Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan.
Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan.
Injury. 2019 Dec;50(12):2240-2246. doi: 10.1016/j.injury.2019.09.028. Epub 2019 Sep 20.
While various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database.
We retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score.
Of the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41-0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20-0.46; P < 0.01).
DCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.
尽管已经讨论了各种创伤患者骨折固定策略，但损伤控制骨科（DCO）对显著临床结果的影响尚无定论。我们使用全国性创伤数据库检查了接受 DCO 治疗的患者的死亡率，并将其与未接受 DCO 的患者进行了比较。
我们回顾性地确定了数据库中四肢损伤的患者，这些患者的损伤严重程度评分（AIS）≥2，包括 2004 年至 2016 年 200 多家大医院的数据。纳入标准为年龄≥15 岁且接受了切开复位内固定术（ORIF）的患者。排除了无生存数据或入院时生命体征无效的患者。将患者数据分为 DCO 或非 DCO 组，并使用多变量逻辑回归分析来开发倾向评分，以估计使用已知生存预测因素（如年龄、入院时生命体征、四肢 AIS、ISS、血管损伤的存在、骨折治疗前的手术程序和输血需求）被分配到 DCO 组的概率。主要结局为住院死亡率，在倾向评分匹配后比较两组之间的差异。进行生存分析，并根据年龄、入院时的收缩压和损伤严重程度评分调整危险比。
本研究共纳入 19319 例患者，其中 4407 例（22.8%）接受了 DCO。在进行倾向评分匹配后，选择了 3858 对。DCO 组的住院死亡率明显低于非 DCO 组（40 [1.0%] vs. 66 [1.7%]；比值比=0.60；95%置信区间 [CI] = 0.41-0.89；P=0.01）。生存分析表明，DCO 与四肢损伤患者死亡率降低独立相关（调整后的危险比=0.30；95%CI=0.20-0.46；P<0.01）。
DCO 与严重骨折患者的住院死亡率降低相关。最终应考虑通过选择患者人群对 DCO 进行进一步的临床研究，以制定严重骨折的适当治疗策略。
