Damage Control Orthopaedics

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Damage ControlOrthopaedics

• Michael J. Bosse, MD
• Lisa Cannada, MD
• Robert Hymes, MD
• John Morris, MD

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Damage Control

• Most misunderstood concept of the decade.
• Simply stated
• If the patient is in the OR for lifesaving
  surgery - do something for open and long bone
  fractures
• If not in the OR, delay until physiology is
  correct
• Protect the brain

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Key Orthopaedic Issues

• Do you need to operate ?
• When do you need to operate ?
• How much surgery is required ?

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Early Fracture fixation

• 2 wks
• 48 hrs
• 24 hrs

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Early Fracture Fixation

• 1977 - Riska
• 1980 - LaDuca
• 1982 - Goris
• 1985 - Johnson
• 1985 - Seibel
• 1989 - Meek

• 1989 - Bone
• 1990 - Behman
• 1990 - Chapman
• 1993 - Riemer
• 1994 - Bone
• 1994 - Charash

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12 Articles

• Only one prospective randomized
• None were designed to account for
• patient or injury variability
• advances in the treatment of the CHI
• advances made in pre-hospital, resuscitative and
  critical care

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Worst Study, Most Misquoted

• Bone et al, JBJS - Early v Delayed fixation of
  Femur Fractures
• Not appropriately randomized
• Cohorts too small
• Only significant finding was total cost of care

THE ORTHO SILVER BULLET !
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Johnson et al , 1985

• 132 patients, retrospective
• ISS gt 18
• 5X ARDS rate if surgery delayed gt 24hrs

Reported from a Center that employed an early
fixation protocol
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Outcomes Analysis

• Any decade
• All trauma specialties evolving and refining
• Combined effect drives decrease in MM
• No one treatment can be implicated as the cause
  without controlling for the impact of the others!

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Early Fixation Gives
Orthopaedic Trauma Surgeon Beliefs

• Less ventilator days
• Less ICU days
• Reduced MOF and Sepsis rates
• Reduced ARDS and FE rates
• Less fracture complications
• Decreased hospital stay cost
• Decreased mortality
• Improved outcome
• Easier patient care
• Decreased decubitus ulcer rates

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Classic Level I Center

• Care for the open injuries
• Fix the long bones
• Fix the upper extremities
• Fix whatever was left to fix

Prolonged OR time, excessive blood loss,
temperature drop
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Religious
Thou Shalt Immediately Nail ALL Long Bone
Fractures !
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The Eleventh Commandment
DOGMA
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However,

• Recognized a group of patients too sick for the
  stresses of major orthopaedic surgery
• Traveling traction External fixation
• Andrew Burgess, Baltimore Shock Trauma 1984

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Damage Control Surgery

• Rotundo 1993
• Described early termination of laparotomy after
  control of bleeding and contamination
• Later definitive care
• 10 of trauma patients

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Respect the Critical Triad

• Hypothermia
• Coagulopathy
• Acidosis

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Unfavorable Surgical Parameters

• Progressive hypoxia
• Unremitting metabolic acidosis
• Mixed venous desaturation
• Hypothermia
• Uncorrected coagulopathy

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Pape - 1993

• Critically ill patients with pulmonary contusions
  and femur fractures did better with delayed
  treatment

J Trauma 34 (1993) 540
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Reynolds - 1995

• 424 Femur fractures
• 105 ISS gt 18
• No rigid early fixation protocol
• stable patients - immediate ORIF
• unstable patients - delayed surgery

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Reynolds - 1995

• Pulmonary outcomes not related to early or late
  fixation
• Pulmonary outcome was related to the severity of
  the injury

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Polytrauma Patient fracture
Stable
Borderline
Unstable
In extremis
If in shock/or need chest decompression
hypoxia, urine output, and IL-6
Stable
Uncertain
OR for ETC
OR for DCO
Pape AJSurg 183 2002
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Polytrauma Patient fracture
Stable
Borderline
Unstable
In extremis
If in shock/or need chest decompression
hypoxia, urine output, and IL-6
Stable
Uncertain
OR for ETC
OR for DCO
Pape AJSurg 183 2002
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TBI Goals

• Oxygenation
• Ventilation
• Restoration of Circulating Volume
• Blood Pressure
• ?ICP

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Unstable patient with a femur fracture
In MOR for life-saving surgery
Responds to Resuscitation
Unstable resuscitation and/or labile CHI
Skeletal Traction
Assess Condition Intra-op
Aggressive Resuscitation in ICU and monitor CHI
FAVORABLE

_
IM NAIL
Parameters Favorable
_

Provisional Ex Fixation
Provisional Ex Fixation (_at_ 3-4 days)
Convert to IM Nail when patients condition allows
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Delayed Femur Fixation Reduces Mortality in the
MIP

• Retrospective study of NTDB
• 3069 pts femur fxs and ISS gt 15
• Determine 12 hrs was the cut point
• Delay beyond 12 hrs 50 reduction in mortality
• Pts with serious abdominal trauma benefit most
• Likely related to patients resuscitation
• Supports delayed fixation Damage Control

Morshed, JBJS 2009
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Taeger DCO Germany

• 75/409 (18) patients with ISS gt 30 and major
  orthopaedic injuries treated with DCO
• 135 fractures 49 femurs 39 tibias 25 pelvic
  and 22 upper extremity
• 73 were closed
• 85 in the OR for DCO
• 14 laps, 13 craniotomies, 2 compartments
• Concluded that DCO reduced initial OR time

Out of Control Damage Control
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Damage Control

• Isolated Trauma
• May have NO functional or positive clinical
  effect
• Likely increases cost of care
• Increased implant cost (ex fix)
• Increased OR exposure
• Increased LOS

Ortho Hype
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Damage Control

• Traction pins, ER washouts and splints ARE Damage
  Control

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Damage Control

• Simply stated
• If the patient is in the OR for lifesaving
  surgery - do something for open and long bone
  fractures
• If not in the OR, delay until physiology is
  correct
• Protect the brain

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Case 1

• 34 yo male MVC
• Segmental Femur Fx open
• Open ankle
• BE -4
• LOC, nl CT , GCS 14

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Case 2

• 26 yo male, MCC
• AIREVAC
• Airway / pneumothorax
• BPsystoliclt90
• LOC GCS 9
• Open Tibia
• Femur
• Pelvic Fx

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On Admission

• Intubated
• Chest tubes
• HR 130
• FAST (-)
• BE -9
• Scrotal hematoma
• Pelvic instability

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Immediate Therapy?
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Work-up / Imaging ?
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CT - diffuse swelling
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Treatment Plan
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Timing of Care
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Case 3

• 26 yo MVC
• CHI GCS 7
• BP gt 90
• Pulse 100
• BE -2

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Other Injuries

• Femur Fx (segmental)
• Open BBFA