Changes in the Management of Femoral Shaft Fractures in Polytrauma Patients: From Early Total Care to Damage Control Orthopedic Surgery Hans-Christoph Pape, MD, Frank Hildebrand, MD, Stephanie Pertschy, MD, Boris Zelle, MD, Rayeed Garapati, MD, Kai Grimme, MD, and Christian Krettek, MD Background: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of poly- trauma patients treated at a Level I trauma cen- ter within the last two decades regarding the ef- fect of changes in the management of their femoral shaft fracture. Methods: In a retrospective cohort study performed at a Level I trauma center, the pa- tient’s injuries and clinical outcomes were stud- ied. Adult blunt polytrauma patients were in- cluded if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (in- cluding external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I° intramedullary nailing [I°IMN]; I° external fixation [I°EF]; I° plate os- teosynthesis [I°plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981–December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990 –December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993–De- cember 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to in- tramedullary nailing in patients at risk of organ failure. Results: The patient groups were com- parable regarding age, gender distribution, and the mechanism of injury. Primary external fixa- tion was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups com- pared with the ETC group (16.6%) (p  0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdom- inal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%, p  0.03) and DCO (17.3%, p  0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of mul- tiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared. Conclusion: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an in- creased awareness toward thoracic and abdom- inal injuries may have played a role. Even dur- ing the DCO era, IMN was associated with a higher rate of ARDS than I°EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of develop- ing posttraumatic systemic complications such as ARDS and multiple organ failure. Key Words: Blunt multiple trauma, Damage control orthopedics, Major frac- tures, Femoral shaft fractures, Operative treatment. J Trauma. 2002;53:452–462. T he immediate and complete definitive operative care of all fractures represents the optimal treatment for the patient with multiple orthopedic injuries. The benefits of this approach have been demonstrated in numerous studies within the past two decades. 1–4 However, certain exceptions have been discussed in the past few years, where the principle of early total care may not be beneficial (head and chest trauma, high Injury Severity Score [ISS] predisposing to posttraumatic complications, bor- derline patients). 5–8 In these, the surgical burden may even increase the risk of postoperative complications. 9 –11 For these patients, the concept of initial temporary fixation and secondary conversion to a definitive procedure has recently Submitted for publication September 24, 2001. Accepted for publication January 9, 2002. Copyright © 2002 by Lippincott Williams & Wilkins, Inc. This work was scheduled for presentation at the 61st Annual Meeting of the American Association for the Surgery of Trauma, which was canceled because of the terrorist attacks of September 11, 2001. From the Department of Orthopaedics and Trauma Surgery, Hannover Medical School (H.-C.P., F.H., S.P., B.Z., K.G., C.K.), Hannover, Germany, and Department of Orthopaedics, Mount Sinai School of Medicine (R.G.), New York, New York. Address for reprints: Hans-Christoph Pape, MD, Department of Trauma Surgery, Hannover Medical School, Carl Neubergstr. 1, 30625 Hannover, Germany; email: pape.hans-christoph@mh-hannover.de. DOI: 10.1097/01.TA.0000025660.37314.0F The Journal of TRAUMA  Injury, Infection, and Critical Care 452 September 2002