n Feature Article

Damage-Control Orthopedics Versus Early

Total Care in the Treatment of Borderline
High-Energy Pelvic Fractures
Gengfen Han, MD; Ziming Wang, MD; Quanyin Du, MD; Yan Xiong, MD; Yu Wang, MD;
Siyu Wu, MD; Bo Zhang, MD; Aimin Wang, PhD, MD

abstract
Full article available online at Healio.com/Orthopedics

The purpose of this study was to compare the effectiveness of damage-control or-
thopedics (DCO) vs early total care (ETC) in the treatment of borderline high-energy
pelvic fractures. Seventy-two patients with borderline high-energy pelvic fractures
were retrospectively reviewed; 39 received DCO and 33 received ETC. Demographic
data and initial injury severities were comparable between groups, except for Abbre-
viated Injury Scale (AIS) head scores and Glasgow Coma Scale (GCS) scores. Regard-
ing postoperative complications, the incidence rates of acute lung injury and acute
respiratory distress syndrome and the mean Acute Physiology and Chronic Health
Evaluation II (APACHE II) score were significantly lower in the DCO group compared
with the ETC group. Similar results were also observed in subgroups stratified by age
(younger than 40 years and 40 years and older). Regarding patients with Tile B frac-
tures, there was no significant difference between groups in incidence rates of overall
postoperative complications. However, in patients with Tile C fractures, especially in
those 40 years and older, the DCO group had a lower incidence rate of ALI and had
lower APACHE II scores than did the ETC group. This study’s findings indicate that
DCO is the most suitable therapeutic option for patients with Tile C fractures, espe-
cially for those 40 years and older, whereas ETC is preferred for patients with Tile B
fractures, provided that it is possible to avoid a second operation as well as any delays
in patient mobilization. [Orthopedics. 2014; 37(12):e1091-e1100.]

The authors are from the Department of Orthopedics (GH), 291st Hospital of the People’s Libera-
tion Army, Baotou; and the Department of Orthopedics (ZW, QD, YX, YW, SW, BZ, AW), Daping Hospi-
tal, Third Military Medical University, Chongqing, China.
Drs Han and Z Wang contributed equally to this work and should be considered as equal first au-
thors.
The authors have no relevant financial relationships to disclose.
The authors thank Professor Jincai Liu for his professional assistance with data collection and
analysis.
Correspondence should be addressed to: Aimin Wang, PhD, MD, Department of Orthopedics, Dap-
ing Hospital, Third Military Medical University, No. 10 Yangtze River Rd, Yuzhong District, Chongqing
400042, China (aiminwang2013@gmail.com).
Received: July 16, 2013; Accepted: March 25, 2014; Posted: December 10, 2014.
doi: 10.3928/01477447-20141124-57

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n Feature Article
P
elvic and acetabular fractures
caused by high-energy forces are
rare injuries, accounting for only
3% to 8% of all traumatic fractures.1
These fractures often occur in conjunc-
tion with other life-threatening injuries,
thereby presenting many challenges for
emergency physicians and trauma sur-
geons.2 In recent years, with advances in
resuscitation, mortality rates associated
with pelvic fractures have been reduced to
approximately 10%.3 However, achieving
effective management of posttraumatic
complications, such as acute respiratory
distress syndrome (ARDS) and multiple
organ dysfunction syndrome (MODS), re-
mains difficult.4
Currently, there are 2 treatment op-
tions for patients with traumatic fractures:
early total care (ETC) and damage-control
orthopedics (DCO).5 Early total care in-
volves definitive surgical fracture fixation
in the early phase of treatment (24 to 48
hours). Previous studies have demonstrat-
ed that in pelvic fracture patients, ETC
could reduce length of stay in the intensive
care unit (ICU) and overall hospitaliza-
tions, as well as aid in early patient mobi-
lization.6,7 Nevertheless, more physicians
have begun to consider ETC unsuitable
for all traumatic fracture patients. In cases
with additional complications (eg, shock
or severe head and chest injury), ETC has
been associated with a high rate of serious
postoperative complications, such as sys-
temic inflammatory response syndrome
(SIRS), acute lung injury (ALI), ARDS,
or MODS.8
Damage-control orthopedics is a
staged strategy in which life-saving pro-
cedures and temporary external fixation of
major skeletal fractures take priority dur-
ing the early phase of treatment and sub-
sequent definitive fixation is performed
only when a patient’s clinical condition
permits it. Researchers have documented
that DCO could offer great advantages in
resuscitation through minimizing blood
loss and effectively reducing the risk of
posttraumatic complications, thereby pro-
e1092
viding benefits for patients with serious
thoracic, head, or abdominal injuries.9
Regarding pelvic fractures caused by
high-energy forces, universal agreement
on all aspects of management remains to
be reached, especially concerning patients
who fall into the borderline category.2 Ac-
cording to Pape et al,5 the term borderline
describes a situation in which a patient is
apparently in stable condition preopera-
tively but deteriorates unexpectedly and
may develop organ dysfunction postop-
eratively.10 Although DCO is becoming
increasingly accepted by physicians as
the most suitable treatment option, there
are data in the literature showing benefits
from ETC for borderline patients.6 There-
fore, uncertainty remains in the choice
between DCO and ETC as the most ap-
propriate therapeutic option for borderline
pelvic fractures.2 The purpose of the cur-
rent study was to retrospectively evaluate
the efficacy of DCO vs ETC in the treat-
ment of borderline high-energy pelvic
fractures to determine the most suitable
treatment strategy.
Materials and Methods
Setting and Inclusion and Exclusion
Criteria
A 69-month retrospective review of the
trauma registry database of the Trauma
Center and the Department of Orthopedics
of the authors’ institution was performed
for the time between May 1, 2005, and
June 30, 2011. The database contained 385
consecutive pelvic fracture patients dur-
ing the study period. This study was ap-
proved by the medical ethical committee
of the authors’ institution. To ensure the
quality of this retrospective observational
study, strict inclusion and exclusion crite-
ria were applied. Inclusion criteria were
(1) patient age between 16 and 65 years;
(2) high-energy pelvic fractures; (3) bor-
derline patients according to the classifica-
tion system proposed by Pape et al11; (4)
New Injury Severity Score (NISS) higher
than 1612; (5) Tile B (rotationally unstable)
or Tile C (rotationally and vertically un-
stable) fracture according to Tile classi-
fication13; (6) treated with either DCO or
ETC; and (7) initial surgery (temporary
stabilization with DCO or early defini-
tive fixation with ETC) within the first 24
hours after injury. Exclusion criteria were
(1) Abbreviated Injury Scale (AIS) score
of 4 or higher14; (2) severe traumatic brain
injuries that required emergency surgery;
(3) a history of organ transplantation, pul-
monary emphysema, pulmonary hyperten-
sion, or malignant tumors; (4) Tile A frac-
ture (avulsion, stable ring); and (5) stable,
unstable, or in extremis patients according
to the classification of Pape et al.11
Treatment
Damage-control orthopedics treatment
consisted of 4 phases: (1) life-saving pro-
cedures during the acute phase; (2) bleed-
ing control, temporary stabilization of
fractures with an external fixation system
or a pelvic C-clamp, and management
of soft tissue injuries during the second
phase; (3) ICU monitoring during the
third phase; and (4) definitive fracture fix-
ation when the patient’s condition permit-
ted it.8 For ETC treatment, pelvic packing,
bowel and bladder repair, and definitive
fracture fixation were performed within
24 hours after injury. Posterior pelvic ring
fractures were fixated with reconstruction
plates or percutaneous iliosacral screws,
and anterior pelvic ring fractures were fix-
ated with reconstruction plates. Intensive
care unit monitoring was implemented
after definitive fixation.7 During the ICU
monitoring period, rewarming, correction
of coagulopathy, mechanical ventilation,
maintenance of vital signs, fluid resuscita-
tion with crystalloid or colloid solutions,
and arterial blood gas and central venous
pressure measurements were undertaken
for both groups.
Data Collection
For all patients included in this study,
the following data were collected from the
authors’ database: demographics (name,
age, sex); injury pattern (mechanism,
ORTHOPEDICS | Healio.com/Orthopedics
 n Feature Article

energy, fracture type); injury severity

(Glasgow Coma Scale [GCS] score, In- Table 1
jury Severity Score [ISS], NISS, and AIS
Patient Baseline Data
score); physiological parameters on ad-
Variable DCO Group ETC Group P
mission, which were only used for patient
classification (blood pressure, body tem- Total patients, No. 39 33
perature, respiratory rate, heart rate, urine Mean±SD age, ya 39.3±13.6 43.4±13.4 .204
volume, PaO2, FiO2, pH, lactate level, Sex, No. .471
base excess and deficit, alveolar-arterial Male 26 19
O2 tension difference [A-aDO2], platelets, Female 13 14
prothrombin time, activated partial throm- Mechanism of injury, No. .167
boplastin time [APTT], hematocrit, serum Traffic accident 23 19
levels of sodium, potassium, fibrinogen,
Fall 12 9
D-dimer, bilirubin, and creatinine, hemo-
Heavy objects 4 5
globin, white blood count [WBC], neutro-
phil count); initial treatment details (blood Tile classification, No. .094

transfusion within the first 24 hours; pri- B

mary fixation method; date, time, and
length of primary fixation); definitive fixa-
tion details (date, method); and outcome
measures (ICU length of stay; ventilator
support time; postoperative complica-
tions, including pneumonia, sepsis, SIRS,
ALI, ARDS, and MOF).
New Injury Severity Score, ISS, and
GCS score were determined based on the
scoring systems described in the litera-
ture.12,15,16 Acute lung injury, SIRS, ARDS,
and MOF were diagnosed according to the
criteria outlined in the literature.5,17,18 Acute
Physiology and Chronic Health Evaluation
II (APACHE II) was used to evaluate the
severity of each patient’s condition after
initial fixation.19 The Faringer system was
used to anatomically classify the location
of soft tissue injuries.20
Follow-up included a review of each
patient’s medical records, including admis-
sion notes, operative records, and postoper-
ative visits. Data on demographics, injury
severity, clinical course, and postoperative
complications were retrospectively ana-
lyzed. Patients were stratified by treatment
strategy (DCO vs ETC), fracture pattern
(Tile classification), and age (younger than
40 years and 40 years and older).
Statistical Analysis
Statistical analysis was performed
with SPSS version 16.0 statistical soft-
B1
B2
B3
C
C1
C2
C3
Fracture type, No.
Closed
Open
Abbreviations: DCO, damage-control orthopedics; ETC, early total care; SD, standard
deviation.
a
Difference of means (95% confidence interval)=4.1 (-2.3 to 10.5).
ware (SPSS Inc, Chicago, Illinois). All
quantitative variables were tested for nor-
mal distribution using the Kolmogorov-
Smirnov test and presented as mean±SD.
Categorical variables are expressed as
counts and percentages. Statistical signifi-
cance of quantitative baseline variables
between groups was assessed by Stu-
dent’s t test for independent samples. Sta-
tistical significance of categorical base-
line variables was assessed by Pearson’s
chi-square test or Fisher’s exact test. For
peri- and postoperative outcomes, gen-
eral linear models and logistic regression
models were used to compare quantitative
and categorical variables between groups,
respectively. Baseline variables that dif-
fered significantly between groups were
4 7
6 4
2 6
16 10
4 2
7 4
.015
27 31
12 2
included as covariates. A P value less than
.05 was considered statistically significant
(2-tailed).
Results
Baseline Patient Characteristics
During the 69-month study period, a
total of 72 patients with borderline high-
energy pelvic fractures who met the inclu-
sion criteria were selected and included
in the study. The patients’ baseline data
are presented in Table 1. Mean follow-
up was 46 months (range, 13-69 months).
Preoperative variables, including age,
sex, cause of fracture, and Tile classifi-
cation, were comparable between the 2
treatment groups (P>.05). Of 72 patients,
14 (19.4%) had open fractures (12 in the

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n Feature Article

inger zone II injury, and 2 (14.3%) had a

Table 2 Faringer zone III injury.
The patients’ initial severities are listed
Initial Injury Severities and Blood Transfusion Requirements
in Table 2. There was no statistical differ-
DCO Group ETC Group Difference of Means
Variable (n=39) (n=33) (95% CI) P
ence in ISS, NISS, AIS scores of different
body regions or blood transfusion require-
Mean±SD ISS 29.7±6.0 28.0±4.5 -1.7 (-4.2 to 0.8) .169
ments within the first 24 hours between the
Mean±SD NISS 33.4±7.5 30.7±6.4 -2.7 (-6.0 to 0.6) .110
groups. Nevertheless, the AIS head score
Mean±SD AIS score
in the DCO group was significantly higher
Head 0.9±1.0 0.4±0.8 -0.5 (-1.0 to -0.1) .026 than that in the ETC group (P=.026), and
Face 0.6±0.9 0.6±1.0 0.0 (-0.4 to 0.5) .831 the GCS score in the DCO group was
Thorax 1.4±1.6 1.4±1.5 0.0 (-0.7 to 0.7) .990 notably lower compared with that in the
Abdomen 2.2±1.6 2.1±1.5 -0.1 (-0.9 to 0.6) .704 ETC group (P=.012). Of the 72 patients,
Extremities 3.7±0.5 3.6±0.6 -0.1 (-0.3 to 0.2) .642 24 (33.3%) received a blood transfusion
External 1.4±0.9 1.2±1.0 -0.2 (-0.7 to 0.3) .380 within the first 24 hours, with a mean of
347.2±685.5 mL of blood transfused.
Mean±SD GCS score 12.6±1.6 13.6±1.4 1.0 (0.2 to 1.7) .012
No. (%) of patients 15 (38.5) 9 (27.3) .316
receiving blood Peri- and Postoperative Outcomes
transfusion within Peri- and postoperative outcomes of
first 24 h
patients in both groups are summarized
Abbreviations: AIS, Abbreviated Injury Scale; CI, confidence interval; DCO, damage-control in Table 3. There was no statistical differ-
orthopedics; ETC, early total care; GCS, Glasgow Coma Scale; ISS, Injury Severity Score;
NISS, New Injury Severity Score; SD, standard deviation. ence in perioperative parameters, includ-
ing ICU length of stay and duration of
ventilator support, between the 2 groups.
In addition, 2 patients with open fractures
Table 3 received skin graft surgery in response to
Differences in Clinical Course and Complications severe soft tissue stripping injuries in the
thigh or leg (1 in the DCO group and 1 in
DCO Group ETC Group Difference of Means
Variable (n=39) (n=33) (95% CI) P the ETC group). No patient with an open
Mean±SD ICU stay, h 72.6±88.3 64.7±60.7 -7.9 (-43.1 to 27.4) .284 fracture underwent muscle flap or free
Mean±SD ventilator 40.9±23.5 37.6±21.5 -3.3 (-14.0 to 7.4) .327 flap reconstruction. In the DCO group,
support, h the mean waiting period between external
Complications, No. (%) fixation and subsequent definitive fixation
Pneumonia 4 (10.2) 4 (12.1) .897 was 7.6±2.1 days.
Sepsis 2 (5.1) 3 (9.1) .748
Regarding postoperative complica-
tions, all patients had similar incidence
SIRS 17 (43.6) 16 (48.5) .225
rates of pneumonia, sepsis, SIRS, and
ALI 10 (25.6) 19 (57.6) .007
MOF. However, the incidence rates of ALI
ARDS 3 (7.7) 6 (18.2) .041
and ARDS and mean APACHE II score in
MOF 5 (12.8) 7 (21.2) .289 the ETC group were significantly higher
Mean±SD APACHE II 17.1±4.0 20.6±5.5 3.5 (1.3 to 5.9) .001 than those in the DCO group (P=.007,
score
.041, and .001, respectively). In addition
Abbreviations: ALI, acute lung injury; APACHE II, Acute Physiology and Chronic Health to the complications listed in Table 3, 9
Evaluation II; ARDS, acute respiratory distress syndrome; CI, confidence interval; DCO,
damage-control orthopedics; ETC, early total care; ICU, intensive care unit; MOF, multiple patients in the DCO group who received
organ failure; SD, standard deviation; SIRS, systemic inflammatory response syndrome. external fixation showed crust formation,
2 had heavy discharge from the wound,
and 3 displayed inflammation and redden-
DCO group and 2 in the ETC group). these 2 groups (P=.015). Of the patients ing around the external pin sites. These
There was a significant difference in the with open fractures, 8 (57.1%) had a Far- patients were successfully treated with
proportion of open fractures between inger zone I injury, 4 (28.6%) had a Far- wound care. No patient in either group

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 n Feature Article

required local debridement nor devel-

oped osteomyelitis by the end of fol-

Abbreviations: AIS, Abbreviated Injury Scale; CI, confidence interval; DCO, damage-control orthopedics; ETC, early total care; GCS, Glasgow Coma Scale; ISS, Injury Severity Score;
.189
.209

.152
.312

.063
.849
.641
.495
.519
.436
.090
.341
P
low-up. Furthermore, all 72 patients
Baseline Data, Initial Injury Severities, and Blood Transfusion Requirements of Patients With Tile B and Tile C Pelvic Fractures

reviewed in this study survived to the

Difference of Means

end of follow-up. In the DCO group,

-5.8 (-14.6 to 3.0)

-2.7 (-6.4 to 1.0)

-2.5 (-7.6 to 2.5)

-0.6 (-1.3 to 0.0)

-0.1 (-0.7 to 0.6)

-0.3 (-1.3 to 0.6)

-0.1 (-0.5 to 0.3)
-0.2 (-0.8 to 0.4)
0.3 (-0.8 to 1.2)

0.8 (-0.1 to 1.7)

29 (74.4%) patients had no chronic
(95% CI)

sequelae from their pelvic fractures,

6 (15.4%) had permanent disability
Tile C Fractures (n=43)

from associated injury of nerve roots,

2 (5.1%) had sexual dysfunction, and
2 (5.1%) had urinary or fecal inconti-
ETC Group

35.8±13.3

nence. In the ETC group, 18 (54.5%)

28.6±5.6
32.5±7.9

0.5 ± 1.0

13.3±1.1
0.5±1.0
1.6±1.5
2.2±1.5
3.6±0.6
1.3±0.9

4 (25.0)
(n=16)

patients had no chronic sequelae, 9

8
8

(27.3%) had permanent disability, and

6 (18.2%) had urinary or fecal incon-
tinence.
DCO Group

41.6±14.2

The effectiveness of DCO vs ETC

31.3±6.0
35.0±7.9

12.5±1.6
11 (40.7)
1.1±1.1
0.6±0.9
1.3±1.6
2.5±1.5
3.7±0.5
1.5±0.9
(n=27)

in patients with different Tile types (B

19
8

and C) was also evaluated and com-

pared. The baseline data and initial
injury severities of patients with Tile
1.000

1.000
.073

.382
.695

.577
.784
.694
.482
.739
.846
.191

B and C pelvic fractures are shown in

P

Table 4. For patients with Tile B or C

fractures, no statistically significant
Difference of Means
Table 4

difference was noted in terms of base-

8.7 (-0.9 to 18.2)

-0.7 (-4.3 to 2.9)

-0.2 (-0.7 to 0.4)

-0.1 (-0.6 to 0.8)
-0.2 (-1.5 to 1.0)

-0.1 (-0.3 to 0.5)

-0.1 (-0.8 to 0.7)
1.3 (-1.7 to 4.2)

0.4 (-0.8 to 1.7)

0.8 (-0.5 to 2.1)

line data and initial injury severity be-

(95% CI)

tween DCO and ETC treatments.

Tile B Fractures (n=29)

Peri- and postoperative outcomes

of DCO vs ETC in patients with Tile B
and C fractures are presented in Table
5. Perioperative parameters, including
ICU stay and ventilator hours, were
ETC Group

42.7±13.3

27.4±3.1
29.1±4.2

13.8±1.7
0.3±0.7
0.8±1.0
1.2±1.6
2.0±1.5
3.7±0.5
1.2±1.1

5 (29.4)
(n=17)

comparable between the 2 treatments.

11
6

In patients with Tile B fractures, there

was no significant difference in the
NISS, New Injury Severity Score; SD, standard deviation.

incidence rates of any postoperative

DCO Group

complications between DCO and ETC

34.0±10.8

26.1±4.6
29.8±5.2

0.5 ± 0.7

12.9±1.7
0.7±0.9
1.4±1.6
1.6±1.6
3.6±0.5
1.3±0.9

4 (33.3)
(n=12)

treatments. Nevertheless, in patients

7
5

with Tile C fractures, patients in the

DCO group displayed lower ALI in-
cidence rates and lower APACHE II
blood transfusion within first
No. (%) of patients receiving

scores than did patients in the ETC

group (P=.010 and .001, respectively).
Mean±SD GCS score

Patients were stratified by age

Mean±SD AIS score

(younger than 40 years and 40 years

Mean±SD age, y

Mean±SD NISS
Mean±SD ISS

and older), and the effectiveness of

Extremities
Abdomen

DCO vs ETC was evaluated in differ-

External
Sex, No.

Female
Variable

Thorax
Head
Male

ent age groups. Baseline data and ini-

Face

24 h

tial injury severities of patients are pre-

sented in Table 6. For patients younger

DECEMBER 2014 | Volume 37 • Number 12 e1095

n Feature Article

than 40 years, there was no statistically proximately 10%.3

significant difference in baseline data and Death within the

damage-control orthopedics; ETC, early total care; ICU, intensive care unit; MOF, multiple organ failure; SD, standard deviation; SIRS, systemic inflammatory response syndrome.
Abbreviations: ALI, acute lung injury; APACHE II, Acute Physiology and Chronic Health Evaluation II; ARDS, acute respiratory distress syndrome; CI, confidence interval; DCO,
Mean±SD APACHE II score

Complications, No. (%)

Mean±SD ventilator support, h
Mean±SD ICU stay, h
Variable
ARDS
ALI
MOF

SIRS
Sepsis
Pneumonia
initial injury severity between DCO and first 24 hours is
ETC treatments. For patients 40 years and most often due
older, a statistically significant difference to hemorrhagic
was noted regarding Tile classification shock caused by
(P=.012) and NISS (P=.031). acute and mas-
Peri- and postoperative outcomes of sive blood loss.22

Differences in Clinical Course and Complications for Patients With Tile B and Tile C Pelvic Fractures
DCO vs ETC in different age groups are When DCO is per-
listed in Table 7. In both age groups, peri- formed, the con-
and postoperative outcomes were compa- trol of hemorrhage
rable between DCO and ETC treatments, and temporary sta-

DCO Group
except for the incidence rate of ALI and bilization of major

65.3±110.0
38.2±26.4
16.1±2.6

3 (25.0)
3 (25.0)

(n=12)
1 (8.3)
1 (8.3)

0 (0.0)
1 (8.3)
mean APACHE II scores. Patients treated skeletal fractures
with DCO had lower ALI incidence rates are top priorities
and lower APACHE II scores than those during the acute
who were treated with ETC (P=.010 phase of resuscita-

ETC Group
35.3±24.2
59.3±73.1
18.7±4.1
for ALI incidence rate and P=.017 for tion. External fixa-

3 (17.6)
2 (11.8)
8 (47.1)
5 (29.4)

2 (11.8)

(n=17)
1 (5.9)

Tile B Fractures (n=29)

APACHE II score in patients younger tion used in DCO
than 40 years; P=.043 for ALI incidence can reduce hem-
rate and P=.042 for APACHE II score in orrhage through

Difference of Means
patients 40 years and older). rapidly decreasing

-2.9 (-22.3 to 16.6)

-6.0 (-82.8 to 70.8)
2.6 (0.1 to 5.2)

the pelvic volume

(95% CI)
Discussion and providing

Table 5
Currently, the treatment and manage- temporary frac-
ment of patients with high-energy pelvic ture stabilization.23
ring fracture poses a challenge for clini- Therefore, it has
cians. This is especially true when pa- been considered
tients fall into the borderline category.21 an effective ap-
1.000
.158
.576
.858
.171
.786

.551

.378
.365
P
Treatment of borderline patients repre- proach in decreas-
sents a controversial issue because the ing early mortal- DCO Group
correct choice between DCO and ETC ity rates related to
42.0±22.5
75.9±79.0
17.4±4.5

14 (51.9)
4 (14.8)

7 (25.9)

3 (11.1)

(n=27)
2 (7.4)

2 (7.4)

as the most appropriate therapeutic op- high-energy pel-

tion remains unclear.2 In the current study, vic fractures.2 In
the authors retrospectively compared the the current study,
clinical effectiveness of DCO vs ETC in comparisons of
ETC Group
40.0±18.7
70.5±45.9
22.5±6.3

11 (68.8)
11 (68.8)
4 (25.0)
4 (25.0)

2 (12.5)
2 (12.5)

(n=16)

the treatment of borderline patients with initial injury sever-

Tile C Fractures (n=43)

high-energy pelvic ring fractures. The ity suggested that

results show that treatment with DCO patients in both
could produce lower incidence rates of treatment groups
Difference of Means
-2.0 (-15.6 to 11.4)
-5.4 (-43.9 to 33.2)

postoperative ALI and ARDS and lower had similar initial

5.1 (1.7 to 8.4)

APACHE II scores than treatment with injury severities,

(95% CI)

ETC. This is the case in patients overall although patients

and in subgroups stratified by age, as well in the DCO group
as in cases with Tile C fractures. For pa- displayed higher
tients with Tile B fractures, there was no AIS head scores
significant difference in clinical effective- and GCS scores.
.001
.288
.062
.010
.172
.763
.751

.914
.875

ness between these 2 treatments. However, both

P

The mortality rate for high-energy pel- study groups had

vic fractures has been reported to be ap- similar 24-hour

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 n Feature Article

blood transfusion requirements,

implying that DCO using exter-

Abbreviations: AIS, Abbreviated Injury Scale; CI, confidence interval; DCO, damage-control orthopedics; ETC, early total care; GCS, Glasgow Coma Scale; ISS, Injury Severity Score;
nal fixation did not provide any
.863
.012

.709

.061
.031

.083
.940
.357
.595
.362
.178
.552
.240
P

advantages in controlling blood

loss over ETC. The authors
thought that this result might be
Difference of Means

-6.6 (-12.5 to -0.7)

-4.4 (-9.0 to 0.2)

-0.6 (-1.4 to 0.1)

-0.5 (-1.6 to 0.6)

-0.2 (-0.6 to 0.2)

-0.5 (-1.2 to 0.2)
0.5 (-5.4 to 6.4)

0.0 (-0.5 to 0.6)

0.3 (-0.8 to 1.4)

0.4 (-1.0 to 1.8)

explained, at least in part, by the
Baseline Data, Initial Injury Severities, and Blood Transfusion Requirements of Patients Stratified by Age

(95% CI)

recent finding that external fixa-

Age >40 Years (n=31)

tion may widen the posterior pel-

vis and even aggravate blood loss
because this fixation is located
anterior to the patient, whereas
ETC Group

52.3±8.2

27.5±5.3
29.5±7.3

13.1±1.7
pelvic ring instability is predomi-

0.3±0.7
0.4±0.8
1.1±1.4
2.6±1.3
3.6±0.6
0.9±1.1

2 (14.3)
(n=14)

nantly posterior.24
9
5

9
5

Regarding clinical course,

Stubig et al25 reported in a ret-
DCO Group

rospective study that multiple

51.8±7.8

31.9±7.2
36.1±8.7

12.7±2.0
0.9±1.3
0.4±0.7
1.6±1.6
2.3±1.7
3.8±0.4
1.4±0.8

6 (35.3)
(n=17)

trauma patients with femoral

14

12
3

shaft fractures who received

DCO treatment had longer
ICU stays and ventilator sup-
.933
.938

.693

.814
.881

.157
.853
.434
.346
.800
.974
.651
.790
P

port times than those who re-

ceived ETC treatment. In ac-
Difference of Means

cordance with this result, the

-0.4 (-0.9 to 0.2)

-0.4 (-1.4 to 0.5)

0.2 (-4.6 to 5.0)

0.3 (-2.3 to 3.0)

0.2 (-3.4 to 3.9)

0.1 (-0.6 to 0.7)

0.4 (-0.6 to 1.4)

0.0 (-0.3 to 0.4)

0.0 (-0.6 to 0.6)
0.2 (-0.7 to 1.1)
Table 6

current authors found that ICU

(95% CI)

stays and ventilator support

times for patients in the DCO
Age <40 Years (n=41)

group were slightly longer

than those of the patients in the
ETC group. This may be due to
ETC Group

29.8±7.2

28.3±3.9
31.6±5.6

13.3±1.2
0.5±0.9
0.8±1.1
1.5±1.6
1.7±1.5
3.6±0.5
1.4±0.9

7 (36.8)
(n=19)

more severe head injuries be-

11

10
8

ing found in the DCO group.

According to previous litera-
ture, polytrauma patients who
NISS, New Injury Severity Score; SD, standard deviation.

have an additional severe head

DCO Group

29.6±7.9

28.0±4.4
31.4±5.8

13.1±1.6
0.9±0.8
0.7±1.0
1.1±1.5
2.1±1.6
3.6±0.5
1.4±1.0

9 (40.9)
(n=22)

injury usually show a tendency

13

14
9

toward a poorer outcome and

may be at increased risk for
complications after they under-
No. (%) of patients receiving blood

go early definitive fixation.26 In

this study, regardless of more
transfusion within first 24 h

severe head injuries, patients

treated with DCO exhibited
Tile classification, No.

Mean±SD GCS score

lower incidence rates of ALI

Mean±SD AIS score

and ARDS and lower APACHE

Mean±SD age, y

Mean±SD NISS
Mean±SD ISS

II scores than those who were

Extremities
Abdomen

treated with ETC, confirming

External
Sex, No.

Female
Variable

Thorax
Head
Male

Face

the efficacy of DCO during the

C
B

acute phase of resuscitation for

borderline pelvic fractures.

DECEMBER 2014 | Volume 37 • Number 12 e1097

n Feature Article

A series of patients.29,30 Therefore, the increased inci-

studies have dem- dence rates of ALI and ARDS in the ETC

.282
.604

.609
.884
.256
.043
.093
.273
.042
P
onstrated that group may be strongly associated with the

damage-control orthopedics; ETC, early total care; ICU, intensive care unit; MOF, multiple organ failure; SD, standard deviation; SIRS, systemic inflammatory response syndrome.
Abbreviations: ALI, acute lung injury; APACHE II, Acute Physiology and Chronic Health Evaluation II; ARDS, acute respiratory distress syndrome; CI, confidence interval; DCO,
polytrauma pa- pulmonary release of inflammatory factors
tients with a bor- induced by early definitive fixation of ETC.
Difference of Means

-0.7 (-18.8 to 17.4)

1.0 (-49.8 to 51.8)

1.9 (-1.7 to 5.5)

derline condition However, this assumption should be further
(95% CI)

have an increased investigated.

incidence of pul- The timing of subsequent definitive
Age ≥40 Years (n=31)

monary compli- fixation after the initial temporary stabili-

cations if they zation of DCO depends on multiple vari-
undergo early de- ables, such as general medical condition,
Differences in Clinical Course and Complications for Patients Stratified by Age

finitive fixation of fracture pattern, and associated injuries. In

ETC Group

61.7±80.8
37.7±27.8

19.4±5.6
2 (14.3)

7 (50.0)
6 (42.9)
3 (21.4)
3 (21.4)
(n=14)

1 (7.3)

ETC5.27 This was a large survey involving more than 4000

also the case in cases, increased incidence rates of MOF
the current study, have been documented when subsequent
which may be definitive fixation was performed within 2
elucidated by the to 4 days after the initial temporary sta-
DCO Group

60.7±45.8
38.4±18.9

17.5±3.8
2 (11.8)

7 (41.2)
4 (23.5)

3 (17.6)
(n=17)

1 (5.9)

1 (5.9)

second hit theory. bilization, whereas patients without MOF

According to this received surgery between the sixth and
theory, early de- eighth day.31 This may be explained by the
finitive fixation pro- and anti-inflammatory cytokine im-
of ETC used after balance that occurs under traumatic con-
.250
.139

.871
.273
.472
.010
.382
.344
.017
P

the initial trau- ditions, which consequently suppresses

matic injury (the immune function and induces severe post-
Table 7

first hit) is called traumatic complications.32 Based on the

Difference of Means

-14.8 (-67.4 to 37.7)

-5.3 (-19.1 to 8.5)

4.8 (1.7 to 7.9)

the second hit, current understanding of the molecular

(95% CI)

which has been pathogenesis of posttraumatic systemic

shown to pro- inflammation response syndrome and
Age <40 Years (n=41)

voke a variety of compensatory anti-inflammatory response

severe subclini- syndrome, Reikeraas et al33 suggested that
cal inflamma- the timing of subsequent definitive fixa-
tory responses.28 tion for polytrauma patients should be 1
ETC Group

67.0±42.8
37.4±16.2

21.5±5.4
13 (68.4)
2 (10.5)
2 (10.5)
9 (47.4)

3 (15.8)
4 (21.1)
(n=19)

Previous studies week after the initial temporary stabiliza-

have documented tion of DCO. In the current study, mean
that posttraumatic waiting period between initial temporary
internal fracture stabilization and subsequent definitive
DCO Group

81.8±111.0

fixation could in- fixation in the DCO group was 7.6 days,
42.7±26.8

16.7±4.2
10 (45.5)
6 (27.3)
(n=22)

2 (9.1)
1 (4.5)

2 (9.1)
2 (9.1)

duce the elevated which was in accordance with these previ-

expression of ous studies. However, according to Har-
inflammatory cy- wood et al,34 the waiting period should be
tokines such as no more than 15 days because substan-
Mean±SD ventilator support, h

interleukin (IL)- tially increased rates of contamination at

Mean±SD APACHE II score

6, IL-8, and IL- pin sites of initial temporary stabilization

Complications, No. (%)
Mean±SD ICU stay, h

10 and promote have been observed after 2 weeks.

the local release In addition, the current authors strati-
of these factors fied patients according to Tile classifica-
Pneumonia

in the lungs, con- tion and compared the efficacy of DCO

Variable

Sepsis

ARDS
MOF

sequently caus- vs ETC in each classification group. For

SIRS
ALI

ing pulmonary patients with Tile B fractures, both treat-

dysfunction in ment groups had similar initial injury se-

e1098 ORTHOPEDICS | Healio.com/Orthopedics


verities, and there was no significant dif-
ference in the incidence of postoperative
complications between DCO and ETC.
This finding may be attributed to the fact
that Tile B fractures are only rotationally
unstable, with less life-threatening condi-
tions and hemodynamic instability than
Tile C fractures. This permitted ETC to be
performed easily and rapidly (only anteri-
or pelvic fractures needed early definitive
fixation), thus avoiding the effects of the
second hit inflammatory reaction, at least
in a portion of the patients. Considering
that DCO requires a second operation and
delays patient mobilization despite its ef-
fects in reducing risks of complications
related to the second hit, the authors con-
cluded that ETC would be preferred for
patients with Tile B pelvic fractures.
For patients with Tile C fractures, the
authors found that the DCO group had
lower incidence rates of ALI and lower
APACHE II scores than patients in the
ETC group, although there was no sig-
nificant difference in initial injury severity
between the 2 groups. Similar outcomes
were also observed in the subgroup of pa-
tients 40 years and older, in which the ma-
jority of patients undergoing DCO treat-
ment had Tile C fractures. As rotationally
and vertically unstable fractures, Tile C
fractures usually cause life-threatening
situations. Immediate definitive fixation
of ETC would cause the second hit to oc-
cur, which may lead to ARDS, MOF, or
even death.2 Therefore, the authors con-
cluded that DCO should be the first option
for patients with Tile C fractures, espe-
cially in patients older than 40 years.
The main limitation of this study is
its retrospective nature, which may have
introduced inherent selection biases and
limited the information the authors were
able to collect. Another limitation is the
small population size, especially patients
with Tile B fractures, which may have
limited the statistical power to detect
differences between the 2 groups. The
authors are currently planning a prospec-
tive clinical trial with a larger population
DECEMBER 2014 | Volume 37 • Number 12
to further assess the efficacy of DCO vs
ETC for the treatment of Tile B pelvic
ring fractures.
Conclusion
The findings of this study indicate that
treatment algorithms for borderline pel-
vic fractures should be carefully formu-
lated according to the nature of the injury.
Damage-control orthopedics is the most
suitable therapeutic option for patients
with Tile C fractures, especially in those
40 years or older, whereas for patients
with Tile B fractures, ETC is preferred,
given that it is possible to avoid a second
operation as well as any delays in patient
mobilization.
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