多发伤中早期主要骨折治疗-合并伤情况下的重点：德尔菲共识过程和系统评价。
Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.
机构信息
From the Department of Trauma Surgery (R.Pf., F.K.-L.K., Y.K., H.-C.P.), Harald-Tscherne Laboratory for Orthopaedic and Trauma Research (R.Pf., F.K.-L.K., Y.K., H.-C.P.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia; Department of Orthopaedic and Trauma Surgery (F.J.P.B.), Lucerne Cantonal Hospital, Lucerne, Switzerland; Riverside University Health System Medical Center and Loma Linda University School of Medicine (R.C.), Loma Linda, California; Department of Orthopaedics and Traumatology (C.F.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong; Academic Department of Trauma and Orthopaedics (P.V.G.), School of Medicine, University of Leeds; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom; Department of Trauma Surgery (F.Hie.), University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Orthopaedics (F.Hil.), Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany; Emergency Surgery Unit (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Trauma Surgery (T.L.), Aarau Cantonal Hospital, Aarau, Switzerland; Department of Trauma (I.M.), Hand, and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Department of Neurosurgery (M.F.O.), Clinical Neuroscience Center (M.F.O.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery (R.Pe.), Trauma Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Surgery (R.Pe.), Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic; Department of Orthopedics and Spine Surgery (S.R.), Ganga Hospital, Coimbatore, India; Department of Surgery, Division of Orthopaedic Surgery (E.H.S.), University of Western Ontario, London, Ontario, Canada; Department of Orthopaedic Surgery (H.A.V.), Case Western Reserve University, Cleveland, Ohio; and Department of Orthopaedics (B.A.Z.), UT Health San Antonio, San Antonio, Texas.
出版信息
J Trauma Acute Care Surg. 2024 Oct 1;97(4):639-650. doi: 10.1097/TA.0000000000004428. Epub 2024 Aug 1.
BACKGROUND
The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.
METHODS
This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.
RESULTS
A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).
CONCLUSION
A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.
LEVEL OF EVIDENCE
Systematic Review/Meta-Analysis; Level IV.
背景
多发创伤患者的主要骨折治疗时机对其预后有重要影响。然而，针对合并伤的标准化治疗策略却很少见。本研究旨在针对颅脑、胸、腹、脊柱/脊髓和血管合并伤以及多发骨折患者的主要骨折治疗时机提供专家建议。
方法
本研究采用德尔菲法（Delphi method）并结合系统评价。通过 Medline 和 EMBASE 数据库检索相关文献，确定上述损伤模式下骨折治疗时机的文献。然后，17 名国际多学科专家根据现有证据制定共识声明。声明在在线和现场会议中反复调整，最终进行投票。共识达成的标准为≥75%的同意率。所确定文献的证据水平采用 GRADE 方法进行评级。
结果
共确定了 12476 篇文献，其中 73 篇被纳入。大多数文献建议早期手术（47/73）。45 篇文献将早期手术的时间阈值设定在 24 小时内。专家组制定了 20 项共识声明，所有声明的共识率均>90%，其中 15 项达到 100%。这些声明定义了在创伤性脑损伤（n=5）、腹部创伤（n=4）、胸部创伤（n=3）、多发四肢骨折（n=3）、脊柱（脊髓）损伤（n=3）和血管损伤（n=2）存在的情况下，早期确定性骨折治疗的条件和例外情况。
结论
本研究共制定了 20 项与合并伤相关的骨折固定时机的声明。所有声明均同意，主要骨折治疗应在入院后 24 小时内开始，并在该时间内完成，除非患者的临床状况或严重合并症使其无法进入手术室。
证据水平
系统评价/荟萃分析；IV 级。
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