American Surgical Association
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Impact of the Method of Initial Stabilization For Femoral Fractures In Polytrauma Patients At Risk For Complications (Borderline Patients) - A Prospective Randomized Analysis By the EPOFF Study Group
Hans C Pape1, Dieter Rixen2, Elisabeth Ellingson*3, peter Giannoudis*4
1Division of Trauma, Pittsburgh, SC;2Division of Trauma, cologne, Germany3Division of Trauma, Oslo, Norway4Division of Trauma, Leeds, United Kingdom

OBJECTIVE(S): To investigate if the optimal initial method of treatment of femoral shaft fractures in polytrauma patients consists of initial definitive stabilization (intramedullary nail), or temporary stabilization (external fixation) in patients at high risk for complications.
METHODS: Multiply injured patients with femur fractures were randomized to initial (<24 hours) femoral nailing (Group I°IMN), or external fixation (Group I°ExFix). Inclusion: New Injury Severity Score (NISS) > 16 points or 3 extremity fractures and Abbreviated Injury Scale (AIS) ≥2 points, femoral midshaft fracture, age 18-65 years. On admission, a subgroup in borderline condition (high risk for systemic complication) was selected. Main outcome: acute lung injury (ALI).
RESULTS: 10 European centers, 165 patients (mean age 32.7 ± 6.7 years, n=38 females). Preoperatively, 121 patients were stable and 44 patients were in borderline condition (b-IMN b-ExFix). In the borderline group, patients randomized to external fixation had higher AIS head scores, (b- I°IMN 2.57±1.01 points, b- I°ExFix 1.18±0.8 points; p=0.01) the NISS and AIS chest was comparable with the subgroup randomized to IMN. B- I°IMN patients had higher incidences of ALI (b-I°ExFix n=3 (14.2%); b-I°IMN n=10 (45.5%), p=0.013), associated with an eightfold increased odds ratio for the development of ALI.
CONCLUSIONS: Intramedullary stabilization of the femur fracture in patients in borderline condition demonstrated a higher incidence of acute lung injuries and higher odds ratios for ALI when primary nailing was performed, suggesting that the type of initial fixation of the femur should be decided according to the clinical preoperative status of polytrauma patients.

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