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Impact of the Method of Initial Stabilization for Femoral Shaft Fractures in Patients With Multiple Injuries at Risk for Complications (Borderline Patients)

Pape, Hans-Christoph MD, FACS*; Rixen, Dieter MD; Morley, John MD; Husebye, Elisabeth Ellingsen MD§; Mueller, Michael MD; Dumont, Clemens MD∥∥; Gruner, Andreas MD; Oestern, Hans Joerg MD**; Bayeff-Filoff, Michael MD††; Garving, Christina***; Pardini, Dustin PhD‡‡; van Griensven, Martijn PhD§§; Krettek, Christian MD, FRACS¶¶; Giannoudis, Peter MDthe EPOFF study group

doi: 10.1097/SLA.0b013e3181485750
Original Articles

Objectives: The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition.

Methods: Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score ≥2 points and another injury (Abbreviated Injury Scale score ≥2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications).

Outcomes: Incidence of acute lung injuries.

Results: Ten European Centers, 165 patients, mean age 32.7 ± 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05.

Conclusion: Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.

Patients with multiple injuries were randomized to initial external fixation or nailing of their femoral shaft fracture. Stable patients experienced shorter ventilation times: patients in uncertain (borderline) condition developed more acute lung injuries after intramedullary nailing. Therefore, the surgical management of the femur fracture should be adapted to the clinical condition.

From the *Division of Trauma, Department of Orthopaedic Surgery, ‡‡Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; †Department of Orthopaedics and Trauma Surgery, University of Witten, Herdecke, Germany; ‡Department of Trauma and Orthopaedics, St. James University Hospital, Leeds, United Kingdom; §Orthopaedic Centre, Ullevaal University Hospital, Oslo, Norway; ¶Department Trauma Surgery, University of Kiel, Germany; ∥Department of Trauma, General Hospital, Braunschweig, Germany; **Department of Trauma, Celle General Hospital, Celle, Germany; ††Department of Trauma, General Hospital, Rosenheim, Germany; ***University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; §§Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria; ¶¶Department of Trauma, Hannover Medical School, Hannover, Germany; and ∥∥Department of Trauma Surgery, Plastic and Reconstructive Surgery, University of Göttingen, Göttingen, Germany.

Members of the European Polytrauma Study on the Management of Femur Fractures (EPOFF) study group: A. Gruner, MD, Braunschweig, Germany; M. Wittke, MD, Celle, Germany; C. Dumont, Göttingen, Germany; K. Grimme, Hannover, Germany; M. Mueller, MD, Kiel, Germany; D. Rixen, MD, Cologne, Germany; J. Morley, MD, Leeds, United Kingdom; R. Stiletto, MD, Marburg, Germany; E. Ellingsen Husbye, MD, Oslo, Norway; and R. Bayeff-Filoff, MD, Rosenheim, Germany.

Supported by AO/ASIF (Grant No. AO/ASIF. 99 P65 and 03 P2).

Reprints: Hans-Christoph Pape, MD, FACS, Director, Division of Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center 3471 Fifth Avenue Suite 1010, Pittsburgh, PA 15213. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.