How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature

Pfeifer, Roman; Klingebiel, Felix Karl-Ludwig; Halvachizadeh, Sascha; Kalbas, Yannik; Pape, Hans‐Christoph

doi:10.1016/j.injury.2022.11.008

Cited by 16 publications

(23 citation statements)

References 96 publications

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“…In the present study, the association between ETC approach and spine injuries becomes more sustained when pathophysiologic parameters are considered as well. This is in keeping with previous results in a different patient population 14 …”

Section: Discussionsupporting

confidence: 93%

“…If these were different, they were included in the multivariate analysis. Furthermore, variables included in the multivariate analyses were chosen as they are discussed in the literature and routinely used as part of the initial assessment of the patient 14 . The results of the prediction model are presented as odds ratios (ORs) and 95% confidence intervals (CIs).…”

Section: Methodsmentioning

confidence: 99%

“…Eventually, a combination of injury burden, physical signs (vital signs, temperature), and laboratory values (lactate, arterial blood gases, and coagulation parameters) used to monitor the adequacy of resuscitation becomes a better predictor of risk and outcomes than each one 2,13 . For example, the use of this strategy for risk determination has been applied to multiple-injury patients to determine if a patient is cleared to go to the operating room for early fixation of major fractures 14 . Data suggest that this comprehensive assessment results in minimal complication rates and improved patient safety (safe definitive surgery [SDS]) 15 .…”

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confidence: 99%

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Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

Halvachizadeh,

Pfeifer,

Duncan

et al. 2024

J Trauma Acute Care Surg

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Background The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. Methods In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an injury severity score (ISS) ≥ 16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury into three groups: Early Total Care (ETC <24 h), Safe Definitive Surgery (SDS < 48 h), and Damage Control (DC >48 h). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. Results Between Jan 1, 2016, and Dec 31, 2022, 1471 patients were included (mean age 55.6 ± 20.4 years, mean ISS 23.1 ± 11.4). The group distribution was ETC; n = 85 (5.8%), SDS; n = 665 (45.2%), and DC; n = 721 (49.0%), mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe non-lethal abdominal injuries (OR 2.2, 95%CI 1.4 to 3.5) and spinal injuries (OR1.6, 95%CI 1.2 to 2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR1.7, 9%%CI 1.4 to 2.2). Severe TBI was associated with DC (OR1.3, 95% CI 1.1 to 1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR0.3, 95%CI 0.2 to 0.4). Conclusion Major spinal injuries and certain abdominal injuries, if identified as non-lethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by Safe Definitive Surgery (definitive care <48 h) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. Level of Evidence III Therapeutic / Care Management

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Section: Discussionsupporting

confidence: 93%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

Halvachizadeh,

Pfeifer,

Duncan

et al. 2024

J Trauma Acute Care Surg

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“…This allows the surgeon to react and adjust the surgical load to the patient’s physiology dynamically by switching between temporary fixation and definitive osteosynthetic if reasonable [ 30 ]. Nowadays, we can assess the patient’s status based on multiple parameters and distinguish in between “stable,” “borderline,” “unstable,” and “in extremis” patients [ 3 , 31 ] and chose the operational procedures with the individually compensable surgical load. Recently, it has been advocated that safe definitive surgery (SDS) is essential in avoiding complications [ 36 ].…”

Section: Discussionmentioning

confidence: 99%

“…Critical analysis of these various pathophysiologic cascades, including the acid–base system, coagulation, hypothermia, and tissue damage, may allow improved predictions of early complications and outcomes [ 32 ]. Another benefit of stratifying patients to treatment strategies based on physiologic status is an enhanced ability to plan surgical strategy and fracture fixation goals, understanding the preoperative risk of further physiologic insult from any sort of operative procedure [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

Surgical load in major fractures — results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

Klingebiel,

Hasegawa,

Strähle

et al. 2023

International Orthopaedics (SICOT)

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Purpose It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions. Methods A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between “1,” defined as the surgical load equivalent to external (monolateral) fixator application, and “5,” defined as the maximal surgical load possible in that specific anatomic region. Results This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load. Conclusion This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient’s physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

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Developments in the understanding of staging a “major fracture” in polytrauma: results from an initiative by the polytrauma section of ESTES

Kalbas

Klingebiel

Halvachizadeh

et al. 2023

Eur J Trauma Emerg Surg

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Purpose Although the term “major fracture” is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of “major fractures” has changed and is modified by a better understanding of patient physiology. Methods A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades. Results 4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000. Conclusion Over time, the way “major fractures” influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

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How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature

Cited by 16 publications

References 96 publications

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

Surgical load in major fractures — results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

Developments in the understanding of staging a “major fracture” in polytrauma: results from an initiative by the polytrauma section of ESTES

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