Surgical load in major fractures — results of a survey on the optimal quantification and timing of surgery in polytraumatized patients
Authors: Klingebiel Felix Karl-Ludwig , Hasegawa Morgan , Strähle Oliver , Kalbas Yannik , Teuben Michel , Halvachizadeh Sascha , Kumabe Yohei , Pape Hans-Christoph , Pfeifer Roman ,   SICOT Trauma Research Group, Al-Rouk Turki Bashir , Ganse Bergita , Hanschen Marc , Hasani Ilir , Korobushkin Gleb , McCaul Jeannie , Parry Joshua A. , Rashed Mohamed , Saveski Jordan , Sharma Hemant , Zarti Mohammed , Zelle Boris A. 
Published: May 2023

Abstract
Purpose
It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.

Methods
A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between “1,” defined as the surgical load equivalent to external (monolateral) fixator application, and “5,” defined as the maximal surgical load possible in that specific anatomic region.

Results
This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.

Conclusion
This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient’s physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.