title: Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society.
abstract: BACKGROUND
  Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database.
  
  
  METHODS
  A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept.
  
  
  RESULTS
  Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death.
  
  
  CONCLUSIONS
  Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.
authors.affiliation: Department of Trauma/Orthopedic Surgery, University of Witten/Herdecke at the Hospital Merheim, Cologne, Germany. D.Rixen@uni-koeln.de
authors.forename: Dieter
authors.initials: D
authors.lastname: Rixen
authors.forename: Guido
authors.initials: G
authors.lastname: Grass
authors.forename: Stefan
authors.initials: S
authors.lastname: Sauerland
authors.forename: Rolf
authors.initials: R
authors.lastname: Lefering
authors.forename: Marcus R
authors.initials: MR
authors.lastname: Raum
authors.forename: Nedim
authors.initials: N
authors.lastname: Yücel
authors.forename: Bertil
authors.initials: B
authors.lastname: Bouillon
authors.forename: Edmund A M
authors.initials: EA
authors.lastname: Neugebauer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D019317:Evidence-Based Medicine; D005264:Femoral Fractures / Q000150:complications / Q000601:surgery*; D005592:Fracture Fixation; D005858:Germany; D006801:Humans; D007223:Infant; D008875:Middle Aged; D009104:Multiple Trauma / Q000150:complications*; D010818:Practice Patterns, Physicians'; D012042:Registries; D018570:Risk Assessment; D013997:Time Factors