Damage control orthopedics can improve outcome in trauma patients
© BioMed Central Ltd. 2007
Published: 22 March 2007
Damage control orthopedics (DCO) is a reviewed concept used in major trauma. Advances in critical care management enable surgical stabilization in the early phase of trauma care. Logistical organization and accessibility to several therapeutic solutions can influence a physician's decisions regarding a trauma patient. The aim of this study is to investigate whether the timing of surgery and method of stabilization in trauma patients with femoral fracture can influence the incidence of pulmonary complication, MOF and the length of stay in the ICU.
In a retrospective study performed at a Level I trauma center, we considered all adult patients with major trauma (ISS > 15) and femoral shaft fracture admitted between January 2003 and July 2006. Patients were separated into two groups according to the management strategies for the femoral fracture: group 1, no surgery within 72 hours after primary admission; group 2, surgical stabilization within 72 hours (DCO). To compare the two groups we considered age, ISS, RTS, TRISS, SAPS II, GCS, comorbidity, and other associated surgery. Parameters of evaluation were: mortality in the ICU, ICU length of stay, respiratory failure and length of ventilation, and daily SOFA collected for 8 days. Statistics were determined with the Student t and chi-squared tests; P < 0.05 was considered significant.
We identified 48 patients, 24 for each group. The groups were comparable regarding all the considered parameters except for GCS at admission (group 1, 8.63 ± 5.12; group 2, 12.2 ± 3.99; P = 0.01) and TRISS (group 1, 62.04 ± 34.55%; group 2, 82.37 ± 18.60%; P = 0.01). We observed in group 2 a significant decrease of mortality (5 vs 0; P = 0.02), incidence of ALI–ARDS (13 vs 4; P = 0.01) and pneumonia (18 vs 6; P = 0.01), a decrease of SOFA score (mean SOFA score: 7.58 ± 4.11 vs 3.97 ± 2.39, P < 0.001; maximum SOFA score: 9.83 ± 4.36 vs 5.62 ± 2.97, P < 0.001; days with SOFA >6: 3.79 ± 3.08 vs 2.16 ± 2.18, P = 0.04).
We observed an improvement of respiratory parameters and SOFA score in patients treated with DCO. Furthermore, patients with worse neurological conditions at admission do not undergo orthopaedic surgery because it could worsen the cerebral perfusion (risk related to transfer to a far operating room). The physician's decisions (and therefore the patient's prognosis), in our experience, are limited by access to optimal therapeutic solutions that could improve the clinical course of the patient.