Olav Røise

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group.

BACKGROUNDnDamage control orthopedic surgery has recently been advocated for the management of femoral shaft fractures in severely injured patients because surgical procedures were found to represent a second-hit phenomenon regarding the operative burden. It has been attempted to determine the operative burden by means of proinflammatory cytokines. In this study in clinically stable patients with multiple injuries, the effects induced by different types of primary fracture stabilization on the systemic release of proinflammatory cytokines were evaluated.nnnMETHODSnThis was a prospective, randomized, multicenter intervention study. Inclusion criteria were long bone shaft fracture of the lower extremity; age 18 to 65 years; Injury Severity Score > 16 or more than three extremity injuries (Abbreviated Injury Scale [AIS] score of 2 or more) in association with another injury (AIS score of 2 or more); and thoracic AIS score < 4. After informed consent, randomization for the treatment of the femoral shaft fracture was performed at admission. Groups were as follows: group I degrees FN (primary, < 24 hours) intramedullary nailing, and group DCO (DCO, I degrees ex.fix.) damage control orthopedic surgery and external fixation. In DCO patients, measurements were also performed at the time of conversion to the intramedullary procedure (DCO II degrees FN). Parameters included clinical parameters and complications (acute respiratory distress syndrome, multiple organ failure, sepsis). From serially sampled central venous blood, the perioperative concentrations of interleukin IL-1, IL-6, and IL-8 were determined. RESULTS Thirty-five patients were included (I degrees FN, n = 17; DCO, n = 18). In I degrees FN-patients, a perioperative increase of IL-6 levels was measured (preoperatively, 55 +/- 33 pg/dL; 24 hours postoperatively, +254 +/- 55 pg/dL; p = 0.03), which was not found in subgroup DCO I degrees Ex.fix.: preoperatively, 71 +/- 42 pg/dL; 24 hours postoperatively, 68 +/- 34 pg/dL; not significant [NS] or in group DCO II degrees FN: preoperatively, 36 +/- 21 pg/dL; 24 hours postoperatively, +39 +/- 25 pg/dL; NS. Likewise, in I degrees FN patients, a perioperative increase of IL-8 levels was measured only at the 7-hour time point (preoperatively, 35 +/- 29 pg/dL; 7 hours postoperatively, 95 +/- 23 pg/dL; p < 0.05), which was not found in group DCO I degrees Ex.fix.: preoperatively, 43 +/- 38 pg/dL; 24 hours postoperatively, 69 +/- 39 pg/dL; NS or in group DCO II degrees FN: preoperatively, 25 +/- 20 pg/dL; 24 hours postoperatively, 36 +/- 29 pg/dL; NS. There were no differences in the complication rate in terms of acute respiratory distress syndrome, sepsis, or multiple organ failure.nnnCONCLUSIONnIn this prospective, randomized, multicenter study, a sustained inflammatory response was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. These findings may become clinically relevant in patients at high risk of developing complications. It confirms previous studies in that damage control orthopedic surgery appears to minimize the additional surgical impact induced by acute stabilization of the femur.

The Utstein template for uniform reporting of data following major trauma: A joint revision by SCANTEM, TARN, DGU-TR and RITG

BackgroundIn 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.MethodsOver a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.ResultsThe expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.ConclusionThrough a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.

A protocol for angiographic embolization in exsanguinating pelvic trauma: A report on 31 patients

Backgroundu2003The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol. Patients and methodsu2003During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization. Resultsu2003The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17–66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding. Interpretationu2003Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.

The Trajectory of Physical and Mental Health From Injury to 5 Years After Multiple Trauma: A Prospective, Longitudinal Cohort Study

OBJECTIVESnTo describe the trajectory of physical and mental health from injury to 5 years postinjury for patients with multiple trauma, and to examine predictors of recovery of physical and mental health.nnnDESIGNnA prospective, longitudinal cohort study with data from injury (baseline), the return home (t1), and 1 (t2), 2 (t3), and 5 (t4) years.nnnSETTINGnHospital and community setting.nnnPARTICIPANTSnPatients (N=105; mean age ± SD, 35.3±14.0y; age range, 18-67y; 83% men) with multiple trauma and a New Injury Severity Score (NISS) ≥16 treated at a regional trauma referral center. Mean NISS ± SD was 34.6±12.6, and mean Glasgow Coma Scale (GCS) score ± SD was 12.2±3.9.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnMedical Outcomes Study 36-Item Short-Form Health Survey physical component summary (PCS) and mental component summary (MCS), injury severity parameters, and World Health Organization Disability Assessment Schedule II (WHODAS II) for activities and participation.nnnRESULTSnThe proportion with poor physical health (<40 points on the PCS) stabilized at 56% at t4 from 81% at t1. The proportion with poor mental health (<40 points on the MCS) stabilized at 31% at t4 from 43% at t1. Generalized estimating equations showed that predictors of PCS were time points of measurement (Wald, 85.50; P<.001), GCS (B=-.48, P=.004), time in hospital/rehabilitation (B=-.22, P=.001), and the rank-transformed WHODAS II subscales Getting around (B=.16, P<.001) and Participation in society (B=.06, P=.015). Predictors of MCS were time points of measurement (Wald 13.46, P=.004), sex (men/women) (B=-4.24, P=.003), education (low/high) (B=3.43, P=.019), and WHODAS II cognitive function (B=.18, P<.001) and Participation in society (B=.18, P≤.001).nnnCONCLUSIONSnPhysical and mental health over the 5 years improved with time, but was still significantly below population means. The physical and mental health status stabilized, but the recovery trajectories differed for physical and mental health. Predictors of health were personal and injury-related factors and function in a biopsychosocial perspective.

Extrinsic Pathway Inhibitor in Postoperative/Posttraumatic Septicemia: Increased Levels in Fatal Cases

The activity of the extrinsic pathway inhibitor (EPI), which is the factor-Xa-dependent inhibitor of the factor VIIa-tissue thromboplastin complex, was serially determined in 13 patients with postoperative/posttraumatic septicemia, and compared to the activity of antithrombin (AT), heparin cofactor II and protein C (PC). In the survivors (n = 8), initial low values for all the inhibitors normalized during recovery. In the demises (n = 5), a progressive increase in EPI activity was observed until death, whereas progressive decreases were observed for the other inhibitors. No correlation was found between the inhibitor values and the endotoxin concentration. We conclude that EPI activities are increased in the late course of fatal septicemia. Apparently, a large EPI-AT gap is a severe prognostic indicator in such patients.

Unstable Sacral Fractures: Associated Injuries and Morbidity at 1 Year

Study Design. A prospective, longitudinal single-cohort study of 32 patients treated with internal fixation for unstable sacral fractures. Objectives. To describe the prevalence of associated injuries in blunt pelvic trauma with unstable sacral fractures, and to characterize late impairments. Summary of Background Data. In high-energy pelvic ring injury, the close association of the spine, the intrapelvic organs and the bony pelvic ring result in high risk for additional injuries. These injuries may result in long-term sequels pertaining to mobility, voiding, bowel function, and sexual function. However, little is known about the components of long-term morbidity after unstable sacral fractures. Methods. The minimum 1-year follow-up included 32 patients surgically treated for unstable sacral fractures. Patients were analyzed for associated injuries, fracture classification, severity of trauma, and long-term measures of neurologic recovery, mobility, and functions pertaining to voiding, defecation, and sexual function. Results. Additional injuries occurred in 84%. Injury Severity Score was 27 (range, 9–57). At follow-up, sensory impairments were observed in 91%; impaired gait in 63%, and bladder, bowel, or sexual impairments in 59%. Sacral radiculopathies explained only 60% to 69% of these impairments. The presence of late impairments correlated to the severity of injury and to the presence of associated injuries, but not to fracture characteristics. Conclusions. Unstable fractures of the sacrum are frequently associated with additional injuries. These injuries have a significant effect on morbidity still 1 year after injury. The multifactor etiology of impairments after sacral fractures should be acknowledged in the assessment of these patients.

IDENTIFICATION AND COMPARISON OF REHABILITATION GOALS AFTER MULTIPLE INJURIES: AN ICF ANALYSIS OF THE PATIENTS', PHYSIOTHERAPISTS' AND OTHER ALLIED PROFESSIONALS' REPORTED GOALS

OBJECTIVEnTo explore and compare severely injured patients rehabilitation goals with respect to their functioning and the reported goals of rehabilitation professionals.nnnDESIGNnA prospective cohort study, including longitudinal data on patients functioning and cross-sectional data from the patients and professionals goal descriptions.nnnSUBJECTSnSixty-six patients (53 men, 13 women, mean age 35 (standard deviation 13.8) years) with multiple injuries with a New Injury Severity Score >15 and 76 physiotherapists and other municipal rehabilitation professionals/services.nnnMETHODSnPatient questionnaire and interview were applied after return home and a further questionnaire one year post-injury. Short-Form Health Survey was used for self-assessed health. A questionnaire was applied to the professionals. Rehabilitation goals were reported by patients and professionals. International Classification of Functioning, Disability and Health coding of the goals was performed.nnnRESULTSnShort-Form Health Survey scores were below those of the general population. The patients goals concerned body functions/structures (8.6%), activities (16.2%) and participation (31.7%). The professionals, mainly physiotherapists, reported few participation goals (10.7%). Agreement between the patients and professionals goals were poor, with kappa scores < or =0.20 for musculoskeletal functions/structures, self-care, mobility, interpersonal interactions/relationships, work and recreation/leisure. A statisticaly significant difference between patients and professionals goals was demonstrated for musculoskeletal functions/structures (p<0.001), interpersonal interactions/relationships (p=0.002), work (p=0.001) and recreation/leisure (p=0.002).nnnCONCLUSIONnThe patients mainly reported activity and participation goals. There was poor agreement between patients and professionals for body functions and participation goals.

Long-Lasting Performance Improvement After Formalization of a Dedicated Trauma Service

BACKGROUNDnFew studies have evaluated intrainstitutional improvement of trauma care. We hypothesized that the formalization of a dedicated multidisciplinary trauma service in a major Scandinavian trauma center in 2005 would result in improved outcome.nnnMETHODSnInstitutional trauma registry data for 7,243 consecutive patients from the years 2002-2008 were retrospectively evaluated using variable life-adjusted display (VLAD) as one of several performance indicators. VLAD is a refinement of the cumulative sum method that adjusts death and survival by each patients risk status (probability of survival) and provides a graphical display of performance over time. Probability of survival was calculated according to Trauma and Injury Severity Score (TRISS) methodology with National Trauma Data Bank 2005 coefficients.nnnRESULTSnVLAD demonstrated a sharp increase in cumulative survival starting at the beginning of 2005 and continuing linearly throughout the study period, amounting to 68 additional saved lives. The increase was mainly caused by improved survival among the critically injured (injury severity score 25-75). A cutoff point t0 for analysis of differences between time periods was set at January 1, 2005, coinciding with the formalization of a dedicated trauma service. Mortality in the whole trauma population showed a 33% decrease after t0. W-statistics confirmed the increased survival to be significant. There were no significant changes in age, gender, or injury mechanism. Injury severity score decreased, but differences in case mix were adjusted for in the survival prediction model.nnnCONCLUSIONnWe have shown that the start of the long-lasting performance improvement coincided with formalization of a dedicated trauma service, providing increased multidisciplinary focus on all aspects of trauma care.

Abbreviated Injury Scale: Not a reliable basis for summation of injury severity in trauma facilities?

BACKGROUNDnInjury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported.nnnMETHODSnNineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland-Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ± 9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering.nnnRESULTSnTen coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ± 9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the raters career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the raters career.nnnCONCLUSIONSnBased on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance.

Returning to work after severe multiple injuries: multidimensional functioning and the trajectory from injury to work at 5 years.

BACKGROUNDnThe process of returning to work (RTW) after multiple injuries is lengthy. Prospective studies with follow-up times of up to 5 years are necessary but lacking. The aim of this study was to describe the trajectory of RTW and to examine the factors that predicted RTW over 5 years for patients with multiple injuries using a prospective cohort design.nnnMETHODSnOne-hundred one patients aged 18 years to 67 years who had been admitted to a trauma referral center with a New Injury Severity Score >15 starting January 2002 through June 2003 were included. The follow-up rate at 5 years was 79%. Outcomes were assessed 6 weeks after discharge and at 1 year, 2 years, and 5 years postinjury. The instruments used to assess patient status were the Short Form 36, the World Health Organization Disability Assessment Schedule II cognitive subscale, a Cognitive Function Scale, and the Brief Approach/Avoidance Coping Questionnaire. Repeated measures analyses of categorical correlated data were applied.nnnRESULTSnPatients mean age was 34.5 years (SD, 13.5); 83% were men and 25% had a university or college education; 66% were blue-collar workers. Mean New Injury Severity Score was 35.1 (SD, 12.7). RTW rates were 28% at 1 year, 43% at 2 years, and 49% at 5 years postinjury. There were differences among patients in RTW status, and personal factors and physical and psychosocial functioning. Predictors of RTW were as follows: measurement occasion, education (high/low), coping, and physical and cognitive functioning. The proportion of unexplained variation between subjects in the models was 31% to 55%.nnnCONCLUSIONnOf the patients included in this study, 49% achieved RTW, and 23% received full disability benefits. Higher education; better physical, social, and cognitive functioning; and coping strategies all predicted RTW.