Time to definitive fixation of femoral fractures: Association with morbidity and costs and the role of damage control orthopedics
Creators: name: Varkey, Dax
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2011

description: Literature Review: A literature review was conducted to determine the recommended regarding the choice of early total care (ETC) or damage control orthopedics (DCO) in poly-trauma patients. PubMed, CINAHL, and Cochrane databases were queried for articles regarding damage control orthopedics resulting in 4 articles that met criteria for review. Hand searches of citations led to the identification of 3 additional articles. Articles were graded on 6 parameters resulting in three “good” articles, four “fair”, and one “poor”. The review of the literature did not result in consistent evidence that could be used to definitively guide clinical practice.Original Research Background: The optimal time from injury to internal fixation of femoral fractures has been a point of contention in orthopedic literature. Some recent studies suggest that delaying definitive management of orthopedic injuries until the patient is suitably stabilized may lower morbidity and mortality. The purpose of this study was to reevaluate whether time to definitive fixation of femoral shaft fractures has an effect on patient morbidity or hospital costs. Methods: We performed a retrospective cohort study using an existing trauma registry from one Level 1 trauma center. Of the patients contained in the registry over an 11 year period (2000-2010), 566 patients with a femoral shaft fracture were included in this analysis. Patients were dichotomized into cohorts by Injury Severity Score above and below 18. Time to fixation was defined as time from arrival at a hospital until definitive fixation was performed. Time was divided into periods in which fixation occurred: t0 (<12 hours), t1 (12-24 hours), t2 (24-48 hours), t3 (48-120 hours) and t4 (>120 hours). t0 served as the referent category. Morbidity was estimated using the following surrogate markers for morbidity: intensive care unit length-of-stay (ICU-LOS), days on ventilator (VDAYS), hospital length-of-stay (H-LOS), and discharge iv disposition (DISPO). The effect of time to fixation on patient specific hospital costs (COST), data for which was also present in the registry, was analyzed as well. Results: In patients with ISS≤18 there was no demonstrated relationship between time to management and ICU-LOS or VDAYS. Management after 48 hours was associated with significantly longer H-LOS (t0 7.55 days versus t3 13.84 days, p<0.001; t4 15.60 days, p=0.020) and higher hospital costs (t0 $41,600 versus t2 $66,500, p=0.006; t3 $72,100, p=0.005). In patients with ISS>18 management after 24 hours was associated with more VDAYS (t0 1.65 days versus t2 4.57, p=0.030; t3 5.62, p=0.012; t4 10.84, p<0.001) and COST (t0 $65,100 versus t2 $96,400 p=0.033; t3 130,100, p<0.001; t4 $210,200, p<0.001). After 48 hours there was also a significant increase in ICU-LOS (t0 3.77 days versus t3 7.91 days, p=0.036; t4 17.61 days, p=0.001) and H-LOS (t0 11.90 days versus t3 22.44 days, p=0.004; t4 36.63 days, p<0.001). There was no relationship found between time to fixation and DISPO. Conclusions: Definitive management of femoral fractures more than 48 hours after injury is associated with increased morbidity. Additionally, delayed management is more costly. These data suggest that early appropriate care of femoral fractures can minimize patient morbidity and financial burden in most patients.