title: Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care.
abstract: OBJECTIVE
  The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications.
  
  
  METHODS
  Statistical modeling based on retrospective database.
  
  
  METHODS
  Level 1 trauma center.
  
  
  METHODS
  A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures.
  
  
  METHODS
  All fractures were treated surgically.
  
  
  METHODS
  Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated.
  
  
  RESULTS
  Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis.
  
  
  CONCLUSIONS
  Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, OH.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
authors.forename: Xiaofeng
authors.initials: X
authors.lastname: Wang
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Moore
authors.forename: John H
authors.initials: JH
authors.lastname: Wilber
authors.forename: John J
authors.initials: JJ
authors.lastname: Como
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D016063:Blood Loss, Surgical / Q000517:prevention & control* / Q000706:statistics & numerical data*; D002648:Child; D015897:Comorbidity; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods / Q000706:statistics & numerical data; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000453:epidemiology* / Q000601:surgery*; D009820:Ohio / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D055502:Secondary Prevention / Q000379:methods* / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult