Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial
Authors: Ghneim Mira , Kufera Joseph , Zhang Ashling , Penaloza-Villalobos Liz , Swentek Lourdes , Watras Jill , Smith Alison , Hahn Alexandra , Rodriguez Mederos Dalier , Dickhudt Timothy John , Laverick Paige , Cunningham Kyle , Norwood Scott , Fernandez Luis , Jacobson Lewis E. , Williams Jamie M. , Lottenberg Lawrence , Azar Faris , Shillinglaw William , Slivinski Andrea , Nahmias Jeffry , Donnelly Megan , Bala Miklosh , Egodage Tanya , Zhu Clara , Udekwu Pascal O. , Norton Hannah , Dunn Julie A. , Baer Robert , McBride Katherine , Santos Ariel P. , Shrestha Kripa , Metzner Caleb J. , Murphy Jade M. , Schroeppel Thomas J. , Stillman Zachery , O'Connor Rick , Johnson Dirk , Berry Cherisse , Ratner Molly , Reynolds Jessica K. , Humphrey Mackenzie , Scott Mark , Hickman Zachary L. , Twelker Kate , Legister Candice , Glass Nina E. , Siebenburgen Christa , Palmer Brandi , Semon Gregory R. , Lieser Mark , McDonald Hannah , Bugaev Nikolay , LeClair Madison J. , Stein Deborah ,   the Brain vs. Bone Study Group
Published: June 2023

OBJECTIVE
This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients.

METHODS
A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R).

RESULTS
Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4–5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8–24] vs. ORIF, 26 [12–85] vs. IMN, 31 [12–70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002–1.03 and OR, 2.37; 95% CI, 1.75–3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73–0.97) was associated with higher RLAS-R score at discharge.

CONCLUSION
Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level III.