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, MD, Tiffany L. Overton, MPH, Elliott R. Haut, MD, PhD, Brandyn Lau, MPH, Heather A. Vallier, MD, Thomas Rohs, MD, Erik Hasenboehler, MD, Jane Kayle Lee, MD, Darrell Alley, MD, Jennifer Watters, MD, Frederick B. Rogers, MD, and Shahid Shafi, MD, Fort Worth, Texas 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 thromboem- bolism (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 Recom- mendations, 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], 0.50Y1.08). The quality of evidence was rated as ‘‘low.’’ No significant reduction in infection (RR, 0.4; 95% CI, 0.10Y1.6) or VTE (RR, 0.63; 95% CI, 0.37Y1.07) 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. (J Trauma Acute Care Surg. 2014;77: 787Y795. Copyright * 2014 by Lippincott Williams & Wilkins) KEY WORDS: Long bone stabilization; fracture fixation; timing fixation; early fixation; delayed fixation. F emur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. 1 Internal fixation with intramedullary nailing is the ideal method of treatment. However, the optimal timing for internal fixation remains controversial. 2Y4 Proponents of early stabilization point to more desirable outcomes, such as fewer complications, shorter hospital stays, and lower costs of care. 5Y12 Opponents suggest that early definitive stabilization may not be safe for the most severely injured patients or those with associated head, chest, or serious abdominal injuries due to increased blood loss, surgical stress, and pulmonary complica- tions and that these and other factors may lead to increased mortality. 13Y17 Several other researchers have suggested a lack of benefit to early stabilization. 18Y25 In 2001, an Eastern Association for the Surgery of Trauma (EAST) practice management guideline (PMG) promoted early stabilization of long bone fractures, including the femur, in polytrauma patients. 6 EAST recently adopted the methodology of the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for PMGs. 26,27 The purpose of the current review was to update EAST’s femur fracture stabilization guidelines using GRADE methodology and systematic review. 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 in trauma patients. The GRADE methodology addresses many of the per- ceived shortcomings of existing models of evidence evaluation. Crucially, when using GRADE, the evidence is rated not by each study individually but across studies for specific clinical out- comes and evaluation of alternative management strategies. Evaluating clinical outcomes makes the guideline a useful and relevant tool for clinicians and, more importantly, for patients. 28 GUIDELINES J Trauma Acute Care Surg Volume 77, Number 5 787 Submitted: June 16, 2014, Accepted: July 16, 2014. From the Department of Surgery (R.R.G., T.L.O., S.S.), JPS Health Network, Fort Worth; and Department of Surgery (D.A.), East Texas Medical Center, Tyler, Texas; Departments of Surgery (E.R.H., B.L.), and Orthopaedic Surgery (E.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Orthopaedics (H.A.V.), MetroHealth, Cleveland, Ohio; Department of Surgery (T.R.), Borgess Health, Kalamazoo, Michigan; Department of Surgery (J.K.L.), Advocate Medical Group, Chicago, Illinois; Department of Surgery (J.W.), Oregon Health and Science University, Portland, Oregon; and Department of Trauma and Acute Care Surgery (F.B.R.), Lancaster General Health, Lancaster, Pennsylvania. This study was part of the podium presentation at the 2014 EAST Conference. Address for reprints: Tiffany L. Overton, MPH, JPS Health Network, Trauma Services, 1500 S Main St, Fort Worth, TX; email: toverton@jpshealth.org. DOI: 10.1097/TA.0000000000000434 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.