Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma Patients: ???Evidence-Based Medicine??? versus ???Reality??? in the Trauma Registry of the German Trauma Society

Rixen, Dieter; Grass, Guido; Sauerland, Stefan; Lefering, Rolf; Raum, M.; Yücel, Nedim; Bouillon, Bertil; Neugebauer, Edmund

doi:10.1097/01.ta.0000198364.50334.39

Cited by 95 publications

(48 citation statements)

References 77 publications

(51 reference statements)

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“…In order to provide clinically relevant categories for treatment beyond a simple dichotomy at twelve or twenty-four hours, we chose five time periods a priori on the basis of commonly used cut-points from the literature 14,15,24 : t 0 (twelve hours or less), t 1 (more than twelve hours to twenty-four hours), t 2 (more than twenty-four hours to fortyeight hours), t 3 (more than forty-eight hours to 120 hours), and t 4 (more than 120 hours). While twenty-four hours is the most commonly used threshold before which ''early'' treatment has been described in previous studies, we defined our referent group (t 0 ) as treatment within the first twelve hours in order to represent those subjects who were most likely to have been inadequately resuscitated and in a state of occult hypoperfusion 10,25 .…”

Section: Treatment Variablesmentioning

confidence: 99%

“…Other studies have suggested that internal fixation of long-bone fractures, either with intramedullary nailing or plate osteosynthesis, may have potentially deleterious effects in the acute setting, when systemic hypoperfusion 10 and inflammation [11][12][13] may increase susceptibility to end-organ injury and increase morbidity. A meta-analysis 14 demonstrated a large relative risk reduction (relative risk, 0.30; 95% confidence interval, 0.22 to 0.40) in respiratory complications in association with early operative fixation (usually within twenty-four hours), whereas two systematic reviews 15,16 demonstrated no difference in morbidity or mortality between early operative treatment (usually at less than twenty-four hours) and late operative treatment of femoral shaft fractures, either overall or within subgroups of patients with associated head injuries or thoracic injuries. These inconsistent findings have left clinicians debating what effect definitive fracture care has on adverse outcomes.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Morshed

Miclau

Bembom

et al. 2009

The Journal of Bone and Joint Surgery-American Volume

129

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Section: Treatment Variablesmentioning

confidence: 99%

mentioning

confidence: 99%

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Morshed

Miclau

Bembom

et al. 2009

The Journal of Bone and Joint Surgery-American Volume

129

View full text Add to dashboard Cite

“…Data from a randomized multicenter clinical trial indicated, that while in stable severely injured patients femoral nailing was associated with a shorter ventilation time, in borderline patients with increased risk of systemic complications it was associated with a higher incidence of lung dysfunction when compared to initial external fixation treatment [65]. However, an analysis of the literature indicated that from 63 controlled trials no generalized management strategy with respect to damage control orthopedics (DCO) could be provided and that the data from the German Trauma Registry Database were also inconclusive [66].…”

Section: Clinical Insightsmentioning

confidence: 99%

The influence of coagulation and inflammation research on the improvement of polytrauma care

Perl

Huber‐Lang

Gebhard

2011

Eur J Trauma Emerg Surg

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Treatment guidelines and management principles of polytrauma patients are largely derived from experience, supplemented by the results of few clinical studies. Their clinical impact on survival outcome is rarely scientifically evaluated. Hence, research algorithms need to be developed which enable a rapid and profound reevaluation of the current treatment strategies in polytrauma care and which provide a solid basis for the assessment of future treatment options. Such new concepts might include a more individualized approach and a better identification of operative windows for early definitive care. Since polytrauma results in a complex physiological and immunological disorder, which is additionally influenced by multiple confounding variables, it is challenging to establish such novel algorithms by clinical research only. In this regard, the well defined parameters in valid basic science models can provide a solid base for evaluating current concepts and investigating future treatment options. Here we have analyzed the contribution of basic science to well-established concepts in polytrauma care, such as the management of trauma induced coagulopathy or the damage control orthopedics concept. Many of these ideas moved from previous basic science activities to clinical studies but in many cases the direct effects of basic science on clinical trials or even clinical management strategies often remain elusive. Nevertheless, the knowledge which is created on a daily basis by basic science studies acts as an invaluable data pool, which can be accessed and combined for the clinical researcher to develop and address clinically relevant questions, providing them with a comprehensive pool of information to carefully plan and conduct their clinical trials. This may then subsequently lead to the development of new management principles for polytrauma patients.

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“…Koagulopathische Traumapatienten soll ten nach den Konzepten der "damage control surgery" behandelt werden [49,74,83]. Dabei wird die definitive anatomische Versorgung temporär zugunsten einer Sta bilisierung der lebensnotwendigen Physio logie zurückgestellt.…”

Section: Prophylaxe Und Therapieunclassified

Coagulation management in the treatment of multiple trauma

2009

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In recent years a new understanding of trauma-associated hemorrhaging and trauma-induced coagulopathy has been achieved. This coagulopathy is multifactorial with the predominant mechanisms being tissue trauma, shock and hypoperfusion which can lead to hyperfibrinolysis by activation of the endothelium. Routinely tested coagulation parameters, such as prothrombin time and partial thromboplastin time, are frequently employed for decision making but remain problematic as they do not give any information on clot stability, lysis or platelet function. Thrombelastometry seems to be a useful alternative. A pro-active anticipatory approach is required for a successful outcome to be achieved as rescue correction is more difficult than prevention. While the pathophysiological conception of causal relationship of the mentioned therapeutic options is conclusive, an evidence-based validation by randomized controlled studies is mostly lacking. The emergency and anesthesiological concept of damage control resuscitation consists of limiting volume therapy with crystalloids and colloids to reach a mean arterial pressure > or =65 mmHg (higher for head injuries), active (re-)warming management, the prevention of a pH< or =7.2 and a base excess (BE) < or =-6 mmol/l. The early and sufficient application of hemostatic drugs is essential. Because erythrocytes play a substantial role in the coagulation process, hemoglobin (Hb) values of around 6. 2 mmol/l (10 g/dl) and/or a hematocrit of 30% should be strived for when massive non-arrested hemorrhaging occurs. After severe multiple trauma a fibrinogen deficit develops and must be adequately compensated. If coagulation therapy is carried out using fresh frozen plasma sufficient quantities (20-30 ml/kgBW) must be administered to correspondingly raise the coagulation factors. Prothrombin complex concentrates can be helpful to optimize thrombin generation during severe hemorrhaging. Because hyperfibrinolysis occurs more often than previously assumed during severe trauma, an anti-fibrinolytic therapy should be used especially for patients with an instable circulation. The platelet count should not go below 100,000/microl when hemorrhaging occurs after multiple trauma. For thrombocytopathic patients with diffuse bleeding desmopressin (DDAVP) is a therapeutic option and the "off label" use of recombinant activated factor VIIa (rFVIIa) remains an option for individual situations with stringent indications and when the above named measures to optimize the coagulation situation have been taken.

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Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma Patients: ???Evidence-Based Medicine??? versus ???Reality??? in the Trauma Registry of the German Trauma Society

Abstract: Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.

Cited by 95 publications

References 77 publications

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

The influence of coagulation and inflammation research on the improvement of polytrauma care

Coagulation management in the treatment of multiple trauma

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