From the Department of Orthopedic and Trauma Surgery (E.S., D.R,), Berufsgenossenschaftliche Unfallklinik Duisburg; Institute for Research in Operative Medicine (R.L., E.A.M.N.), Faculty of Medicine, University of Witten-Herdecke; and Department of Orthopedic and Trauma Surgery (T.T., B.B.), University of Witten-Herdecke at the Hospital Cologne-Merheim, Germany.
J Trauma Acute Care Surg. 2014 May;76(5):1288-93. doi: 10.1097/TA.0000000000000167.
Today, there is a trend toward damage-control orthopedics (DCO) in the management of multiple trauma patients with long bone fractures. However, there is no widely accepted concept. A risk-adapted approach seems to result in low acute morbidity and mortality. Multiple trauma patients with bilateral femoral shaft fractures (FSFs) are considered to be more severely injured. The objective of this study was to validate the risk-adapted approach in the management of multiple trauma patients with bilateral FSF.
Data analysis is based on the trauma registry of the German Trauma Society (1993-2008, n = 42,248). Multiple trauma patients with bilateral FSF were analyzed in subgroups according to the type of primary operative strategy. Outcome parameters were mortality and major complications as (multiple) organ failure and sepsis.
A total of 379 patients with bilateral FSF were divided into four groups as follows: (1) no operation (8.4%), (2) bilateral temporary external fixation (DCO) (50.9%), bilateral primary definitive osteosynthesis (early total care [ETC]) (25.1%), and primary definitive osteosynthesis of one FSF and DCO contralaterally (mixed) (15.6%). Compared with the ETC group, the DCO group was more severely injured. The incidence of (multiple) organ failure and mortality rates were higher in the DCO group but without significance. Adjusted for injury severity, there was no significant difference of mortality rates between DCO and ETC. Injury severity and mortality rates were significantly increased in the no-operation group. The mixed group was similar to the ETC group regarding injury severity and outcome.
In Germany, both DCO and ETC are practiced in multiple trauma patients with bilateral FSF so far. The unstable or potentially unstable patient is reasonably treated with DCO. The clearly stable patient is reasonably treated with nailing. When in doubt, the patient is probably not totally stable, and the safest precaution may be to use DCO as a risk-adapted approach.
Therapeutic study, level IV. Epidemiologic study, level III.
如今，在处理长骨骨折的多发创伤患者时，有一种倾向于采用损伤控制骨科（DCO）的趋势。然而，目前还没有一个被广泛接受的概念。风险适应的方法似乎会导致较低的急性发病率和死亡率。双侧股骨干骨折（FSF）的多发创伤患者被认为伤势更重。本研究的目的是验证风险适应方法在处理双侧 FSF 的多发创伤患者中的应用。
数据分析基于德国创伤学会的创伤登记处（1993-2008 年，n=42248）。根据初次手术策略的类型，将双侧 FSF 的多发创伤患者分为亚组进行分析。观察指标为死亡率和主要并发症（如多器官功能衰竭和脓毒症）。
共有 379 例双侧 FSF 患者分为以下 4 组：（1）未手术（8.4%）；（2）双侧临时外固定（DCO）（50.9%）；双侧初次确定性内固定（ETC）（25.1%）；以及一侧 FSF 初次确定性内固定和对侧 DCO（混合）（15.6%）。与 ETC 组相比，DCO 组患者的伤情更为严重。DCO 组的多器官功能衰竭发生率和死亡率较高，但无统计学意义。调整损伤严重程度后，DCO 与 ETC 之间的死亡率无显著差异。未手术组的损伤严重程度和死亡率明显增加。混合组在损伤严重程度和结果方面与 ETC 组相似。
目前，德国在双侧 FSF 的多发创伤患者中同时应用 DCO 和 ETC。对于不稳定或潜在不稳定的患者，合理采用 DCO 治疗；对于明确稳定的患者，合理采用髓内钉治疗。如果存在疑虑，患者可能并非完全稳定，最安全的预防措施可能是采用 DCO 作为风险适应方法。
治疗性研究，IV 级；流行病学研究，III 级。
