Damage Control Orthopaedics

• Damage Control Orthopaedics (DCO) is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology can improve.
  
• Its purpose is to avoid worsening of the patient's condition by the “second hit” of a major orthopaedic procedure and to delay definitive fracture repair until a time when the overall condition of the patient is optimized.
  
• Minimally invasive surgical techniques, such as external fixation, are used initially.
  
• The initial trauma represents the “first hit”.
  

 Damage control focuses on

1. Control of haemorrhage,
2. Management of soft-tissue injury, and
3. Achievement of provisional fracture stability,
4. While avoiding additional insults to the patient.

Physiology Of Damage Control Orthopaedics

• Traumatic injury leads to systemic inflammation (Systemic Inflammatory Response Syndrome) followed by a period of recovery.
• Severe inflammation may lead to acute organ failure and early death after an injury.

• A lesser inflammatory response followed by an excessive compensatory anti-inflammatory response syndrome may induce a prolonged immunosuppressed state that can be deleterious to the host.

                    This explains why Multiple Organ Dysfunction Syndrome develops early after trauma in some patients and much later in others.

• When the stimulus is less intense and would normally resolve without consequence, the patient is
  vulnerable to secondary inflammatory insults that can re-activate the Systemic Inflammatory
  Response Syndrome and precipitate late Multiple Organ Dysfunction Syndrome.
  
• The second insult may take many forms as a result of a variety of circumstances, such as sepsis and surgical procedures, and it is the basis for the decision-making process regarding when and how
  much to do for a «borderline» multiply injured patient.
  

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1. The First And 2nd Hit Phenomena
   

          The two-hit theory is shown schematically. 

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   0. The first hit is the initial traumatic event, and the second hit is the definitive orthopaedic procedure, usually femoral nailing.
   1. (MODS= Multiple Organ Dysfunction Syndrome, ARDS= Adult Respiratory Distress Syndrome). 

Markers Of Immune Reactivity

• Inflammatory markers are useful in identifying patients at risk for the development of post- traumatic complications such as MODS.
  
• At present, only two markers, IL-6 and HLA-DR class-II molecules, accurately predict the clinical course and outcome after trauma.
  
  

Patient Selection For Damage Control Orthopaedics

• Whether patients should be treated with Damage Control Orthopaedics instead of Early Total Care after orthopaedic trauma, should be decided on the basis of the patient's overall physiologic status and injury complexes.
  
• Patients who have sustained orthopaedic trauma have been divided into four groups: stable, borderline, unstable, and in extremis
  
• Stable patients should be treated with the local preferred method for managing their orthopaedic injuries.
  
  
• Unstable patients and patients in extremis should be treated with Damage Control Orthopaedics for their orthopaedic injuries.

• Borderline patients are more difficult to define.

✫ Borderline patients are defined as patients with polytrauma and

1. An injury severity score of >40 points in the absence of thoracic injury
   
2. An injury severity score of >20 points with thoracic injury
   
3. Polytrauma with abdominal trauma
   
4. A chest radiograph showing bilateral lung contusions
   
5. An initial mean pulmonary artery pressure of >24 mm Hg
   
6. An increase in pulmonary artery pressure of >6 mm Hg during nailing 
   

Borderline orthopaedic trauma patients are probably best treated with Damage Control Orthopaedics. 

Some of the additional clinical criteria that used as a basis for shifting to damage control orthopaedics include

1. a)  Ph of <7.24,
   
2. b)  Temperature of <35°C,
   
3. c)  Operative time >90min,
   
4. d)  Coagulopathy, and
   
5. e)  Transfusion of > 10 units of packed red blood cells. 
   

• Furthermore, certain specific orthopaedic injury complexes appear to be more amenable to Damage Control Orthopaedics; these include, for example,

1. a)  femoral fractures in a multiply injured patient,
   
2. b)  pelvic ring injuries with exsanguinating hemorrhage, and
   
3. c)  polytrauma in a geriatric patient. 
   

The current treatment algorithm from Hannover (Germany) for the use of Damage Control Orthopaedics is based on a prompt and accurate determination of whether the patient is stable, borderline, unstable, or in extremis (ER=Emergency Room, ABG=Arterial Blood Gases, FAST=Focused Assessment Sonography For Trauma, I/O ratio=Intake/Output Ratio, ABP=Arterial Blood Pressure, IL-6=Interleukin-6, ETC=Early Total Care, OR=Operating Room, DCO=Damage Control Orthopaedics, ICU=intensive care unit). 

When Can Secondary Orthopaedic Procedures Be Performed?

• One of the most important issues in Damage Control Orthopaedics is the timing of the secondary surgical procedures (Definitive osteosynthesis).

Days 2, 3, and 4 are not safe for performing definitive surgery.

• During this period, marked immune reactions are ongoing and increased generalized edema is observed. 

• Patients who are treated with Damage Control Orthopaedics demonstrate a lower risk of Adult Respiratory Distress Syndrome than those treated with initial intramedullary nailing.
  
• However, the use of spanning external fixation carries the risk of pin-track infection.
  
• Contemporary rates of pin-track infection are still substantial, but they are minimized when the duration of external fixation is brief

Overview And Future Directions 

 Damage Control Orthopaedics is ideal for an unstable patient or a patient in extremis, and it has some utility for the borderline patient as well.

• Specific injury complexes for which damage Control Orthopaedics should be considered are

•   Femoral fractures (especially bilateral fractures),
  
•   Pelvic ring injuries with profound hemorrhage, and
  
•   Multiple injuries in elderly patients.
  

✫ Specific subgroups of multiply injured orthopaedic patients who may benefit from Damage Control Orthopaedics are those with a head injury, chest trauma, or a mangled limb.