McGowan Institute for Regenerative Medicine faculty member Hans-Christoph Pape, MD, associate professor of orthopaedic surgery and chief of the division of Orthopaedic Traumatology at the University of Pittsburgh School of Medicine and UPMC, recently reported at the 23rd Annual Meeting of the Orthopaedic Trauma Association in Boston that polytrauma patients who are in an uncertain condition and receive initial external fixation for femoral shaft fractures have a significantly lower incidence of lung dysfunction than those undergoing intramedullary femoral nailing. The prospective, multicenter study, which began enrolling participants in 1999, was aimed at addressing the need for more definitive data regarding the benefits of initial temporary fixation of femoral shaft fractures in trauma patients. The Orthopaedic Trauma Association identified Dr. Pape’s paper as a Winning Highlight Paper.
"There was some controversy surrounding the benefits of temporary fixation, primarily because earlier data was retrospective," said Pape. "There were some questions over whether the results were due to the fixation technique being used, or improvements in other areas, such as preoperative care or ICU treatment."
Pape, a former trauma surgeon at the Hannover Medical School in Germany, said the prospective, randomized study, which covered the most recent time period with up-to-date preoperative care procedures, "clearly demonstrates that there is an absolute trend for patients to function better postoperatively when temporary stabilization is used."
Dr. Pape collected data from 10 European medical centers and included 165 patients ranging in age from 18 to 65 years old, with a mean age of 32.7 years. Multiply injured patients with femoral shaft fractures were randomized to either intramedullary femoral nailing or external fixation with subsequent conversion to intramedullary nailing. The intramedullary nailing group included 94 patients; the other 71 patients underwent temporary external fixation. Preoperatively, 121 patients were stable and 44 patients were in borderline condition.
Using the New Injury Severity Score (NISS) and Abbreviated Injury Scale (AIS), researchers defined inclusion criteria as patients with an NISS of greater than 16 points, as well as those with three fractures and an AIS of 2 points or greater and another injury with an AIS of 2 or greater.
Patients were excluded based on their degree of hemorrhagic shock, degree of hypothermia, levels of soft tissue injury, and presence of coagulopathy, Pape told Orthopedics Today.
Pape said determining inclusion criteria for the study proved daunting.
"It is extremely difficult to pick a population that is healthy enough to withstand the procedures you need to do in this case, and you have to be sure to rule out all the other factors that may cause the patient to have internal complications," Pape said. "We struggled for about a year to develop the inclusion criteria for the study. There was a lot of involvement of ethical committees."
After adjusting for differences in initial injury severity between the two groups, the study revealed those borderline patients who underwent intramedullary nailing were 6.69-times as likely to develop acute lung dysfunction in comparison to those in the temporary external fixation group.
Patients who were stable benefitted from definitive fixation, Pape said.
He said he hopes the results of the study will firmly establish the need to thoroughly consider a patient's preoperative condition prior to deciding whether to initially proceed with intramedullary nailing.
"The fact that there is a significant increase in lung dysfunction associated with initial definitive fixation certainly indicates that external fixation is the treatment of choice in this patient population," Pape said.
Illustration: McGowan Institute for Regenerative Medicine.
Ortho Supersite (01/10/08)
Fracture Lines, The Newsletter of the Orthopaedic Trauma Association, Winter 2007-2008, Annual Meeting Update, Winning Highlight Papers (Page 3).
Abstract (Presented at the 23rd Annual Meeting of the Orthopaedic Trauma Association. Oct. 17-20, 2007. Boston. Conference final program, Page 104, Thurs., 10/18/07 Polytrauma, Paper #8, 2:21 pm).