Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety.
In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients.
Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 ± 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3–46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 ± 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by Trauma and Injury Severity Score (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%).
DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.