title: A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society.
abstract: BACKGROUND
  Today, there is a trend toward damage-control orthopedics (DCO) in the management of multiple trauma patients with long bone fractures. However, there is no widely accepted concept. A risk-adapted approach seems to result in low acute morbidity and mortality. Multiple trauma patients with bilateral femoral shaft fractures (FSFs) are considered to be more severely injured. The objective of this study was to validate the risk-adapted approach in the management of multiple trauma patients with bilateral FSF.
  
  
  METHODS
  Data analysis is based on the trauma registry of the German Trauma Society (1993-2008, n = 42,248). Multiple trauma patients with bilateral FSF were analyzed in subgroups according to the type of primary operative strategy. Outcome parameters were mortality and major complications as (multiple) organ failure and sepsis.
  
  
  RESULTS
  A total of 379 patients with bilateral FSF were divided into four groups as follows: (1) no operation (8.4%), (2) bilateral temporary external fixation (DCO) (50.9%), bilateral primary definitive osteosynthesis (early total care [ETC]) (25.1%), and primary definitive osteosynthesis of one FSF and DCO contralaterally (mixed) (15.6%). Compared with the ETC group, the DCO group was more severely injured. The incidence of (multiple) organ failure and mortality rates were higher in the DCO group but without significance. Adjusted for injury severity, there was no significant difference of mortality rates between DCO and ETC. Injury severity and mortality rates were significantly increased in the no-operation group. The mixed group was similar to the ETC group regarding injury severity and outcome.
  
  
  CONCLUSIONS
  In Germany, both DCO and ETC are practiced in multiple trauma patients with bilateral FSF so far. The unstable or potentially unstable patient is reasonably treated with DCO. The clearly stable patient is reasonably treated with nailing. When in doubt, the patient is probably not totally stable, and the safest precaution may be to use DCO as a risk-adapted approach.
  
  
  METHODS
  Therapeutic study, level IV. Epidemiologic study, level III.
authors.affiliation: From the Department of Orthopedic and Trauma Surgery (E.S., D.R,), Berufsgenossenschaftliche Unfallklinik Duisburg; Institute for Research in Operative Medicine (R.L., E.A.M.N.), Faculty of Medicine, University of Witten-Herdecke; and Department of Orthopedic and Trauma Surgery (T.T., B.B.), University of Witten-Herdecke at the Hospital Cologne-Merheim, Germany.
authors.forename: Eva
authors.initials: E
authors.lastname: Steinhausen
authors.forename: Rolf
authors.initials: R
authors.lastname: Lefering
authors.forename: Thorsten
authors.initials: T
authors.lastname: Tjardes
authors.forename: Edmund A M
authors.initials: EA
authors.lastname: Neugebauer
authors.forename: Bertil
authors.initials: B
authors.lastname: Bouillon
authors.forename: Dieter
authors.initials: D
authors.lastname: Rixen
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016267:External Fixators; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods* / Q000401:mortality; D005593:Fracture Fixation, Internal / Q000379:methods / Q000401:mortality; D005594:Fracture Fixation, Intramedullary / Q000379:methods / Q000401:mortality; D017102:Fracture Healing / Q000502:physiology; D005858:Germany; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D009104:Multiple Trauma / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012042:Registries; D012189:Retrospective Studies; D020379:Risk Adjustment; D018570:Risk Assessment; D012955:Societies, Medical; D014193:Trauma Centers; D016896:Treatment Outcome