In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006

The optimal time for definitive fixation of femur fractures is an important topic in orthopedic surgery because it can impact the physiologic status and patient mortality. There has been an evolution over time in what is considered the ideal time for definitive fixation. Several studies in the 1980s supported early stabilization of long bone fractures in patients with multiple injuries.1–10 In 1985, Johnson et al.4 reported that early stabilization of femur fractures was associated with a fivefold reduction in the rate of adult respiratory distress syndrome (ARDS) compared with late fixation. In a 1989 prospective study, Bone et al.11 showed that reamed intramedullary nailing of femur fractures within 24 hours of injury led to fewer complications and a shorter hospital stay compared with delayed treatment. In recent years, the concept of “damage-control orthopedics” with delay of definitive fixation in patients with multiple injuries has taken hold.12 Whether an external fixator,13 traction, or an unreamed proximally unlocked retrograde nail11 is used, proponents of damage-control orthopedics agree that definitive surgery should be delayed until the patient has more reserve and can tolerate a second inflammatory “hit.”14 Some have suggested that 2 days to 5 days after major injury is a potentially vulnerable time when further surgery can result in a significant release of inflammatory mediators that may increase the risk of ARDS, sepsis, and pneumonia.15 Thus, those who advocate the avoidance of a “second hit,”during this 2-day to 5-day window, would support the delay of definitive fixation beyond 5 days.1–10 As the technology and understanding of the physiology of major systemic injuries have progressed, whether delayed definitive fixation offers a significant advantage over primary intramedullary nail fixation remains a controversial question. Although there have been many individual studies investigating this question, to date, few have used large databases. Morshed et al.16 in 2009 used the National Trauma Data Bank (NTDB) version 5.0 for 2000 to 2004 to look at severely injured patients (Injury Severity Score [ISS] > 15) and found that delaying definitive fixation beyond 12 hours in these patients, particularly those with abdominal trauma, resulted in a lower relative risk of mortality. However, contrary to many surgeons’ personal experience and earlier findings that early fixation is better, they found no disadvantage to delaying fixation beyond 120 hours. A 2012 systematic review by Nahm and Vallier17 examined the literature from 1946 to 2011 and found that 38 studies met their inclusion criteria. Because of the heterogeneity of the studies, they were not able to obtain a pooled estimate but concluded that there was no difference in ARDS or mortality for early versus delayed fixation. They did find increased length of stay for those undergoing delayed fixation. The purpose of this study was to investigate the optimal time for definitive fixation of femur fractures for patients with varying levels of injury severity.