Application Of Damage Control Orthopedics In Treatment Of Unstable Pelvic Fractures

Objective: Unstable pelvic fractures mainly caused by high-energyinjury such as traffic injuries are serious and complex, which often associatedwith multiple injuries. If definitive operation for unstable pelvic fractures isperformed in the first stage, patients will aggravate the trauma, how to treatthis kind of fracture is still orthopedic surgeon’s tough questions. The purposeof this study is to investigate application and clinical results of damage controlorthopedics (DCO) in treating unstable pelvic fractures combined withmultiple trauma.Methods:A retrospective analysis was done on the clinical data of83patients withunstable pelvic fractures combined with multiple trauma from2007to2012.Among them，51patients from2009to2012managed by DCO were designedto treatment group，including37males and14females，at age of average36.5years. According to Tile classification，there were29patients with type B and22patients with type C fractures. The injury severity scores (ISS) avaraged31.2points.There were33patients of traffic accident injuries,9of high fallinjury and9of crush injury. Associated injuries: traumatic brain injury in5cases, chest injuries in18cases, abdoominal injuries in11cases, bladder andurethra injuries in14cases, rectum and perineal injuries in4cases, limbfractures in27cases and thoracollumbar fractures in11cases.The other32patients from2009to2009managed without DCO wereclassified as control group，including23males and9females，at age ofaverage38.2years. According to Tile classification，there were19patientswith type B and13patients with type C fractures.The ISS avaraged30.8points. There were21patients of traffic accident injuries,7of high fall injuryand4of crush injury. Associated injuries: traumatic brain injury in3cases, chest injuries in6cases, abdoominal injuries in5cases, bladder and urethrainjuries in10cases, rectum and perineal injuries in3cases, limb fractures in21cases and thoracic and lumbar fractures in7cases.DCO treatment process is divided into three stages. The first stage:control of infection and bleeding, positive anti-shock. Priority to deal withlife-threatening injuries, such as brain, chest and abdomen associated injuries.The unstable pelvic fractures were treated with external fixtion in the firststage, meanwhile received skeletal traction in case of displacement unstablepelvic fractures. Bleeding from pelvic received internal iliac artery ligation,embolization or tamponade for hemostasis. Spinal cord conpression ofthoracic and lumbar fractures underwent simple laminectomy. Open limbfractures were treated with early debridement, traction or simple externalfixtion. There were decompressive craniectomy in3cases, thoracic closedrainage in14cases, exploratory laparotomy in9cases, liver repair in2cases,splenectomy in3cases, intestinal repair or enterostomy in3cases, cystostomyin10cases and urethral realignment in7cases. The second stage: transferpatients to the ICU, correct the acidosis and coagulopathy and restore bodytemperature. Treatment time in ICU ranged from2to16days, averaged8.7days. After the first two stage of treatment,5patients died and46patientssurvived. The third stage: when patients’ physical condition reached stable,definitive operation was performed for unstable pelvic fractures. Among them,7cases treated external fixators as definitive therapy,11cases undrewentminimally invasive internal fixtion by locking comprasion plate or sacroiliacscrews in secondary operation,24cases received open reduction and internalfixtion in secondary operation and4cases of conservative treatment. Theintervals from injuries to operation ranged from3to17days, averaged8.8days.After the rescue of life-threatening trauma, the patients in control groupreceived definitive operation such as open reduction and internal fixtion in onestage operation for unstable pelvic fractures. The intervals from injuries tooperation ranged from2to13days, averaged6.2days. Patients in both groups postoperatively underwent routine X-rayexamination for measurement of maximum residual shift of anteroposterior,inlet and outlet views of pelvic, according to Lindahl imaging standards toassess the quality of fracture reduction. Guidance with lower limb joint musclefunction exercise and regular postoperative follow-up were received inpatients, according to Majeed standards to assess the postoperative functionalrecovery.Statistical analysed the measured data with SPSS19.0statistical software,the Mann-Whitney rank-sum test was used to the measurement data, whichwas expressed as; the chi-square test was used to count data andcomparison of positive rates, which was expressed as%. Differences wereregarded as statistically significant when P values were less than0.05.Results:In the treatment group,46patients survived (90%), with postoperativecomplications in10patients (22%).1case of acute respiratory distresssyndrome (ARDS), recovering after ventilator treatment;3cases of deepinfection, recovering after antibiotic therapy;2cases of malunion;1case ofpleural effusion, recovering after closed thoracic drainage;2cases of lowerlimb deep venous thrombosis;1case of pulmonary embolism.5patients died,including3cases died of hemorrhagic shock,1case died of multiple organdysfunction syndrome (MODS) and1case died of disseminated intravascularcoagulation (DIC). Only43patients in the treatment group were followed-up，which showed excellence rate of88%in fracture reduction quality accordingto Lindahl criterion，with Majeed score of (84.1±8.2) points.In the control group,23patients survived (72%), with postoperativecomplications in11patients (48%).2case of acute respiratory distresssyndrome (ARDS), recovering after ventilator treatment;3cases of deepinfection, recovering after antibiotic therapy;1case of malunion;3cases oflower limb deep venous thrombosis;2cases of intestinal obstruction.9patients died, including3cases died of hemorrhagic shock,4case died ofmultiple organ dysfunction syndrome (MODS) and2case died of disseminated intravascular coagulation (DIC).21patients in the control groupreceived followed-up，which showed excellence rate of91%in fracturereduction quality according to Lindahl criterion， with Majeed score of(79.0±9.8) points.The difference of time interval from admittance to hospital to definitiveoperation, survival rates, postoperative complication rates and Majeed scorebetween the two groups of patients was statistically signficant (P<0.05), whilethe difference of the excellent and good rate of fracture reduction according toLindahl criterion was not statistically signficant.Conclusion: DCO can effectively control further aggravation of theprimary injury, shorten the time of early surgery, reduce bleeding, avoidpremature depletion of patients’ physiological potential and minimize the“two-hit” injury. In conclusion, DCO, combined with injury severity scoresand Tile classification is an effective and safe method in treatment of unstablepelvic fractures combined with multiple trauma，which improves survivalrate， reduces postoperative complications and benefits postoperativefunctional restoration.