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Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma
Saam Morshed, MD, MPH1; Theodore MiclauIII, MD1; Oliver Bembom, PhD2; Mitchell Cohen, MD3; M. Margaret Knudson, MD3; John M. ColfordJr., MD, PhD2
1 University of California at San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Room 3A-36, San Francisco, CA 94110. E-mail address for S. Morshed: morsheds@orthosurg.ucsf.edu
2 Division of Epidemiology and Biostatistics, University of California at Berkeley, 101 Haviland Hall MC 7358, Berkeley, CA 94720-7358
3 University of California at San Francisco, Department of Surgery, Box 0870 (M.C.) and Box 0807 (M.M.K.), San Francisco, CA 94143-0870
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Research and Education Foundation (OREF), the Association Internationale Pour L'Osteosynthese Dynamique (AIOD) (#100805-SMTM), and the National Institutes of Health. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at the Departments of Orthopaedic Surgery and Surgery, University of California at San Francisco, San Francisco, California, and the Division of Epidemiology and Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, California

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jan 01;91(1):3-13. doi: 10.2106/JBJS.H.00338
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Background: Fractures of the femoral shaft are common and have potentially serious consequences in patients with multiple injuries. The appropriate timing of fracture repair is controversial. The purpose of the present study was to assess the effect of timing of internal fixation on mortality in patients with multisystem trauma.

Methods: We performed a retrospective cohort study with use of data from public and private trauma centers throughout the United States that were reported to the National Trauma Data Bank (version 5.0 for 2000 through 2004). The study included 3069 patients with multisystem trauma (Injury Severity Score, =15) who underwent internal fixation of a femoral shaft fracture. The time to treatment was defined in categories as the time from admission to internal fixation: t0 (twelve hours or less), t1 (more than twelve hours to twenty-four hours), t2 (more than twenty-four hours to forty-eight hours), t3 (more than forty-eight hours to 120 hours), and t4 (more than 120 hours). The relative risk of in-hospital mortality when the four later periods were compared with the earliest one was estimated with inverse probability of treatment-weighted analysis. Subgroups with serious head or neck, chest, abdominal, and additional extremity injury were investigated.

Results: When compared with that during the first twelve hours after admission, the estimated mortality risk was significantly lower in three time categories: t1 (relative risk, 0.45; 95% confidence interval, 0.15 to 0.98; p = 0.03), t3 (relative risk, 0.58; 95% confidence interval, 0.28 to 0.93; p = 0.03), and t4 (relative risk, 0.43; 95% confidence interval, 0.10 to 0.94; p = 0.03). Patients with serious abdominal trauma (Abbreviated Injury Score, =3) experienced the greatest benefit from a delay of internal fixation beyond twelve hours (relative risk, 0.82 [95% confidence interval, 0.54 to 1.35] for patients with an Abbreviated Injury Score of <3, compared with 0.36 [95% confidence interval, 0.13 to 0.87] for those with an Abbreviated Injury Score of =3) (p value for effect modification, 0.09).

Conclusions: Delayed repair of femoral shaft fracture beyond twelve hours in patients with multisystem trauma, which may allow time for appropriate resuscitation, reduces mortality by approximately 50%. Patients with serious abdominal injury benefit most from delayed treatment. These results support delaying definitive treatment of long-bone injuries in patients with multisystem trauma as a means of so-called damage-control in order to reduce adverse outcomes.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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