delayed internal fixation of the femoral shaft

5/22/2018 Delayed internal fixation of the femoral shaft

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Journal clubSlide 1From 35

19.02.09


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J BONEJOINTSURGAM.VOLUME91-A . NUMBER1 . JANUARY2009


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TOFIXORNOTTOFIXEARLY.

Riska (1976), Boulanger (1997) and Bone LB(1989) have suggested that early stabilization ofmajor long-bone fractures (most commonly

femur fracture) will reducethe incidence ofpulmonary complications and mortality

Crowl (2000), Pape (2000) and Giannoudis(2003) have suggested that internal fixation oflong-bone fractur

es, either with intramedullary

nailing or plateing, may have potentiallydeleterious effectsin the acute setting, whensystemic hypoperfusion and inflammation mayincrease susceptibility to end-organ injury and

increase morbidity

Whereas Rixen (2005) and Dunham (2001)demonstrated no differencein morbidity or

mortality between early and late operative

treatment of femoral shaft fractures.


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MATERIALANDMETHODS

Sampling

National Trauma Data Bank

567trauma centers around the US

Nearly one million incident trauma casesthat occurred overthe five-year period)2000 to 2004)


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MATERIALANDMETHODS

Sampling


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MATERIALANDMETHODS

Confounders

Potentially confounding covariates:

age,sex,race,Glasgow Coma Scale score on arrivalfirst systolic blood pressure


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MATERIALANDMETHODS

Treatment Variables

t0 12 hrs

t1 1224 hrs

t2 2448 hrs

t3 48120 hrs

t4 > 120 hrs



MATERIALANDMETHODS

Hypothesis

Authors hypothesize that additionalphysiologic stress from definitive fracturesurgery could activate an adverse systemic

responseleading to end-organ injury,multiple organ failure, and excessmortality.



MATERIALANDMETHODSMain Outcome Measure

Authors believe in the absence of patient-centered outcomes (i.e., health-relatedquality of life) and systematic assessment

of morbid events after treatment,mortality is the most objective, andtherefore likely valid, end point.



MATERIALANDMETHODSStatistical Methods

Marginal Structural Study (MSM)

Inverse Probability of Treatment

Weighting (IPTW) Potential for differences of treatment

effect (effect modification) four different

subgroups (head or neck, chest,abdominal, or additional extremity/pelvicinjury)




Hypothesis that patients with seriousinjuries (AIS 3) in any one of these fourgroup would have a greater relative risk

reduction with fixation delayed beyond thefirst twelve hours of hospitalization thanthose without such associated injuries




Test performed by modified bootstrapapproach (non-parametrical)

The level of significance p < 0.05



RESULTS

More than

50 % cases



RESULTS



In general, more

severely injuredpatients appear tobenefit morestrongly fromdelaying surgery for

at least twelve hours

RESULTS



RESULTS



Authors emphasized on cautious approachto early definitive femoral shaft fracturefixation in patients with multisystem

trauma (especially abdominal injuries).

This finding was supported by otherinvestigations including Ziran et al (1997)and White et al (2004)

DISCUSSION



Hypoperfusion resulting from trauma mayprime the immune system for aninflammatory response if such treatment

is undertaken prior to adequateresuscitation and can lead to substantialend-organ injury.

DISCUSSION



The realization of this phenomenon hasled to the description of so-calledDamage Control Orthopaedics, whereby

definitive treatment is delayed untilresuscitation of the patient has beenadequately achieved.

DISCUSSION



Retrospective observational study


Inverse Probability of TreatmentWeighting (IPTW)

Methodology well designed

HINTS



Methodology - well designed

Objective achieved

Confounding factors included

Was the cut point of 12 hoursappropriate...?

Practically useful. mmm!!!

HINTS



URAMANAT -IRAN



ISFAHAN -IRAN




In observational studies, estimation of thecausal effect of an exposure on an outcomemay be biased because of confounding

In a point-exposure study, this istraditionally done by modelingtheprobability of disease as a function ofexposure and pretreatment covariates




First described by Robines in 1990s

Allow proper adjustment for time-

dependent confounding



Time-dependent confounding

If time-varying covariates aresimultaneously confounders andintermediatesthat is, covariates are

predictors of outcomeand also predictsubsequent exposure, and past exposurehistory predicts resulting covariate level

Such covariates are called time-dependentconfounders, and they pose uniqueanalytical challenges


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Inverse Probability of Treatment Weighting(IPTW)

Frequently used to estimate the causal effectsof treatments and interventions

The consistency of the IPTW estimator reliesnot only on the well-recognized assumptionof no unmeasured confounders (SequentialRandomization Assumption or SRA), butalso on the assumption of experimentation inthe assignment of treatment (ExperimentalTreatment Assignment or ETA).


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This method uses the reciprocal of theconditional probability of a subjectreceiving an assigned treatment given other

covariates as a means of confoundingcontrol in order to determine the effect oftreatment

Inverse Probability of Treatment Weighting(IPTW)


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Abbreviated Injury Scale (AIS)


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C


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SaamMorshed, MD, MPH,

TheodoreMiclau III, MD,

Oliver Bembom, PhD,

Mitchell Cohen, MD,

M. Margaret Knudson, MD,

John M. Colford Jr., MD, PhD


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DELAYEDINTERNALFIXATION OF

FEMORAL SHAFT FRACTURE REDUCES

MORTALITYAMONG PATIENTWITH

MULTISYSTEM TRUAMA


TheodoreMiclau III, MD,Oliver Bembom, PhD,

Mitchell Cohen, MD,




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DELAYEDINTERNALFIXATION OF FEMORAL SHAFTFRACTURE REDUCES MORTALITYAMONG PATIENT

WITH MULTISYSTEM TRUAMA


TheodoreMiclau III, MD,

Oliver Bembom, PhD,

Mitchell Cohen, MD,



TITLE

WRITERS

J BONE JOINT SURGAM. 2009;91:3-13doi:10.2106/JBJS. H. 00338

PUBLICATION


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J BONEJOINTSURGAM.VOLUME91-A . NUMBER1 . JANUARY2009


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To fix or not to fix early

Riska (1976), Boulanger (1997) and Bone LB(1989) have suggested that early stabilization ofmajor long-bone fractures (most commonlyfemur fracture) will reducethe incidence ofpulmonary complications and mortality


38/41


Crowl (2000), Pape (2000) and Giannoudis(2003) have suggested that internal fixation oflong-bone fractures, either with intramedullarynailing or plateing, may have potentiallydeleterious effectsin the acute setting, whensystemic hypoperfusion and inflammation mayincrease susceptibility to end-organ injury and

increase morbidity



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Whereas Rixen (2005) and Dunham (2001)demonstrated no differencein morbidity ormortality between early and late operativetreatment of femoral shaft fractures.



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Crowl (2000), Pape (2000) and Giannoudis(2003) have suggested that internal fixation oflong-bone fractures, either with intramedullarynailing or plateing, may have potentiallydeleterious effectsin the acute setting, whensystemic hypoperfusion and inflammation mayincrease susceptibility to end-organ injury and

increase morbidity


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Whereas Rixen (2005) and Dunham (2001)demonstrated no differencein morbidity ormortality between early and late operativetreatment of femoral shaft fractures.

delayed internal fixation of the femoral shaft

Documents

delayed internal fixation

journal clubslide

trauma centers

bone lb1989

end point

incident trauma casesthat

multiple organ failure

early stabilization