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Christian Krettek

Publications and source records attributed to Christian Krettek.

At least 73 records · Page 4Linked to original sources
PubMed2004

Clinical applications--pelvis.

Navigation procedures based on CT data were introduced into spinal surgery in 1994. Since then, the method has been used in other areas such as joint replacement, reconstructive surgery, and tumor surgery because of its high precision and reduced radiation exposure. The original CT-based spine module can be adjusted for pelvic surgery with the prerequisite that the positioning of the fragments is identical in CT and in the OR; otherwise a new dataset has to be acquired. Our experiences with CT-based navigation in pelvic surgery are explained on five percutaneous screw fixations and three tumor resections, including description of the technique. For modality-based navigation, the navigated procedure is performed in the CT suite with the advantage of immediate CT control of reduction quality and screw positioning. The technique is explained and illustrated on two cases. Fluoroscopy-based navigation has been used in trauma surgery since the late nineties. Since then, the method has been wide spread in the field of joint replacement and reconstructive surgery. Between June 2000 and December 2002, we performed 36 percutaneous screw fixations in the pelvis with postoperative x-ray and CT control. 35 of the 36 screws were placed correctly. In one screw, an anterior cortex perforation of the sacrum was seen in the CT without any neurological consequences. The Iso C 3-D fluoroscope has recently been approved for pelvic surgery. With the ability to reconstruct images, visualization of the acetabulum and the posterior pelvic ring, there is marked an improvement compare to conventional 2-D fluoroscopy. Thus, the field for navigation is also enhanced. Based on our clinical experiences, the indications for navigated techniques in pelvic and acetabular surgery are defined and illustrated.

Adult↗
PubMed2004

Computer aided tumor resection in the pelvis.

Surgical treatment of malignant tumors within the pelvis is a complex problem due to the anatomy and biomechanics. There are standardized preoperative diagnostic tools like computed tomography (CT) or magnetic resonance imaging (MRI) that provide multidimensional information. However, this information cannot be transferred intraoperatively. Computer aided orthopedic surgery (CAOS) may be a solution for precise intraoperative accuracy for these indications. We report on two patients with tumors within the pelvis. In one patient, an infiltrating recurrent chordoma within the sacrum was resected with CAOS. The other patient presented with a periacetabular chondrosarcoma. Resection was done with navigation so precise that a custom-made hemipelvis prosthesis with a special coating fit. In both patients, a complete resection was achieved with tumor-free resection margins. Navigation may be helpful in tumor surgery within the pelvis.

Bone Neoplasms↗
PubMed2004

Femoral nail removal should be restricted in asymptomatic patients.

Femoral nail removal has been suggested as a routine procedure for symptomatic and asymptomatic patients. The aim of this study was to evaluate whether asymptomatic patients have long-term complaints after femoral nail removal. Additionally, factors that might extend operation time and effect soft tissue healing negatively were analyzed. A retrospective study on the removal of 164 femoral nails after fracture consolidation was done. A review of the patient charts and radiographs was done. Neither the interval between nail implantation and nail removal or the use of an end-cap significantly influenced the operation time. The surgeon's qualification and nail depth were the only variables that influenced operation time. Neither operation time, nail depth, surgeon's qualification, nor the grade of heterotopic ossification significantly influenced the incidence of wound healing problems. One hundred nine patients (73%) were available for the followup interview. Preoperatively, 58 patients (53%) had local complaints. Of these 58 patients, 78% reported improvement and 7% reported an aggravation of their local complaints. Of the 51 patients who were asymptomatic before surgery, 20% reported long-term complaints at followup. Only symptomatic patients should be considered for femoral nail removal.

Adolescent↗
PubMed2004

New indications for computer-assisted surgery: tumor resection in the pelvis.

The resection of recurrent malignant pelvic tumors was supported by a commercially available navigation system in three patients. Preoperatively three-dimensional images from the pelvis were obtained by computed tomography or magnetic resonance imaging to identify the tumor extension. During surgery navigated tools oriented the surgeon to excise the tumor with adequate virtual margins. Navigation was helpful for tumor identification in one patient with a recurrent presacral mesenchymal chondrosarcoma. In the other two patients the tumor resection in the bone was done with three-dimensional observation of the osteotomies in the sacrum. In all three patients the histopathologic analysis confirmed that the neoplasms were excised accurately within their margins. We think that computer-assisted surgery is a potential method to increase the accuracy of tumor resections.

Adult↗
PubMed2004

Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction.

Injury cause, treatment, and long-term results [American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score, Hannover Scoring System, Hannover Outcome Questionnaire] of patients with Chopart joint dislocations or fracture-dislocations were evaluated. Between 1972 and 1997, 100 patients with 110 Chopart joint dislocations were treated in the authors' institution. Pure Chopart joint dislocations were observed in 28 (25%) feet, fracture-dislocations in 60 (55%) feet, and combined Chopart-Lisfranc joint fracture-dislocations in 22 (20%) feet. The primary treatment was operative in 91 (83%) feet and nonoperative in 19 (17%) feet. Sixty-five (65%) patients had follow-up after an average of 9 years (range, 2-25 years). The mean scores of the entire follow-up group were: AOFAS score, 75 points; Hannover Scoring System, 69 points (maximium possible score = 100 points); Hannover Outcome Questionnaire, 68 points (maximium possible score = 100 points). There were no differences between the scores for pure dislocations or fracture-dislocations of the Chopart joint, but significantly lower scores were noted with combined Chopart-Lisfranc joint fracture-dislocations. In all three injury pattern groups, an initial anatomic reduction was essential for good results. The high functional restrictions in Chopart dislocations can most likely be minimized with initial open reduction, especially in fracture-dislocations. A closed reduction yielded good results only with pure dislocations, when anatomic conditions could be restored, or if there were contraindications to surgery.

Adult↗
PubMed2004

Functional outcome following scapulothoracic dissociation.

BACKGROUND: Scapulothoracic dissociation is an infrequent injury that is often accompanied by neurovascular injuries with a potentially devastating outcome. The aim of this study was to evaluate the functional outcome following scapulothoracic dissociation. METHODS: During a twenty-four-year period, we treated twenty-five patients with a scapulothoracic dissociation. The average age was 32.5 years. The average Injury Severity Score was 22 points. Nine patients had a complete brachial plexus avulsion, and ten had an incomplete brachial plexus avulsion. Three patients died from their associated injuries, and six patients required an above-the-elbow amputation. The outcome was assessed with use of the Short-Form 36-Item Health Survey, and the shoulder function of the patients who had not had an amputation was evaluated with use of the Subjective Shoulder Rating System. The degree of initial scapular lateralization was quantified with the scapula index. RESULTS: The average duration of follow-up was 12.6 years. The physical and mental component summary scores and the scores on the role-physical, general health, vitality, and mental health subscales of the Short-Form 36-Item Health Survey were significantly lower for patients with a complete brachial plexus avulsion (p < 0.05). The Subjective Shoulder Rating System score was also significantly lower in patients with a complete brachial plexus avulsion (33.8 points compared with 72.5 points for the patients with no or an incomplete avulsion, p = 0.046). The average scapula index was 1.29 +/- 0.19. The scores on the Short-Form 36-Item Health Survey scales and the Subjective Shoulder Rating System score did not correlate with the initial scapula index (p > 0.05). CONCLUSIONS: The presence of a complete brachial plexus avulsion is predictive of a poor functional outcome in a patient with a scapulothoracic dissociation. Therefore, we suggest a modification of the classification of the severity of this injury, with complete brachial plexus avulsion considered to be the most severe injury type. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Acromioclavicular Joint↗
PubMed2003

Cyclic mechanical strain induces NO production in human patellar tendon fibroblasts--a possible role for remodelling and pathological transformation.

The mechanism by which tendon fibroblasts can detect strain forces and respond to them is fairly unknown. Nitric oxide (NO) is a messenger molecule that among others can respond to shear stress in endothelial cells. Therefore, it was investigated whether cyclic mechanical strain induces NO in vitro in human patellar tendon fibroblasts. Human patellar tendon fibroblasts were cultured from remnants of patellar tendon transplants after reconstructive surgery. Fibroblasts were cultured on elastic silicone dishes. The cells were longitudinally strained (5%, 1 Hz) for 15' or 60'. As a control, no strain was applied. The experiments were finished after 0', 5', 15', and 30'. NO was determined using the Griess reaction. 15' strain showed at 0' and 5' 200% activation, which thereafter at 15' and 30' returned to normal levels. 60' strain showed a biphasic pattern. At 5' and 30', NO levels were increased to 175%. At 15', NO measurement displayed 120% increased levels. Mechanical strain induces NO production by tendon fibroblasts. Therefore, NO produced by tendon fibroblasts, as a response to alteration in their mechanical microenvironment, could modulate fibroblast function. The results of our study suggests that strain-related adaptive changes may, at least in part, be controlled by a process in which strain-related NO production from the fibroblast network may play a pivotal role. Moreover, these are basic findings that are important for further unravelling pathophysiology of tendon diseases.

Adaptation, Biological↗
PubMed2003

Effects of cardiac contusion in isolated perfused rat hearts.

Myocardial contusion is frequently suspected after blunt chest trauma, but the exact mechanisms of resulting cardiac dysfunction and the time course for enzymatic alterations have not yet been fully understood. Therefore, we investigated pathophysiological aspects of myocardial contusion in a controlled animal model. Male Wistar rat hearts were studied in an isolated perfusion model and were divided into two groups: control (n = 4) and heart contusion (n = 6) groups. The cardiac contusion was produced by a single blow with a weighted pendulum (m = 44 g, height = 20 cm). Functional implications of the contusion were examined in an "isolated perfused heart" model. Troponin 1 concentrations were determined in the perfusate. Cardiac contusion resulted in an increase of coronary perfusion pressure (CPP) of 9 mmHg (P < 0.05, 20 min postcontusion versus baseline and control), followed by a significant increase of left ventricular end-diastolic pressure (LVEDP) of 6 mmHg (P < 0.05, 20 min postcontusion versus baseline and control). Heart contusion was followed by an early increase of troponin 1 (+0.82 ng/mL). The troponin 1 concentration decreased again and, after 20 min, baseline levels were reached. The control group showed no such changes. In this model, high troponin 1 levels after cardiac contusion suggest direct damage to the myocardium. First functional response was shown by the alteration of the coronary perfusion, followed by impaired diastolic function, which persisted even after lowering of the troponin 1 levels.

Animals↗
PubMed2003

The importance of systemic cytokines in the pathogenesis of polymicrobial sepsis and dehydroepiandrosterone treatment in a rodent model.

The pathogenesis of sepsis is still undetermined to a large extent. It is an established fact that female gender is associated with a lower mortality and that sex steroid hormones influence the immunologic response. Dehydroepiandrosterone (DHEA) seems to have a protective immunologic effect in sepsis. It is still unknown in which way DHEA influences the pathogenesis of sepsis. Therefore, the effect of DHEA application on cytokine concentrations in tumor necrosis factor (TNF) receptor (TNF-RI(-/-)) and interleukin-6 (IL-6(-/-)) knockout mice was determined. In a model of polymicrobial sepsis induced by coecal ligation and puncture (CLP), the effect of DHEA on survival and cytokine concentrations was examined. For clarification of the role of TNF-RI, CLP was performed in TNF-RI knockout mice (TNF-RI(-/-)). In addition, IL-6 knockout mice (IL-6(-/-)) were used to clarify the role of IL-6. Furthermore, experiments were performed in mice that were not genetically modified (wild type, WT). The protective effect of DHEA could be confirmed in this CLP model. DHEA application was associated with a reduction in mortality in WT animals. Moreover, DHEA-treated animals demonstrated a reduction in systemic inflammatory effects, as determined by proinflammatory cytokines TNF-alpha, IL-1beta, IL-6, and the antiinflammatory cytokine IL-10. In this work, it was shown that the TNF-RI is essential for survival after CLP. DHEA application was associated with a reduction of mortality of 100% in TNF-RI(-/-) mice after CLP to 50%. This result engages, that the effect of DHEA is TNF-RI independent. However, the application of DHEA had no influence on the mortality in IL-6-/- mice. It can be concluded that the protective effect of DHEA in polymicrobial sepsis is mediated IL-6 dependently. DHEA reduces the systemic inflammation, measurable via the proinflammatory cytokines TNF-alpha, IL-1beta, IL-6, and the antiinflammatory cytokine IL-10. IL-6 might be involved in the DHEA-mediated reduction of postseptic complications. In contrast, DHEA seems to be TNF-RI independent. Consequently, DHEA might be useful as an adjunct therapy for the immune modulation in sepsis.

Adjuvants, Immunologic↗
PubMed2003

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group.

BACKGROUND: Damage control orthopedic surgery has recently been advocated for the management of femoral shaft fractures in severely injured patients because surgical procedures were found to represent a second-hit phenomenon regarding the operative burden. It has been attempted to determine the operative burden by means of proinflammatory cytokines. In this study in clinically stable patients with multiple injuries, the effects induced by different types of primary fracture stabilization on the systemic release of proinflammatory cytokines were evaluated. METHODS: This was a prospective, randomized, multicenter intervention study. Inclusion criteria were long bone shaft fracture of the lower extremity; age 18 to 65 years; Injury Severity Score > 16 or more than three extremity injuries (Abbreviated Injury Scale [AIS] score of 2 or more) in association with another injury (AIS score of 2 or more); and thoracic AIS score < 4. After informed consent, randomization for the treatment of the femoral shaft fracture was performed at admission. Groups were as follows: group I degrees FN (primary, < 24 hours) intramedullary nailing, and group DCO (DCO, I degrees ex.fix.) damage control orthopedic surgery and external fixation. In DCO patients, measurements were also performed at the time of conversion to the intramedullary procedure (DCO II degrees FN). Parameters included clinical parameters and complications (acute respiratory distress syndrome, multiple organ failure, sepsis). From serially sampled central venous blood, the perioperative concentrations of interleukin IL-1, IL-6, and IL-8 were determined. RESULTS Thirty-five patients were included (I degrees FN, n = 17; DCO, n = 18). In I degrees FN-patients, a perioperative increase of IL-6 levels was measured (preoperatively, 55 +/- 33 pg/dL; 24 hours postoperatively, +254 +/- 55 pg/dL; p = 0.03), which was not found in subgroup DCO I degrees Ex.fix.: preoperatively, 71 +/- 42 pg/dL; 24 hours postoperatively, 68 +/- 34 pg/dL; not significant [NS] or in group DCO II degrees FN: preoperatively, 36 +/- 21 pg/dL; 24 hours postoperatively, +39 +/- 25 pg/dL; NS. Likewise, in I degrees FN patients, a perioperative increase of IL-8 levels was measured only at the 7-hour time point (preoperatively, 35 +/- 29 pg/dL; 7 hours postoperatively, 95 +/- 23 pg/dL; p < 0.05), which was not found in group DCO I degrees Ex.fix.: preoperatively, 43 +/- 38 pg/dL; 24 hours postoperatively, 69 +/- 39 pg/dL; NS or in group DCO II degrees FN: preoperatively, 25 +/- 20 pg/dL; 24 hours postoperatively, 36 +/- 29 pg/dL; NS. There were no differences in the complication rate in terms of acute respiratory distress syndrome, sepsis, or multiple organ failure. CONCLUSION: In this prospective, randomized, multicenter study, a sustained inflammatory response was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. These findings may become clinically relevant in patients at high risk of developing complications. It confirms previous studies in that damage control orthopedic surgery appears to minimize the additional surgical impact induced by acute stabilization of the femur.

Female↗
PubMed2003

Computer assisted pelvic surgery: registration based on a modified external fixator.

A fundamental step in Computer Assisted Surgery (CAS) is the registration, when the preoperative virtual data and the corresponding operative anatomy of the region of interest are merged. To provide exact landmarks for anatomical registration, a tubular external fixator was modified. Two intact pelvic bones (one artificial foam pelvis and one cadaver specimen) were used for the experimental setup. Registration was carried out using a standardized protocol for anatomy-based registration in the control group; anatomical registration was achieved using a modified external fixator in the study group. This external fixator had titanium fiducials wedged into the fixator carbon tubes serving as landmarks for paired-point registration. The tubes were used for surface registration. The standard anterior pelvis fixator assembly was augmented with additional bilateral tubes oriented towards the posterior, enabling registration of the sacroiliac areas. The accuracy of registration was checked by "reversed verification", where the examiner used only the screen display to control the virtual position of the pointer tip in relation to selected landmarks. By virtual matching, the real distance was measured with a digital caliper. We defined the verification as "accurate" when the residual distance was less than 1 mm; "acceptable" when it was between 1 mm and 2 mm; and "insufficient" when it exceeded 2 mm. The paired T-test with significance levels of p < 0.05 was used for statistical analysis. The anatomical registration based on the external fixator landmarks was statistically as accurate as that obtained using anatomical landmarks on the pelvic bone. This study concludes that the external fixator, a conventional tool in the management of acute traumatic pelvic instability, can also be useful for landmark registration in CAS.

External Fixators↗
PubMed2002

The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery.

Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution of "damage control orthopedic surgery."

Embolism, Fat↗
PubMed2002

Polymicrobial sepsis induces organ changes due to granulocyte adhesion in a murine two hit model of trauma.

INTRODUCTION: Polytrauma patients, who develop organ dysfunction, have often undergone multiple subsequent insults ("hits"). The sequence of organs that show a dysfunction mostly is lung, liver, kidney and heart. The aim of the present study was to investigate whether a second hit after trauma induces organ changes. Furthermore, it was of interest to identify possible pathogenic mediators such as polymorphonuclear granulocytes (PMN) and cytokines. For this purpose, a two hit model of systemic damage in mice was developed. Sepsis was induced by caecal ligation and puncture (CLP), which was preceded 48 hours by a femur fracture, the most common fracture of long bones in trauma patients. This fracture was combined with a haemorrhagic shock. METHODS: In both mouse groups studied, a standardized femur fracture was produced using a blunt guillotine device with a weight of 500 g. This was followed by a haemorrhagic shock with substitution of ringer's lactate after 1 hour. In the study group, CLP was induced by puncturing the caecum using a 21G needle. As a control, sham animals underwent a laparotomy without CLP. Both groups were sacrificed after 48 or 96 hours. Clinical parameters were investigated on a daily basis to evaluate the animals' status. Lung, liver and kidney morphology was studied by light microscopy. PMN adhesion was determined by counting the number of adherent PMN per 100 microm of endothelium. Serum levels of TNF-alpha were measured after 48 and 96 hours. RESULTS: In the group submitted to laparotomy, all animals survived. The induction of polymicrobial sepsis by CLP resulted in an 85% (34/40) mortality within 96 hours after surgery (p < 0.05). The induction of a polymicrobial sepsis resulted in a significantly steady worsening of the clinical situation compared to the sham animals (p < 0.05). Lung morphology demonstrated significant changes at the end of the experimental period after 96 h in the two hit group. The alveolar septa were thickened and in all lungs haemorrhagic foci were observed. The number of PMN adhering to the pulmonary endothelium significantly increased at 96 hours. Some of the liver specimens in the two hit group showed focal hydropic degeneration and PMN infiltration. No kidney pathology was observed. This result coincided with an increase in TNF-alpha serum levels. DISCUSSION: A new rodent model mimicking the situation in the polytraumatized patient was developed. Although the animals showed minimal organ manifestation, a high percentage died probably due to cytokinemia. Furthermore, the increased TNF-alpha levels may lead to increased adhesion of PMN in the lung venules. This adhesion developed four days after the second hit. This might be the initial step for the development of extensive lung lesions in later phases. This model represents the SIRS more than MODS. This is a model for devolopment of posttraumatic disease due to cytokinemia and less for chronic multiple organ dysfunction and failure.

Animals↗
PubMed2002

Reduction and fixation of displaced intracapsular fractures of the proximal femur.

Intracapsular fractures of the femoral neck are one of the most common fractures in the elderly. The incidence of these fractures will increase significantly in the next decades as a result of increasing life expectancy. Although treatment of these fractures by closed or open reduction and internal fixation is standard in young patients, arthroplasty is the standard treatment in geriatric patients in most countries. Comorbidities of the patients and current socioeconomic changes in healthcare led to reconsideration of closed reduction and internal fixation of femoral neck fractures as an alternative treatment modality. With correct decision-making, proper reduction, and proper consideration of the biomechanical principle of three-point fixation, minimally invasive screw fixation of femoral neck fractures is a safe and inexpensive procedure even in elderly patients. The purpose of the current review was to give an overview of the history, current techniques and developments, results, limitations, and complications of closed reduction and internal fixation of intracapsular femoral neck fractures.

Aged↗
PubMed2002

Standardized outcome evaluation after blunt multiple injuries by scoring systems: a clinical follow-up investigation 2 years after injury.

OBJECTIVE: The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multicenter study. METHODS: Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score > or = 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient-assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider-report (physician's examination) and self-report (score systems) criteria. RESULTS: Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self-report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC. CONCLUSION: In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC).

Adult↗
PubMed2002

Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery.

BACKGROUND: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture. METHODS: In a retrospective cohort study performed at a Level I trauma center, the patient's injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I degrees intramedullary nailing [I degrees IMN]; I degrees external fixation [I degrees EF]; I degrees plate osteosynthesis [I degrees plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981-December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990-December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993-December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure. RESULTS: The patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) ( = 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I degrees EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I degrees IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I degrees EF in the INT (13.6%, = 0.03) and DCO (17.3%, = 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I degrees IMN (15.1%) and I degrees EF (9.1%) in the DCO subgroup were compared. CONCLUSION: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I degrees EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of developing posttraumatic systemic complications such as ARDS and multiple organ failure.

Adult↗