Damage Control In Orthopaedic Surgery: fad Or Fact ?

Ahmed Azmy (MSc)TEAM A-ORTHOPAEDIC DEP.

KHOULA HOSPITAL

outline

HISTORY

PATHOPHYSIOLOGY

PATIENT SELECTION

MANAGEMENT

CONCLUSION

HISTORICAL PERSPECTIVES

HISTORICAL PERSPECTIVES

“Definitive reduction of fractures in patients who

have other injuries and who may have been in

shock should be delayed until the general

condition of the patient is satisfactory.”

When was this phrase published?

“The care of fractures in the patient with multiple injuries”Compere EL. J IntCollSurg.1961 Feb;35:216-20.

RATIONALE FOR DELAYED FIXATION-THE 1960S:-

the philosophy prevailed that the polytrauma patient was ‘too sick to operate on’

The development of fat embolism syndrome and pulmonary dysfunction was feared (Bradford DS ET AL., 1970)

Definitive surgical stabilization was often delayed to 10-14 days

Cast and skeletal tractions preferred

1970S :-

Pioneering studies

showed that early

stabilization of femoral

fractures reduced

dramatically incidence of

Fat Emb.Syndrome,

pulmonary failure

(ARDS) and

postoperative

complications

RATIONALE OF EARLY FIXATION:-1980S (ETC) EARLY TOTAL CARE)

“ There is a beneficial effect of early

Stabilization of fractures on both

mortality and morbidity and length

of hospital stay.”

This new philosophy was named

Early Total Care ( ETC ). “The patient is

too sick not to be treated surgically”

Surgeries were done within 24 hrs of admission

Early 1990s Outcome after ETC increased incidence of ARDS and (M.O.F)

These complications mainly developed in patients with severe chest injuries, severe hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma.

Early total care (CONT.):-

patients with high ISS had high mortality rate

even when treated early (Pape J Trauma 1995 - 3406

polytrauma Pts).

Early total care (CONT.):-

IN THE EARLY 1990S:-

a variety of unexpected complications related to the

early stabilisation of fractures of long bones was

described. It was suggested that the operative

procedure used to fix the bone, in most cases a reamed

intramedullary nail, could provoke rather than protect

against the development of pulmonary complications.

This led to the conclusion that the method of

stabilisation and the timing of surgery may have played

a major role in the development of such complications.

THE EVOLUTION OF DAMAGE CONTROL ORTHOPAEDICS-1990S:-

An approach to achieve rapid

skeletal stapilization of major

orthopaedic injuries to stop the

cycle of ongoing musculo -skeletal

injury and to control haemorrhage

Its purpose is to avoid worsening

of the patient's condition by the

"second hit" of a major orthopaedic

procedures

WHAT IS DAMAGE CONTROL ?

WHAT IS DAMAGE CONTROL ?

DAMAGE CONTROL IS A NAVAL

TERM:-

SAVE THE SHIP

LIMIT DAMAGE

EMERGENCY REPAIR

FINISH THE MISSION

5 TENETS OF DAMAGE CONTROL ORTHOPAEDICS:-

1. Recognize who needs

damage control.

2. Salvage operations.

3. Keep the patient

alive.

4. Accept morbidity of

the salvage

procedures.

5. Definitive repair later

PATHOPHYSIOLOGY

HYPOTHERMIACOAGULOPATH

Y

TRAUMA BLOODTRANSFUSION

BLEEDING

THE BLOODY VICIOUS CIRCLE

TRAUMA TRIAD OF DEATH

TRAUMA MORTALITY

BimodalEarly death – Blood loss

– Brain injury

Late death – Secondary brain injury

– Host defense failure -sepsis

TWO-HITS THEORY

“Hits” Induce a Host Immune Response

First Hit–Hypoxia– Hypotension– organ & soft tissue injury– fractures

Second Hit– ischemia/reperfusion injury– compartment syndrome– operative intervention– infection

INFLAMMATORY HOST RESPONSE

Local and systemic release of:

– pro-inflammatory cytokines

– arachidonic acid metabolites

– proteins of the coagulation system

– complement factors

– acute phase proteins

– hormonal mediators

Systemic

Inflammator

y

Response

Syndrome

(SIRS)

TOO MUCH

RESPONSE

SIRS• Endothelial cell damage

• Accumulation of leukocytes

• Disseminated intravascular coagulation

• Apoptosis / necrosis of parenchymal

cells

• Multiple organ dysfunction

syndrome(MODS)

• Multiple organ failure (MOF)

ANTI-INFLAMMATORY HOST RESPONSE

Local and systemically, TH2-

cells and Monocytes

/macrophages release:

–IL-4

–IL-10

–IL-13

– transforming growth factor-β

(TGF-β)

It’s a Feedback Loop:-

– Anti-inflammatory mediators (CARS):-

• Depress the activity of intracellular transcription

factors

• Depress synthesis of pro-inflammatory cytokines.

TOO MUCH

NEGATIVE

FEEDBACK

CARSINCREASE

SUSCEPTIBILI

TY TO

INFECTION

2ND HIT

Host defense response:-

Balance between SIRS and CARS

induce reparative

mechanisms

limit entry or overload of

microorganisms

avoid auto-aggressive

inflammation, with secondary

tissue damage

Avoid susceptibility to

infection

What Are We Doing?

We’re limiting the 2nd hit.

SO..WHAT WE ARE DOING?

WE ARE LIMITING THE 2ND HIT

PATIENT SELECTION

PATIENT SELECTIONPATIENT ASSESSMENT:-

PATIENT CLINICALLY ASSESSED ABOUT THEIR PHYSICAL STATUS AND CLASSIFIED AS:-

I. STABLE: GRADE 1

II. BORDERLINE: GRADE2

III. UNSTABLE: GRADE 3

IV. EXTREMIS: GRADE 4

BORDER LINE PATIENTS (PAPE HC 2001) :-

COAGULOPATHIC

HYPOTHERMIA (T <32)

ACIDOSIS

SHOCK

PERSUMED OR TIME > 6H

ARTERIAL INJURY AND HAEMODYNAMIC

INSTABILITY

EXAGGERATED INFLAMMATORY RESPONSE

MANAGMENT

DCO: PRINCIPLES

Do reconstruction under best circumstances

More time for planning is usually better

Best team possible for difficult work

APPLICATION OF DCO STRATEGY

Multiply injured patient

Physiologically unstable

Severe chest injury

Severe hemorrhge

Mass casualty situation

Damage control in orthopedic surgery

Stage 1: early temporary External Fixation Stabilization of unstable fractures and the control of hemorrhage and, if indicated, decompression of intracranial lesion.

Stage 2: resuscitation of the patient in ICU and optimization of his condition.

Stage 3: delayed definitive management of the fracture

STATGED TREATMENT

OT

OT

ICU

MINIMALLY INVASIVE OPERATIONS

External fixation of femur- 35 minutes 90 ml blood loss

Intramedullary nailing of femur-130 minutes 400 ml blood loss

Scales et al., “ External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopaedics”, J.Trauma 2000; 48: 613-23

Reamed Intramedullary nailing Has been associated with development of “second hit” phenomena (Pape 1993).

Primary external fixation has not stimulated any inflammatory reaction“second hit”

REAMED IMN VS. EX. FIX

SKELETAL TRACTION VS. EXTERNAL FIXATION

External fixation of femur fractures in severely injured

patients offers no significant advantages compared

with skeletal traction. The use of ST as a temporization

method remains a practical option.

(SCANELL,BRIAN P. ,2010: JOURNAL OF TRAUMA –INJURY INFECTION AND CRITICAL CARE-VOLUME 68- ISSUE 3-PP) 633-640)

SECONDARY PROCEDURE FOR WHOME ?

&WHEN?

RESUSCITATION:-

• Stable hemodynamics

• Stable oxygen saturation

• Lactat level < 2 mmol/l

• No coagulation

disturbances

• Normal temperature

• Urinary output > 1

ml/kg/hour

• No isotropic support

E.T.CDEFINITIVE OPERATION

When to perform the secondary procedure?

One of the most important decisions to be made in designing a DCO protocol is the timing of secondary surgical proceduresIn a retrospective analysis of 4314 patients, it was found that a secondary procedure lasting more than 3 h was associated with the development of MODS Also the patients who developed complications had their surgery performed between days 2 and 4, whereas patients who did not go on to develop MODS were operated between days 6 and 8 (PAPE HC 1999)OPERATE BETWEEN DAYS

6 & 8

DCO IN CHEST INJURY

Bosse and Associates studied the method of fixation used to manage femoral shaft fractures. They compared early reamed intramedullary nailing to open reduction and internal fixation. No difference was noted between the plating and nailing groups in terms of mortality, the occurrence of ARDS, pulmonary embolism or pneumonia. In their study, the incidence of ARDS was only 2% (bosse et al., 1997)

In a retrospective review of 138 patients with multiple injuries, the patients with significant pulmonary injuries had a 56% complication rate when fixation was delayed compared with a 16% complication rate for those who had earlyStabilization (Charash WE et al., 1994)

There is no evidence in basic physiology research to suggest that reamed intramedullary nailing would have a significant negative effect on pulmonary function in the clinical setting (beter j. et al., 2003)

DCO IN HEAD INJURY (Hofman and Goris,1991) in their retrospective review of head injured patients with long-bone fracture found that mortality was more than 3 times higher in patients with delayed or no fracture fixation and that the neurologic outcome, based on the glasgow outcome score, was better in patients who had early fracture stabilization.

(Townsend and colleagues, 1998) retrospectively reviewed 61 patients with severe or moderate closed head injury and femoral fracture. They demonstrated an 8-fold increase in the risk of intraoperative hypotension if the operation was carried out within 2 hours of admission to hospital and a 2-fold increase if the operation was carried out within 24 hours of admission. They found that the risk of low intraoperative cerebral perfusion pressure lasted even longer than 24 hours

DCO IN MANGLED EXTREMITY

A DCO approach to save the limb:-

Spanning ex. Fix.

Antibiotic bead pouches

Vacuum assisted wound closure

CONCLUSION

DCO: Principles in polytrauma

Ortho team must be resuscitators and stabilizers: not “fixers”