Journal of the American
Academy of Orthopaedic
Prolonged Orthopaedic Surgery Should Be Avoided in Certain Cases
September 16, 2009
Trauma patients who have several orthopedic injuries and are considered to be in unstable condition should only have a few hours of surgery when first arriving at the hospital.
This principle is called "damage control," Dr. Hans-Christoph Pape, chairman of Orthopedic/Trauma Surgery at the University of Aachen in Aachen, Germany, tells DOTmed News.
Summarizing current practices in a review article he published in the September issue of the Journal of the American Academy of Orthopaedic Surgeons, he says that more and more general surgeons--who clear patients for surgery--are working closely with orthopaedic surgeons to follow this principle. It was the general surgeons who initiated the damage control principle in the first place, Dr. Pape says.
Initially, he recalls, "the damage-control concept came from Philadelphia, where patients suffered abdominal gun shot injuries. Now, 10 years later orthopaedic surgeons are becoming aware that the same principles apply to major fractures."
Immune System Hyperstimulation
"We know that if you operate more than six hours, there is a 20 percent increase in death from multiple organ failure. That's because if you do too much surgery at once, you hyperstimulate the immune system, which results in organ failure," Dr. Pape tells DOTmed.
In addition, performing multiple surgeries at once can cause blood loss that results in complications, he says. He adds that if a patient has just a couple of fractures it is okay operate on them all at once.
He and his colleagues found it is often best to use an external fixator (where pins in the bone are connected by an external bar) to stabilize an orthopaedic injury in order to stop initial pain and bleeding. Two or three days later, once the patient is stable, data suggests it is okay to begin other more invasive and time-consuming operations, Dr. Pape says in a press release from American Association of Orthopaedic Surgeons (AAOS).
Study Findings Confirm Three Hours Are Optimal
In his study, Dr. Pape and his colleagues analyzed data from several trauma registries in Germany. They compared patient outcomes in about 21,000 trauma patients with the amount of hours each patient had spent in the operating room.
"We found that patients with life-threatening injuries, such as chest contusions or liver lacerations, in association with multiple bone fractures, who have surgery for six or more hours do not always do as well. If you limit the amount of time in the operating room to less than three hours, patients appear to do better."
Dr. Pape concludes, "Timing is key in patients with life-threatening injuries. There needs to be close communication between the orthopaedic surgeon, the general surgeon and ICU staff, so that all members of the care team can re-evaluate the patient throughout the process to see if it is safe to fix the next fracture."