 422:306. 12 Nast-Kolb D, Waydhas C, Schweiberer L (1996) Intramedullary nailing in multiple trauma. Orthopade ; 25:26673. 13 Pape HC, Grimme K, van Griensven M et al (2003) Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters in a prospective randomized analysis. J Trauma; 55: 17. 14 Keel M, Trentz O (2005) Pathophysiology of polytrauma. Injury ; 36:691709. 15 Burch JM, Ortiz VB, Richardson RJ et al (1992) Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg ; 215:47683. 16 Talbert S, Trooskin SZ, Scalea T et al (1992) Packing and reexploration for patients with nonhepatic injuries. J Trauma; 33:121126. 17 Johnson JW, Gracias VH, Schwab CW et al (2001) Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma; 51:26171. 18 Shapiro MB, Jenkins DH, Schwab CW et al (2000) Damage control: collective review. J Trauma; 49:96978. 19 Moore EE, Burch JM, Franciose RJ et al (1998) Staged physiologic restoration and damage control surgery. World J Surg ; 22:118491. 20 Brasel KJ, Weigelt JA (2000) Damage control in trauma surgery. Curr Opin Crit Care ; 6:27680. 21 Hirshberg A, Walden R (1997) Damage control for abdominal trauma. Surg Clin North Am; 77:81320. 22 Ziran BH, Le T, Zhou H et al (1997) The impact of the quantity of skeletal injury on mortality and pulmonary morbidity. J Trauma; 43:91621. 23 Rixen D, Grass G, Sauerland S et al (2005) Polytrauma Study Group of the German Trauma Society. 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. Trauma; 59:137595.

Hans-Christoph Pape

Director - Division of Trauma Department of Orthopaedic Surgery Pittsburgh, PA USA papehc@upmc.edu hcpape@web.de