Damage control: extremities

Frank Hildebranda, Peter Giannoudisb, Cristian Kretteka,Hans-Christoph Papea,*

aDepartment of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Straße 1,30625 Hannover, GermanybDepartment of Orthopaedics, St. James’s University Hospital, Leeds, UK

Introduction

It has long been recognised that, in patients withsevere abdominal injuries initial managementshould avoid complex operative procedures. Per-formed under emergency conditions, such inter-ventions should be rapid and minimally traumaticto the patient. The primary focus is haemorrhagecontrol and other life saving measures. Complexreconstructive work is delayed until the patient is

better able to withstand the additional trauma. Thisapproach was adopted in patients with extremityinjuries as it became apparent that patients under-going drawn out operations following major traumasuffered an excess of complications. Homeostaticanomalies, the systemic inflammatory response,multiple organ dysfunction and an increased mor-tality were observed.6,9,52

Specific criteria have been developed, whichshould be fulfilled in order to apply this new concept(damage control orthopaedics, DCO) (Table 1).77

In the followingdocumentwediscuss thepotentialadvantages of applying damage control methodologyto major extremity injuries.

Injury, Int. J. Care Injured (2004) 35, 678—689

KEYWORDS

Trauma;

Damage control

orthopedics (DCO);

Early total care (ETC);

Borderline patient;

Immunmonitoring

Summary The principles of fracture management in polytrauma patients continue tobe of crucial importance. Over the last five decades, various strategies of fracturetreatment in the multiply injured patient have evolved. The various new methodol-ogies remain controversial. In the beginning, early surgical fracture treatment of longbone fractures after multiple trauma was not routinely advocated. It was believed thatthe polytraumatised patient did not have the physiological reserve to withstandprolonged operations. The introduction of standardised, definitive surgical protocols,led to the concept of early total care (ETC) in the 1980s. This concept was subsequentlyapplied universally, in all patient groups, regardless of injury severity and distribution.Later, it became apparent that certain patients did not appear to benefit from ETC.Indeed, extended operative procedures, during the early phase of multiple traumarecovery, were associated with adverse outcome. This applied for patients withsignificant thoracic, abdominal and head injuries and those with high injury severityscores (ISS). In response, the concept of damage control orthopaedics (DCO) wasdeveloped in the 1990s. DCO methodology is characterised by primary, rapid, tem-porary fracture stabilization. Secondary definitive management follows, once theacute phase of systemic recovery has passed. We explore the processes underlyingthe systemic biological impact of fracture fixation, the evolution of operative treat-ment strategies for major fractures in polytrauma and the current trends towardstaged management of these patients.� 2004 Elsevier Ltd. All rights reserved.

*Corresponding author. Tel.: þ49-511-532-2028;fax: þ49-511-532-8027.

E-mail address: pape.hans-christoph@mh-hannover.de(H.-C. Pape).

0020–1383/$ — see front matter � 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2004.03.004

Background and pathogenesis:why should DCO be necessary inextremity injuries?

Systemic impact of extremity injuries

All extremity fractures must be considered with theassociated haemorrhage and local soft tissue inju-ries.28 The injury initiates a local inflammatoryresponse with increased systemic concentrationsof pro-inflammatory cytokines. Cytokine levels cor-relate with the degree of tissue damage and theincidence of osseous fractures. This suggests thatinjury plays a major role in determining the releaseof these pro-inflammatory mediators.28 Concentra-tions of inflammatory cytokines in injured tissuehave been measured at many times those foundsystemically, supporting our understanding thatthey are locally generated.27,62

This inflammatory response ultimately results inmicrovascular damage. This process is mediated inpart by activated polymorphonuclear leukocytes. Acrucial pathophysiological step in this process isneutrophil adherence to capillary endothelial cellsand subsequent extravasation.18 The neutrophilsare then stimulated to release oxygen free radicalsand proteases,42 resulting in injury to the vesselwall. This contributes to increased capillary perme-ability, leading to interstitial oedema. All thesefactors are known to be involved in the develop-ment of multiple organ dysfunction syndrome(MODS).

Neutrophil adherence has been shown to occur intwo steps. Initially, neutrophils interact transientlywith the endothelium, mainly via P- and E-selectin89

on the endothelial cell and L-selectin on the neu-trophil.67 This transient process (termed ‘‘rolling‘‘)is then replaced by a more definite adherencemechanism, mediated by ICAM-1 on the endothelialcell76 and integrins on the neutrophil.97

The release of formed inflammatory mediatorsand products of cell injury from sites of trauma has

shown the potential to induce systemic inflamma-tory changes.29 This is compounded by the presenceof ischaemic, necrotic or infected tissue.

Influence of the injury type

Certain injuries have been observed to occur morefrequently in patients who go on to develop sys-temic complications. Among the long bone injuries,femoral shaft fracture has been associated with anincreased risk of adverse outcome. This appears tobe based on the fact that:

1. The femoral shaft fracture is the most frequentlong bone fracture in polytrauma patients.

2. A femoral fracture is associated with highvelocity impact, associated soft tissue damageand blood loss in view of the fact that thelargest soft tissue envelope of any long bonesurrounds the femoral shaft.

The importance of these entities are supportedby the fact that patients with bilateral femoral shaftfractures have demonstrated a compound highermorbidity and mortality rate (16% versus 4% forisolated femoral injuries).49 In contrast no suchchange in morbidity is known for tibial or upperextremity injuries.

With these facts in mind, it seems clear thatmultiply injured patients with extremity injuriesshould also benefit from a damage control strategy.The associated soft tissue injury rather than acutehaemorrhage appears to be most important ininitiation of the systemic response. Prolongedfracture manipulation in the presence of severesoft tissue injury may cause further damage andincrease systemic delivery of inflammatory media-tors.28

Systemic impact of fracture treatment

Osteosynthesis of long bone fractures by intra-medullary nailing has proven a reliable procedure.Compared to traditional plate fixation, a de-creased infection rate, reduced soft tissuetrauma, decreased incidence of non-union andimproved biomechanical function have beendescribed.1,13

Effect of reamed versus unreamed nailingIn experimental studies, reamed femoral nailingwas associated with significant inflammatorychanges. Smith et al. found, that reaming wasassociated with a marked impairment of immunereactivity. Furthermore, an increased stimulatorycapacity of polymorphonuclear leukocytes hasbeen described after reamed femoral nailing.

Table 1 Indications for ‘‘Damage control’’ in ab-dominal surgery (according to Shapiro77)

1 Inability to achieve hemostasis due tocoagulopathy

2 Inaccessible major venous injury3 Time-consuming procedure in a patient with

suboptimal response to resuscitation4 Management of extra-abdominal

life-threatening injury5 Reassessment of intra-abdominal contents6 Inability to reapproximate abdominal

fascia due to visceral edema

Damage control 679

These effects were shown to be reduced when anunreamed procedure was performed.53,79

The piston like effect of intramedullary instru-mentation has been well described.37,91 Reamednailing was associated with a significantly higherintramedullary pressure increase compared withthe unreamed procedure.91 This pressure increasehas been shown to cause liberation of bone marrowcontent with systemic immobilisation of the intra-vasated bone marrow, occasionally leading to fataloutcome.54,100

Furthermore, an investigation in sheep in thepresence of previous damage induced by shockand lung contusion demonstrated fewer abnormal-ities in pulmonary permeability following unreamednailing.48 In the absence of a previous injury,reamed nailing caused only a transient pulmonaryartery pressure increase and no effect on pulmonarypermeability.53 In a further study, animals weretreated by either reamed or unreamed nailing orplate osteosynthesis followed by pressurisation ofthe medullary canal. No significant changes in pul-monary function were detected regardless of thetype of surgical procedure employed.74

Duwelius et al. investigated the effects offemoral stabilization with and without previousunilateral lung contusion and in a sheep model witha femoral fracture. The authors measured signifi-cant increases in pulmonary vascular resistancesubjected to reamed nailing at 120 and 150 minpost lung contusion. It was concluded that theseresults represented ‘‘transient increases in pulmon-ary vascular resistance, but little pulmonary dys-function’’.16

Kropfl et al. reported the first clinical outcomestudy of patients undergoing unreamed femoralnailing, 36% of whom had concomitant severe chestinjuries. No patient developed ARDS following theprocedure. The authors concluded that unreamedfemur nailing might be a safe method for femoralfracture fixation even in the presence of severethoracic trauma.38 Moed suggests retrograde nailingwithout reaming for the treatment of femoral shaftfractures in the multiply injured patient. Theyreport the outcome of 20 patients in whom atrans-articular approach was used, with the pro-posed advantage of a short operation time and littleblood loss. There were an unexpectedly high num-ber of delayed unions, which could not be readilyexplained.44

In a prospective clinical study no significant dif-ferences between two patients groups submitted toeither reamed or unreamed nailing were observed.In this well conducted study, a large number ofpatients was enrolled and many of them had multi-ple injuries.14

Therefore it can be concluded, that the effect ofreamed and unreamed femoral nailing on the inci-dence of post-traumatic complications is clinicallynot proven and seems to be difficult to evaluate.

Based on the assumption, that the most impor-tant principle in human medicine is ‘‘primum nonnocere’’, a new reaming system has recently beendeveloped. It was designed to minimise the localand systemic impact of reaming. This reaming sys-tem allows intraoperative irrigation and suctionduring reaming of the medullary canal (RIA�,Synthes). This might offer an elegant solution tothe dilemma by combining the positive effectsof reaming (primary stability) whilst avoiding anypossible problems induced by fat intravasation intothe systemic circulation. If this can be achievedwith consequent reduction in embolization andimmunological abnormalities, it will be a great steptowards resolving an ongoing debate amongsttrauma surgeons.

The second hit theory

Before invasive measurements and complex bloodtests became available, clinical evaluation was theonly method available to gauge the multiply injuredpatients condition. These modern adjuncts to clin-ical assessment are one requirement for the imple-mentation of DCO.

The premise of DCO is based upon the hypothesisthat the clinical course following polytrauma isprimarily determined by three factors; the initialtrauma (‘‘first hit’’), the patient’s biological con-stitution and the timing and quality of any medicalintervention, which can be thought of as additionaltrauma (‘‘second hit’’), if the procedure is largeenough. The treating physician can modulate onlyone of these three variables, it is therefore essentialthat their decision-making is evidence based andwell informed. The more severely traumatised thepatient is, the more critical the strategy becomes.

It is imperative that multi-disciplinary, patientcentred care is maintained throughout when usingthis approach. With rapid rescue facilities, promptand appropriate resuscitation and the availability ofintensive care facilities, it appears that the decisionregarding the timing and type of surgery performedis the primary, variable determinant of outcome.Clinical experience with these patients initiallyresulted in a reduction in the extent of primarysurgery performed. This did appear to reduce thenumber and severity of unexpected complications.The underlying mechanism of this observedphenomenon was largely not understood. Morerecently, increased knowledge of post-traumaticimmunological responses has resulted in a clearer

680 F. Hildebrand et al.

appreciation of the processes at work.22,50 Itappears that the ‘‘second hit’’ is additive to theprimary insult and, if the combination sufficientlysevere, the patient’s physiological reserve is over-come. The result is either rapid deterioration, ora prolonged course characterised by systemicinflammation, associated microvascular damage,widespread interstitial oedema and multi-organfailure.50,82

The ‘‘second hit’’ is observed to be compoundedby factors such as blood loss, sepsis and ischaemia,all of which will heighten the inflammatoryresponse.50 Furthermore, one can consider any sub-sequent physiological stresses as serial subsequent‘‘hits’’ including septic episodes, blood transfusion,dehydration and surgical intervention. When con-sidered in these terms it becomes easy to under-stand how, even in a patient with only a moderatefirst hit, the clinical situation can rapidly deterio-rate if further insults are allowed to take place.The over-riding principle of DCO is therefore tominimize subsequent stresses subjected uponunstable patients with high risk of post-traumaticcomplications.

With advances in laboratory techniques it hasbecome possible to quantify the inflammatoryresponse to trauma and operative procedures.The measurement of inflammatory markers hasbeen proven to be reliable in estimating the initialresponse to trauma. Comparison of differentinflammatory mediators has demonstrated thatmeasurement of pro-inflammatory cytokinesappeared to be most useful for routine clinicalwork. Roumen et al.71,72 reported that levels ofthe primary inflammatory cytokines, tumour necro-sis factor-a (TNF-a) and interleukin-1b (IL-1b) had agood correlation with initial degree of haemorrhageand non-survival after ARDS and MODS. This findingis, however, not consistent.10,66 Previous resultsfrom our group demonstrated that the reliabilityof both TNF-a and IL-1b concentrations as acutemarkers for trauma and surgery is low. Also, in otherclinical studies, the use of TNF-a as a marker hasbeen disappointing. This is in part due to its phar-macokinetics; TNF-a has a short plasma half-life of14—18 min. Binding to soluble TNF-a receptors andnatural TNF-a binding proteins can also interferewith measured plasma levels.87

In contrast, IL-6 appears to be a more reliablemarker. The association between early elevations inIL-6 plasma concentrations, high ISS and lateadverse outcome is well established.58 A clinicalstudy confirmed early elevation of IL-6 levels imme-diately after trauma; patients with the most severeinjuries had the highest IL-6 concentrations.21

Levels remained elevated for more than 5 days in

patients with a high Injury Severity Score (ISS).58 Anearly raised IL-6 was able to discriminate traumapatients who later developed MODS.58 Accordingly,previous results from our group have shown thatsystemic IL-6 concentrations exceeding 800 pg/mlon admission are predictive of later MODS.60 Intrauma patients undergoing orthopaedic proce-dures, subsequent increases in IL-6 plasma levelswere proportional to the magnitude of the opera-tion. Most investigations examining quantificationof the second hit response induced by orthopaedicsurgery deal with the stabilization of long bonefractures. Femoral nailing was found to have asignificant impact on inflammatory response, andlead to a marked increase in IL-6 concentra-tions.22,56 Our recent clinical findings support theseresults, demonstrating that IL-6 concentrations var-ied according to the type of orthopaedic surgeryperformed. The inflammatory response induced byfemoral nailing was comparable to that induced byun-cemented total hip arthroplasty.56

After the initial pro-inflammatory response, asecondary immune suppressive effect of operativetreatment is described. This was characterised byraised concentrations of the anti-inflammatory IL-10 and reduced pf class II human leukocyte antigen(HLA) expression on peripheral blood mononuclearcells. Again, the effect of femoral nailing wasinvestigated, demonstrating that reamed femoralnailing was associated with greater impairment ofimmune reactivity than the unreamed nailing tech-nique.8,30,80

The significance of associated injures(injury distribution)

For many years, the concept of early total care(ETC) was performed dogmatically. It was believedthat patients were too unstable not to have fracturestabilization, and this usually entailed definitivefracture management.

Despite the positive effects of early fracturemanagement, there was much controversial discus-sion. Reynolds et al.65 demonstrated in a retrospec-tive study, that those patients with femoral shaftfractures and a low injury severity (injury severityscore <18) had a tendency toward fewer and pul-monary complications if they underwent early intra-medullary nailing when compared to those havinglate stabilization. In polytraumatised patients (ISS>18), no relationship between timing and outcomewas seen. The authors criticised all previous reportsshowing benefits of ETC. They argued that none ofthese studies had proven that the improvements inoutcome were independently associated with earlydefinitive fracture fixation.65

Damage control 681

Following this, certain centres described using astepwise approach in multiple injured patients.This concept included the stabilization of majorfractures within 24 h. The ‘‘acute period’’ (1—2 h)was used for life-saving procedures, followed bythe ‘‘primary period’’ (day 1), which includedmanagement of open fractures and joints, stabili-zation of fractures and decompression of anycompartment syndrome. The ‘‘secondary period’’(48—72 h) and ‘‘tertiary period’’ (>72) servedfor prolonged reconstructive surgical treatment(e.g. intra-articular fractures).17 In a multi-centrestudy,17 including 1127 patients with femur frac-tures, an unexpectedly high rate of pulmonarycomplications was observed after primary(<24 h) stabilization. These complications wereparticularly worrying when observed in youngpatients (20—30 years), without pre-existing pul-monary risk factors. It appeared that the timingand type of operative fracture stabilization mightplay a major role.

Several studies supported the previous findings ofEckeetal.,17 thatahigher incidenceofcomplicationswere observed in the presence of severe thoracicinjuries, hemorrhagic shock or in unstable patientswho underwent surgical procedures.46,52,65,75

With the results of various clinical and animalstudies it became apparent that both the severityand distribution of injuries were risk factors forcomplications after ETC. There is a high incidenceof thoracic injury in association with long bonefracture in polytrauma patients. Early quantifica-tion of the severity of chest trauma has provendifficult. Parenchymal injury (e.g. lung contusion)is more important for lung function than osseousinjury.

Several diagnostic tools are available for earlyassessment of pulmonary injuries:

(1) Plain chest X-ray: Some authors based thediagnosis of pulmonary injury on admissionplain chest radiograph alone.83 However, at thetime of admission the severity of pulmonarycontusion is frequently underestimated byplain chest X-ray.15,25,40

(2) Computed tomography (CT-scan) chest: Whilstthe value of thoracic CT is undisputed, thetherapeutic relevance of additional informa-tion is questioned.2,15,41,69,90 The superiority ofCT against chest X-ray in diagnosing thoracicinjuries and the quantification of these injurieswas demonstrated.26,40,60,70 However, no im-provement in outcome was seen and thus,the authors did not unilaterally recommendedemergent thoracic CT-scan in all polytraumapatients.26 In contrast, other studies demon-

strated that the additional information gainedfrom chest CT resulted in therapeutic conse-quences in up to 70% of patients.20,36,41 Due tothese findings, spiral chest CT is becomingstandard during initial trauma assessment inmost major trauma centres, once initial stabi-lity is achieved. Only in patients with severemultiple injuries requiring immediate surgery isCT-scanning deferred.

(3) Ultrasound examination: Ultrasound scanningcan substantially shorten the time to diagnosisand consequently the commencement oftherapeutic measures.70,98 However, neitherpneumothorax nor bony injury can be demon-strated.70 Consequently, ultra-sonographycannot replace radiographic diagnostics nor beused as an exclusive investigation in thoracictrauma.

(4) Other diagnostic options: Bronchoscopy allowsdiagnostic and therapeutic interventions to beperformed,63 but the blood gas values ofpolytraumatised patients deteriorated substan-tially after bronchoscopy.32 Therefore,bronchoscopy is not advocated as a routineprocedure in the primary diagnosis of poly-trauma patients.

Due to long procedure times and limited amountof information obtained, ventilation-perfusion-scintigraphy is not suitable for the initial assessmentof the polytraumatised patient.43,93

Arterial blood gases remain a useful method ofassessment, they must be interpreted with cautionalong with the results of other investigations andthe patients clinical state.4,19,31,43,95

Clinical studies demonstrated that the pulmon-ary arterial pressure (PAP) might represented agood predictor for the development of pulmonaryfailure,84 but a great variability in the increase inPAP between patients despite comparable pulmon-ary injury severity has been observed.96 Thus, theincrease in pulmonary arterial pressure can notpredict the severity of thoracic injuries.

The determination of the extravascular lungwater (EVLW) represents a reliable bedside mea-surement.85 As pulmonary oedema does not usuallydevelop until 2—3 days following injury,78, EVLW isnot a useful early predictor for the development ofpulmonary complications.

In summary, the dynamic nature of parenchymallung injuries and the difficulty in early determina-tion of injury severity are still significant problemsin the decision-making process for the timing offracture stabilization. Unexpected complicationsafter ETC were observed in those patients whoseinjury severity was initially underestimated.

682 F. Hildebrand et al.

Influence of head traumaAlso in polytraumatised patients concerns havebeen raised about patients with associated headtrauma. It was supposed, that prolonged operationcould cause intraoperative hypotension, hypoxiaand coagulopathy in combination with increasedblood loss and fluid requirements during and afterthe orthopedic operation. This will be detrimentalto cerebral perfusion and would be an additionalinsult to the already injured brain, thus outweighingthe benefits of early fracture stabilization.23

The strict application of ETC, even in patientswith a high ISS, brain injury or severe chest trauma,limited discussion of best management for thesepolytraumatised patients. Patients submitted toETC during the last three decades have demon-strated a progressively lower ISS. It could be con-cluded that a more cautious approach regardingsurgical treatment has been chosen (Table 2).61 Insome studies, favouring the concept of ETC, it isobserved that primary fracture stabilization wasonly performed in multiple injured patients witha lower injury severity score.6,11

Historical background

Development of the treatment of majorfractures in polytrauma

The era of secondary fracture stabilizationUntil the middle of the last century, early definitivefracture stabilization was performed only as anexception, as it was believed that multiply injuredpatients were too unstable to survive surgical inter-vention. Complex laboratory investigations andmonitoring facilities were not available. Conse-quently estimation of the patient’s status was, onthe whole, performed by clinical assessment only.Thus, complications were usually only identified intheir late stages. Signs of MODS in the first post-

traumatic week was diagnosed as the ‘‘fat embo-lism syndrome’’, characterised by hypoxia, cerebraldepression (somnolence, coma), coagulopathy(petechial bleeding) or renal failure (anuria). Embo-lism was thought to be directly related to therelease of fat and intramedullary content fromthe fracture site by fracture or early surgical treat-ment.7,64 However, it was also believed, that patho-logical movements of the fracture line might beresponsible for further liberation of intramedullarycontent in the blood stream.

Early fracture stabilization was then performed,as more advanced techniques for the postoperativecare were available, with improved outcomeobserved.45 However, this methodology was notwidely accepted initially, it seemed common sensethat surgical fracture stabilization should only beperformed in patients, who were in a condition, i.e.without signs of fat embolism syndrome. Further-more, rapid fracture healing was observed whenoperations were performed later in the post-trau-matic course. Therefore, a great number of patientswere subjected to prolonged skeletal traction.79,101

Not until the early 1980s was the first meaningfulstudy published, showing that early, definitive sta-bilization of long bone fractures reduced the inci-dence of the fat embolism syndrome compared totraditional non-surgical treatment.68

Aiming at early definitive fracture treatmentAs further clinical studies demonstrated the benefitof early, definitive fracture stabilization, accep-tance of this treatment methodology became morewidespread.24,86 Early operative treatment impliedstabilization within 24 h.68 It was reported that theeffect of early fracture stabilization became moreevident with increasing injury severity.35 The firstprospective, randomised trial ever available wasthen published by Bone et al.3 demonstrating theadvantages of early fracture stabilization: 178patients with femoral fractures were randomised

Table 2 Patient description used for the diagnosis of the ‘‘borderline’’ patient (according to Pape et al.61);ISS ¼ Injury Severity Score; AIS ¼ Abbreviated Injury Scale; BP ¼ Blood Pressure

Author Year Inclusioncriteria

Mean injuryseverityscore (ISS)

Mean ISSprimarydefinitive surgery

Mean ISSsecondarydefinitive surgery

ARDSincidence(%)

Mortality(%)

Johnson 1985 ISS >18 38 38.2 38.0 7—39 4.5Bone 1989 — 31—32 31.8 31.3 0.6—3.3 1.2Pape 1993 ISS >18 34—55 52.2 55.2 7—33 2—21van Os 1994 ? 29—38 — — 20—26 5.3Charash 1994 ISS >18 25—29 27 29 0—10 8—60Bone 1995 ISS >18 26—29 — — 0—33 8.2Bosse 1997 ISS >17 23—30 — — 1—3 2.7Carlsson 1998 ? 18—34 — — 21—72 0—6

Damage control 683

to early stabilization (within 24 h after trauma) anda late stabilization (within 48 h after trauma).Patients with delayed fracture stabilization had aprolonged duration of ventilatory therapy andstayed longer in both, critical care and hospitaloverall.35,68

An essential prerequisite for ETC was an optimi-sation of rescue conditions and a reduction of therescue time. Furthermore, the improvements ofintensive care medicine with improved cardiovas-cular monitoring and facilities for prolonged venti-latory support supported the development of amore aggressive surgical approach.33,92

Consequently, early definitive fracture stabiliza-tion represented significant progress resulting inpain reduction, early mobilisation and the asso-ciated reduction in thromboembolic and infectiouscomplications. The advantages gained by countlesspatients who were able to mobilise early are welldescribed.39,94

However, patients with a very high ISS did notappear to benefit from this procedure. Even withexcellent rescue conditions, an unacceptably highnumber of complications was observed.

Questioning the dogma–—the borderline eraAs it became evident that not all patients benefitedfrom ETC, a specific subgroup of patients were

identified, termed the ‘‘borderline patient’’. Thesepatients were demonstrated to be at particular riskof late, poor outcome. Studies attempted to definethe borderline patient using clinical and laboratoryfindings57,59 (Table 3). These parameters had aphysiological basis, obtained by routine laboratorytests and monitoring. Some of the criteria werederived from clinical experience, others were theresult of clinical studies undertaken to evaluate theimpact of initial surgery on outcome. Using datafrom the ‘‘German Trauma Registry’’, it was clearlydemonstrated that initial surgery of more than 6 h is

Table 3 Injury Severity (ISS) and complications inpatients undergoing orthopedic surgery at severalvarious time points within the last decade; ISS ¼ In-jury Severity Score; ARDS ¼ Adult Respiratory DistressSyndrome (according to Pape et al.61)

Polytrauma þ ISS >20 and additional thoracic trauma(AIS >2)

Polytrauma þ abdominal/pelvic trauma12 andhemorrhagic shock (initial RR <90 mmHg)

ISS >40, without additional thoracic traumaBilateral lung contusion on chest X-rayInitial mean pulmonary arterial pressure >24 mmHgIncrease of pulmonary arterial pressure during

intramedullary nailing of >6 mmHg

Table 4 Immune monitoring in trauma patients

Parameter Significance

Tumor-necrosis factor-a (TNF-a) Short half live due to binding to soluble receptors; no reliableparameter in trauma

Interleukin (IL)-1b Short half live due to early degradation and binding to solublereceptors; no reliable marker in trauma

IL-6 Reliable parameter regarding injury severity and incidence ofpost-traumatic complications; association with magnitude ofsurgical procedure

IL-8 Association to injury severity with highest levels in head injuriesand chest trauma; early predictor of survival after trauma

IL-10 Increase in the later post-traumatic course associated withinfectious complications

IL-18 Prognostic marker for survival in post-traumatic/postoperativeseptic patients; no increase in trauma-induced systemic inflammation

C-reactive protein (CRP) Non-specific marker; no reliable parameter for quantification ofinflammatory response and sepsis

Procalcitonin (PCT) Association with severity of bacterial infections; prognostic value intrauma unclear

Endotoxin Limited usefulness due to transient endotoxaemia in MODS;predictive value in Gram-negative sepsis insufficiently accurate

Lipopolysaccharid binding protein (LBP) Post-traumatic differentiation of SIRS and infectious complications;prognostic significance in sepsis unclear

Immunglobulins, RES-function,plasma DNA, leukocyte antigens,adhesion molecules, intracellularcytokine measurement

Limited clinical use, measurements for scientific purposes

684 F. Hildebrand et al.

associated with a significantly higher incidence ofsubsequent organ dysfunction.59

Specific markers of systemic inflammatoryresponse have recently been identified and cannow be included in the assessment of these patients(Table 4).

In summary, initial temporary fracture stabiliza-tion appears to be an advantageous treatment strat-egy in order to prevent unexpected post-traumaticcomplications in borderline patients. This resultedin a new approach in the management of orthopae-dic trauma in multiple injured trauma patients.Nevertheless, the selection of these patients, bymeans of routine clinical parameters, in the early1990s was difficult.

DCO: a current concept

The impact of surgery on the immune response thatoccurs in polytraumatised patients, in addition tothat caused by the primary insult, has been clearlydemonstrated.58 Sub-clinical consequences of theinitial trauma and subsequent operative treatmentare compound and manifest as abnormalities inorgan function, leading to MODS. It is clear thatthe burden of the second hit should be minimised inmultiple injured patients with a high risk of adverseoutcome.

Different studies report favourable results forhigh risk patients treated to a DCO protocol.5,47,55

The commonest approach is the temporary applica-tion of external fixation to provide stability. Theprocedure is not time consuming and can be per-formed in the emergency department or in theintensive care unit.73 Concerns have been raised

over the increased risk of infection due to pin sitesepsis, though, whilst superficial problems are com-mon, no significant increase in clinically relevantlocal infection has been reported.34,55 Our clinicbegan using DCO protocols in 1990.

Following this alteration in our practice, ourgroup carried out a retrospective analysis of out-come, including trauma patients with femoralfractures. This clearly demonstrated, that in allstudy groups–—intramedullary nailing, external fixa-tion, plate osteosynthesis–—systemic complicationswere reduced. Nevertheless, an increased ARDSincidence was demonstrated in patients with pri-mary definitive fracture stabilization. We havedeveloped a four-step management plan that isnow applied to all high-risk patients. This comprisesa re-evaluation of clinical and laboratory para-meters in the emergency department after primarydiagnostics.88

When to perform the secondary procedure

One of the most important decisions to be made indesigning a DCO protocol is the timing of secondarysurgical procedures. It has been shown that days 2—4 do not offer optimal conditions for definitivesurgery. In general during this period, markedimmune reactions are ongoing99 and enhanced gen-eralised oedema is observed.81 Nevertheless, thesepatients represent a highly diverse group and indi-vidual clinical judgement is more reliable, espe-cially when combined with information from thenewer laboratory tests. In a retrospective analysisof 4314 patients treated in our clinic, it was foundthat a secondary procedure lasting more than 3 hwas associated with the development of MODS.

POLYTRAUMATIZED PATIENT

In extremis

ICUEx. Fix.

(distractor)

UnstableStable

DCO

OROR

ETC 60 80 %

Clinical condition

Borderline

if required, shock roomhemorrhage control and/or

decompression (thorax)

Reevaluation (shock room)

ABG, ultrasound, urine output

RR, inflammatory response (IL-6)

Uncertain

DCO

StableOROR

OR = operating room

ETC = early total care

DCO = damage control orthopaedics

Ex.Fix.= external fixation

-

Figure 1 Flow diagram highlighting the algorithms for treatment of major fractures in consideration of the impact ofsurgery after severe trauma. OR, operating room; ICU, intensive care unit; ETC, early total care; DCO, damage controlorthopedic; Ex fix, external fixation (modified according to Pape et al.61).

Damage control 685

Also the patients who developed complications hadtheir surgery performed between days 2 and 4,whereas patients who did not go on to develop MODSwere operated between days 6 and 8 (P < 0:001).51

The measurement of inflammatory mediators hasbeen shown to be sensitive in gauging the ongoingresponse in recovering patients.51 A prospectivestudy has recently shown that polytraumatisedpatients submitted to secondary definitive surgeryat days 2—4, developed a significantly increasedinflammatory response, compared to those oper-ated at days 6—8. It was concluded that, in differentpost-traumatic periods, a variable inflammatoryresponse to comparable stimuli is observed. Thismay contribute to variations in clinical outcomethat have been observed, e.g. the higher incidenceof MODS.58 Based on this concept, the followingrecommendations can be made for specific groupsof patients (Fig. 1).

Summary

Damage control orthopaedics has evolved as a newapproach to minimize the impact of primary sur-gery. DCO should be regarded as a part of theresuscitation process. By careful choice of surgicaltechnique, blood loss and tissue trauma are mini-mised and tissue oxygenation maintained. Thereby,the impact of operative fracture stabilization isminimised. Several experimental and clinical stu-dies demonstrated that using the DCO concept candecrease the resultant inflammatory response,leading to improved clinical outcome.

With this evidence, early major surgery has to bejudged as too great a burden for polytraumatisedpatients. Primary procedures of greater than 6 hduration and major surgical procedures at days 2—4should be avoided. Increased knowledge andadvances in the field of molecular biology andgenetics may lead to new parameters, helping toselect patients with a high risk for adverse outcome.

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