title: Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation.
abstract: BACKGROUND
  Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.
  
  
  METHODS
  Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.
  
  
  RESULTS
  All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).
  
  
  CONCLUSIONS
  Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. hvallier@metrohealth.org.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. tmoore@metrohealth.org.|Departments of Orthopaedic Surgery and Neurosciences, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, USA. tmoore@metrohealth.org.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Moore
authors.affiliation: Division of Trauma, Department of Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA. jcomo@metrohealth.org.
authors.forename: John J
authors.initials: JJ
authors.lastname: Como
authors.affiliation: Division of Trauma, Department of Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA. pwilczewski@gmail.com.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Wilczewski
authors.affiliation: Department of Neurosciences, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA. msteinmetz@metrohealth.org.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Steinmetz
authors.affiliation: Department of Anesthesiology, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA. kwagner@metrohealth.org.
authors.forename: Karl G
authors.initials: KG
authors.lastname: Wagner
authors.affiliation: Department of Anesthesiology, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA. csmith@metrohealth.org.
authors.forename: Charles E
authors.initials: CE
authors.lastname: Smith
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. xfwang@gmail.com.
authors.forename: Xiao-Feng
authors.initials: XF
authors.lastname: Wang
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. dolencaj@gmail.com.
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Dolenc
mesh_terms: D000138:Acidosis / Q000209:etiology / Q000628:therapy; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D005260:Female; D005592:Fracture Fixation / Q000009:adverse effects* / Q000379:methods / Q000592:standards; D050723:Fractures, Bone / Q000150:complications / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000150:complications / Q000601:surgery; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult