Damage control orthopaedic surgery

Damage control orthopaedic surgery

1. Damage Control O rthopaedics Mohamed Abulsoud (M.D) Lecturer of orthopedic surgery Faculty of medicine – Al-Azhar university Cairo- Egypt

2. Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient’s overall physiology can improve. Its purpose is to avoid worsening of the patient’s condition by the “second hit” of a major orthopaedic procedure and to delay definitive fracture repair until a time when the overall condition of the patient is optimized. Introduction

3. Damage control focuses control of hemorrhage , management of soft-tissue injury, achievement of provisional fracture stability, while avoiding additional insults to the patient . Introduction

4. The term damage control was borrowed from a traditional Navy term and philosophy. Temporary measures are used to limit further damage and stabilize the ship to allow for a thorough assessment of the damage and development of a comprehensive strategy for definitive repair Historical overview

5. Evolution The advent of damage control orthopedics (DCO) in the late 1990s and early 2000s represented a major shift if philosophy for the treatment of orthopedic injuries in severely injured trauma patients .

6. In the 1960s delayed fixation of long bone fractures was recommended. Immediate stabilization was associated with mortality rates up to 50% due to perioperative pulmonary and cardiovascular complication. Patients with long bone fractures were treated with traction or splinting for 10–14 days, until the effects of fat embolism syndrome resolved and pulmonary, cardiovascular, neurovascular and coagulation systems had stabilized. Evolution

7. In the 1980s, a major shift occurred in the treatment of long bone fractures in multiply injured trauma patients. There is a beneficial effect of early stabilization of fractures on both mortality and morbidity and length of hospital stay. This new philosophy in the management of the patient with multiple injuries was named Early Total Care ( ETC ). Evolution

8. In early 1990s, Outcome after ETC – increased incidence of adult respiratory distress syndrome ARDS and multiple organ failure (M.O.F) These complications mainly developed in patients with severe chest injuries, severe hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma. Evolution

9. Polytrauma Polytrauma is a syndrome of multiple injuries exceeding a defined severity (ISS ≥ 17) with sequential systemic reactions that may lead to dysfunction or failure of remote organs and vital systems, which have not themselves been directly injured Definitions

10. Definitions

11. Definitions Stable patients have no immediately life-threatening injuries and respond to initial therapy. • Borderline patients have stabilized in response to initial resuscitative attempts but sustained injuries that put them at risk of rapid deterioration . • Unstable patients remain hemodynamically unstable despite initial intervention and are at high risk for clinical complications. Patients in extremis have ongoing uncontrolled blood loss despite resuscitation and may die if blood loss is not immediately stopped.

12. Definitions

13. Borderline patients • Polytrauma + ISS > 20 + thoracic trauma (AIS > 2) • Polytrauma + abdominal/pelvic trauma + hemorrhagic shock (initial SBP < 90 mmHg) • ISS > 40 , without additional thoracic trauma • Initial mean pulmonary arterial pressure > 24 mmHg • Increase of pulmonary arterial pressure during Intramedullary nailing of > 6 mmHg • Bilateral femoral fractures • Radiographic evidence of pulmonary contusion • Hypothermia ( < 35C) • Additional moderate or severe head injuries(AIS ≥ 3)

14. • Early total care (ETC): a concept implying the primary definitive management of all major injuries within 24 hours after trauma • Damage control orthopedics (DCO): minimally invasive surgical techniques are used for the primary stabilization of all major fractures. Based upon the patient’s physiological status , temporary stabilization with external fixation for certain fractures is used. Definitions

15. Pathophysiology Traumatic injury leads to systemic inflammation ( systemic inflammatory response syndrome) followed by a period of recovery mediated by a counter-regulatory anti-inflammatory response. Within this inflammatory process, there is a fine balance between the inflammation and the potential for the process to cause and aggravate tissue injury leading to ARDS and MODS

16. The First and Second-Hit Phenomena First hit phenomenon :- The body response by stimulation of a variety of inflammatory mediators in the immediate aftermath of trauma IL-6 and HLA-DR class-II molecules(ICAM-1 e- selectin and CD11b), accurately predict the clinical course and outcome after trauma . Pathophysiology

17. the ratio of IL-6 to IL-10 was found to correlate with injury severity after major trauma , and this ratio was recommended as a useful marker to predict the degree of injury following trauma Pathophysiology

18. Second hit :- Another trauma during the acute phase major surgery adverse event during ICU treatment septic stimulus Pathophysiology

19. Pathophysiology

20. The Lethal triad Hypothermia Coagulopathy Acidosis

21. heart rate > 90 beats/min WBC count <4000cells/mm³ OR >12,000 cells/mm³ respiratory rate > 20/min or   PaCO2 > 32mm temperature   < 36 ° or > 38° Calculation each component is given 1 point if it meets the above criteria Interpretation score of 2 or more meets criteria for SIRS SIRS Score

22. Management

23. Management 1- Resuscitation

24. Goals to be achieved by damage control surgery Management

25. Damage control orthopaedics (DCO)

26. Damage control orthopaedics (DCO)

27. The general aims and scopes for fracture management are: control of hemorrhage; control of sources of contamination, removal of dead tissue, prevention of ischemia-reperfusion injury; pain relief; facilitation of intensive care. Damage control orthopaedics (DCO)

28. Damage Control and Pelvic Ring Injuries exsanguinating hemorrhage is the major cause of death in multiply injured patients with pelvic ring disruptions. Concomitant bowel injury places these fractures at high risk for infection and the need for access to the abdomen for visceral or genitourinary system injuries may limit the treatment options . Damage control orthopaedics (DCO)

29. Damage control treatment in pelvic ring injury sheet or pelvic binder, placed at the level of the greater trochanters External Fixator C-Clamp Iliosacral screw Sacral bar (in stable and borderline pts ) Angiography and embolization Damage control orthopaedics (DCO)

30. Damage control orthopaedics (DCO)

31. Damage control treatment for long bones fractures Long bones fractures in a multiply injured patient are not automatically treated with intramedullary nailing because of concerns about the second hit of such a procedure patients with pulmonary injury should undergo unreamed nailing to avoid increased risk of ARDS. Damage control orthopaedics (DCO)

32. Bilateral femoral fracture is a unique scenario in polytrauma that is associated with a higher mortality rate and incidence of ARDS than is a unilateral femoral fracture. the use of external fixation as a temporizing measure allows for the advantages of rigid fixation without the risk of hypotension and hypoxia associated with IMN in seriously injured patients . Damage control orthopaedics (DCO)

33. 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures. Patients with bilateral femoral shaft fractures had Higher Injury Severity Score (ISS) (29.5 vs. 25.7 points), Higher incidence of ARDS (34.7% vs. 20.6%) multiple organ failure (25.0% vs. 14.6%) Higher mortality rate (16.9% vs. 9.4%).

34. Early fixation of long-bone fractures—especially of the femoral shaft—in polytrauma : facilitation of nursing care; early mobilization with improved pulmonary function; shorter time on the ventilator; reduced morbidity and mortality Damage control orthopaedics (DCO)

35. External fixation of femur- 35 minutes 90 ml blood loss Intramedullary nailing of femur- 130 minutes 400 ml blood loss Scales et al ., 2000 Damage control orthopaedics (DCO)

36. Damage control orthopaedics (DCO)

37. Damage control orthopaedics (DCO)

38. Damage control in spine trauma Spinal trauma range from 13% to 30 % of spinal injuries in polytraumatized patients. Injuries of the spine originate from motor vehicle accidents and incidental as well as fall from height in most cases Damage control orthopaedics (DCO)

39. Damage control orthopaedics (DCO)

40. EAP Early Appropriate Care Acceptance different patients respond differently to first and second hits Consider severity of initial injury Consider response to resuscitation What further surgery required Continued re assessment and ability to change from ETO TO DCO

41. Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient’s overall physiology can improve. In damage control for trauma patients, the main target is to perform temporary operative procedures to provide time for physiologic stabilization before definitive surgical care. Take home message

42. Acidosis,hypothermia and coagulopathy are called The lethal triad Measures to prevent and revert those triad are of priority The use of external fixators , pelvic stabilization and percutaneus pedicle screw fixation should be considered in polytraumatized patients in the first 24 hours Take home message