Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

Rajesh R. Gandhi, Tiffany L. Overton, Elliott R. Haut, Brandyn Lau, Heather A. Vallier, Thomas Rohs, Erik Hasenboehler, Jane Kayle Lee, Darrell Alley, Jennifer Watters, Frederick B. Rogers, Shahid Shafi

    Research output: Contribution to journalArticle

    19 Citations (Scopus)

    Abstract

    Background: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (G24 hours) versus late (924 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as ''low.'' No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated ''low.'' Conclusion: In trauma patients with open or closed femur fractures, we suggest early (G24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

    Original languageEnglish (US)
    Pages (from-to)787-795
    Number of pages9
    JournalJournal of Trauma and Acute Care Surgery
    Volume77
    Issue number5
    DOIs
    StatePublished - Nov 1 2014

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    Multiple Trauma
    Practice Management
    Practice Guidelines
    Femur
    Venous Thromboembolism
    Wounds and Injuries
    Closed Fractures
    Odds Ratio
    Confidence Intervals
    Mortality
    Software
    Infection
    Internal Fracture Fixation
    Intramedullary Fracture Fixation
    Meta-Analysis

    Keywords

    • Delayed fixation
    • Early fixation
    • Fracture fixation
    • Long bone stabilization
    • Timing fixation

    ASJC Scopus subject areas

    • Critical Care and Intensive Care Medicine
    • Surgery

    Cite this

    Optimal timing of femur fracture stabilization in polytrauma patients : A practice management guideline from the Eastern Association for the Surgery of Trauma. / Gandhi, Rajesh R.; Overton, Tiffany L.; Haut, Elliott R.; Lau, Brandyn; Vallier, Heather A.; Rohs, Thomas; Hasenboehler, Erik; Lee, Jane Kayle; Alley, Darrell; Watters, Jennifer; Rogers, Frederick B.; Shafi, Shahid.

    In: Journal of Trauma and Acute Care Surgery, Vol. 77, No. 5, 01.11.2014, p. 787-795.

    Research output: Contribution to journalArticle

    Gandhi, Rajesh R. ; Overton, Tiffany L. ; Haut, Elliott R. ; Lau, Brandyn ; Vallier, Heather A. ; Rohs, Thomas ; Hasenboehler, Erik ; Lee, Jane Kayle ; Alley, Darrell ; Watters, Jennifer ; Rogers, Frederick B. ; Shafi, Shahid. / Optimal timing of femur fracture stabilization in polytrauma patients : A practice management guideline from the Eastern Association for the Surgery of Trauma. In: Journal of Trauma and Acute Care Surgery. 2014 ; Vol. 77, No. 5. pp. 787-795.
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    abstract = "Background: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (G24 hours) versus late (924 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95{\%} confidence interval [CI], 0.50-1.08). The quality of evidence was rated as ''low.'' No significant reduction in infection (RR, 0.4; 95{\%} CI, 0.10-1.6) or VTE (RR, 0.63; 95{\%} CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated ''low.'' Conclusion: In trauma patients with open or closed femur fractures, we suggest early (G24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.",
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    author = "Gandhi, {Rajesh R.} and Overton, {Tiffany L.} and Haut, {Elliott R.} and Brandyn Lau and Vallier, {Heather A.} and Thomas Rohs and Erik Hasenboehler and Lee, {Jane Kayle} and Darrell Alley and Jennifer Watters and Rogers, {Frederick B.} and Shahid Shafi",
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    T2 - A practice management guideline from the Eastern Association for the Surgery of Trauma

    AU - Gandhi, Rajesh R.

    AU - Overton, Tiffany L.

    AU - Haut, Elliott R.

    AU - Lau, Brandyn

    AU - Vallier, Heather A.

    AU - Rohs, Thomas

    AU - Hasenboehler, Erik

    AU - Lee, Jane Kayle

    AU - Alley, Darrell

    AU - Watters, Jennifer

    AU - Rogers, Frederick B.

    AU - Shafi, Shahid

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    N2 - Background: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (G24 hours) versus late (924 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as ''low.'' No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated ''low.'' Conclusion: In trauma patients with open or closed femur fractures, we suggest early (G24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

    AB - Background: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (G24 hours) versus late (924 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as ''low.'' No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated ''low.'' Conclusion: In trauma patients with open or closed femur fractures, we suggest early (G24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

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    KW - Early fixation

    KW - Fracture fixation

    KW - Long bone stabilization

    KW - Timing fixation

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