Damage control orthopaedics (dco)

DAMAGE CONTROL ORTHOPAEDICS (DCO): CONCEPT, CONTROVERSIES AND COMPARISON WITH ETO

1. DAMAGE CONTROL ORTHOPAEDICS DR. D. P. SWAMI DPS

2. Objectives- Polytrauma Historical perspetive Introduction of DCO Pathophysiology of DCO Literature on DCO DPS

3.  Polytrauma : As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 × AIS score > 2).  The Journal of Trauma and Acute Care Surgery [2014, 77(4):620-623 DPS

4.  To describe the overall condition of the pt many trauma scoring systems have been developed like- Abbrevieted injury scale(AIS) Injury severity scale(ISS) Revised trauma score Anatomic profile Glasgow coma scale DPS

5. ABBREVIATED INJURY SCALE(AIS): AIS is an anatomical scoring system first introduced in 1969 Injuries are ranked on a scale of 1 to 6 , with 1 being minor, 5 severe, and 6 a nonsurvivable injury . . DPS

6. Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an AIS and is allocated to one of six body regions (Head,Face, Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score. DPS

7. The ISS score takes values from to 75 . If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75 DPS

8.  Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.  Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed. DPS

9. Before 1950s  The multi trauma patient-too sick for an operation.  The surgical stabilization of the fractures of the long bones was not routinely performed. DPS

10.  Treatment preferred-cast and skeletal traction. DPS

11. 197 -  Studies shows that early stabilization of femoral fractures dramatically reduces fat embolism syndrome,pulmonary failure(ARDS) and postoperative complications. DPS

12. Late 1980-  There is a beneficial effect of early stabilization of fractures on both morbidity,mortality and hospital stay.  Pt were able to mobilize early and were discharged from hospital sooner ,avoiding the complications associated with prolonged bed rest. DPS

13.  This new philosophy in the management of the pt with multiple injuries -best operation for the patient is one ,early and definitive procedure ; was named: EARLY TOTAL CARE(ETC) DPS

14.  ETC-Patients were able to mobilise early and were discharged from hospital sooner, avoiding the complications associated with prolonged bed rest.  J Trauma 1985;25:375-84  J Trauma 1990;30:792-8 DPS

15. When stabilization was delayed – the incidence of pulmonary complications was higher, the hospital and ICU stay days were increased DPS

16. Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment. DPS

17. Early 1990:  Outcome after ETC-increased incidence of ARDS and MOF.  Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications. DPS

18. An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma. DPS

19.  These complications developed mainly in pts with severe chest injuries,severe hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma . J Trauma 1993;34:540-8 J Bone Joint Surg [Br] 1999;81-B:356-61.20.  This led to the conclusion that the method of stabilisation and the timing of surgery may have played a major role in the development of such complications. DPS

20.  The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental. DPS

21. Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation DPS

22. They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISS>25) DPS

23.  (ISS)>25 :Higher infammatory burden, acute lung injury, and increased mortality rate.  Some patients who are so severely injured that they cannot tolerate long operations, blood loss, and especially medullary canal manipulation , without a signifcant life threatening deterioration of pulmonary function and overall homeostasis . DPS

24. “DAMAGE CONTROL ERA” Clinical Course-Three factors: 1.Trauma load(First hit) 2.Biological response 3.Treatment(Surgical Load,Second hit) DPS

25. Damage Control Orthopaedics: -Damage control orthopaedics(DCO)is a strategy that focuses on managing and stabilising major orthopae dic injuries in selected polytrauma patients who are in an unstable or extremis physiological state .(1) Its priorities are – control of provisional haemorrhage, stabil i sati o n of m a jo r s k eletal f r actu r e s , of soft-tissue injuries the degree of surgical insult to the -management - min i misi n g patient. 1. Injury, Int. J. Care Injured (2009) 40S4, S47 – S52 DPS

26. Staged Treatment Stage 1 :early temporary external fixation stabilization Stage2 : resuscitation of the patient in ICU and optimization of his condition. Stage 3 :delayed definitive management of the fracture DPS

27. Physiology- DPS

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29. The cytokine response evidenced by fever, leukocytosis, hyperventilation, tachycardia commonly seen in injury is referred to as systemic inflammatory response syndrome (SIRS) h a s been i m pl i c a ted i n t h e This inflammatory reaction development of ARDS and MOF J.bone jt surg.1999;81(Br):256-61 J Trauma 2003;55:7-13 DPS

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31. First and second hit phenomenon: DPS

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33. Damage control philosophy in polytruma; Surg Cdr us Dadhwar, Maj N Pathak DPS

34.  Patients who have sustained orthopaedic trauma have been divided into four groups: -stable Borderline unstable, and in extremis. Pape HC, Hildebrand F, Pertschy S, Zelle B, Ga-rapati R, Grimme K, Krettek C, Reed RL 2nd. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery . J Trauma. 2002;53:452-62. DPS

35. Stable patients-ETC Unstable and in extremis-DCO Borderline- DPS

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38. Basic strategies of DCO- Immediate and rapid stabilization of long bone fractures, typically with external fxation Release of tight soft tissue compartments (compartment syndrome) Reductions of dislocations Surgical debridement of open wounds Amputation, in cases of unsalvageable extremities DPS

39. Treatment goals Stop the ongoing injury Facilitate patient care Restore function DPS

40. Stop the ongoing injury Remote organ injury occurs as a consequence of musculoskeletal injury Mediators : activated neutrophils chemical mediators fat emboli marrow contents DPS

41. Remote organ injury long bone fractures Soft tissue injury Compartment syndrome Infection Ischemia/reperfusion Primay target : lungs Secondary targets : gut, kidney, brain, etc Resultant injury is progressive : ARDS/MODS DPS

42. Stop the ongoing injury Release c o mpar t m e nts Reduce d i s loca tio ns Debride open wounds S t abiliz e long bones DPS

43. Stabilize long bones Splints & traction Ex-fix DPS

44. Splints & traction Best reserved for: Es sential l y stable fractures Isolated ext r emity fractures DPS

45.  “External Fixator is a device uses for stabilization and immobilization of long bone open fractures.” DPS

46. Minimally invasive operations External fixation of femur – 35 minutes ,90 ml blood loss Intramedully nailing of femur -130 minutes ,400 ml blood loss Scales et al., “ external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures : damage control orthopaedics” J.Trauma 2000;48 :613-23. DPS

47. 47 Biomechanics of External Fixator  In  trinsic stability of frame (S) EX I S = ----------- L E=modulus of elasticity =constant I= moment of intertia= constant L= distance of frame from axis. DPS

48. 48  Thus Stiffness is inversely proportional to the distance of the assembly from the bone (closer the frame to bone -more stable assembly) Biome c hanics DPS

49. 49 Mechanics of Bone Pin Interface To increase stability of bone – pin interface Adequate no. of pins in each fragments ( 2 for most bone & 3 for femur) Increase pin pitch . Increase size of pin DPS

50. Indications for Rapid Ex Fix Patient in extremis Massive open injury (degloving injury) Vascular damage/repair Mass casualities DPS

51. Patient in Extremis Multiple other severe injuries Extreme hypotension Coagulopathy Massive head injury Aortic transection DPS

52. Early skeletal stabilization Reduce blood loss Min i mize mediator release Improve p ulm o nar y function Decrease sepsis and pain Improved t r ea tm e nt of head injured DPS

53. Issues while applying DCO- Safety???? Timing of definitive fixation???? Is DCO associated with high rate of infection???? DPS

54. They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft the femur in s e l e c t ed m ult i pl y inju r ed p a ti e n ts . DPS

55. In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood loss;can be followed by IMN when pt is stabilized. DPS

56. An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS. DPS

57. When is the right time to perform secondary definitive surgery????  In a study by Pape et al-compared two group having same ISS and GCS: group 1- early definitive surgery between 2- 4 days(46% MOD)-higher level of IL-6 group 2-late definitive surgery 5-8 days (15.7%) DPS

58. Infection rate after DCO is comparable to those after primary IMN.Pin site contamination was more common where the fixator was in place for >14 days DPS