Published 2/12/2024
Terry Stanton

Study Supports Simultaneous Fixation for Multiple Long-Bone Fractures

A study comparing cardiopulmonary outcomes following simultaneous versus staged intramedullary nail (IMN) fixation for multiple lower-extremity long-bone fractures found that simultaneous fixation of multiple fractures was not associated with increased cardiopulmonary events and appeared to expedite time to discharge. Staged fixation was associated with an increase in complications, including acute kidney injury (AKI), ventilator-associated pneumonia (VAP), and acute respiratory distress syndrome (ARDS).

The study was the largest retrospective investigation of this clinical question conducted to date, said Maxwell V. Phillips, MD, a second-year orthopaedic surgery resident at McLaren Health Care–Michigan State University, who presented the findings at the AAOS 2024 Annual Meeting.

The study involved 3,202 patients identified from the American College of Surgeons’ Trauma Quality Improvement Program (TQIP) national database, which was queried to identify patients aged ≥18 years with any combination of two or more fractures of the tibia or femur treated with IMN from January 2016 to December 2019. A variety of lower-extremity fracture combinations were collected.

The following combinations were included: one femur and one tibia fracture (ipsilateral or contralateral), one femur and bilateral tibial fractures, bilateral tibial fractures, bilateral femur and one tibia fracture, bilateral femur fractures and bilateral tibia fractures, and bilateral femur fractures. The subgroups were further categorized into cohorts treated with simultaneous versus staged IMN fixation. The majority (94.6 percent) of patients sustained two fractures. Five percent of patients had three fractures, and 0.3 percent had bilateral tibial and femur fractures.

Patients who underwent staged fixation had a significantly higher rate of VAP, ARDS, and AKI, in addition to longer length of stay (LOS) in the intensive care unit (ICU) and the hospital overall. Additionally, the staged fixation group had higher rates of both superficial and deep surgical site infections. A higher proportion of patients with staged fixation were admitted to the ICU from the emergency department versus a lower-acuity floor. Significantly more patients with staged fixation unexpectedly returned to the OR, compared with the simultaneous fixation cohort.

For complications associated with timing of surgical fixation, no significant difference was seen in evaluated cardiopulmonary or thromboembolic complications. However, there was a significant difference for hospital LOS. Median LOS with simultaneous fixation was 11 days versus 17 days for staged fixation (P <0.0001).>

Dr. Phillips said he and his colleagues undertook the study after having observed a high volume of lower-extremity fractures at their level 1 trauma center in Michigan. “We wanted to examine an existing thought that simultaneous IMN fixation of multiple lower-extremity long-bone fractures may carry higher risk for subsequent cardiopulmonary complications, while staged fixation—separate trips to the OR—may be deemed as a safer option.” They first conducted a smaller study of patients solely in Michigan utilizing the Michigan Trauma Quality Improvement Program database. Then, “due to patients with three or even four lower-extremity fractures being less common, we utilized the national TQIP database to increase our sample size, validate our previous findings, and demonstrate similar results that could be generalized to a national audience,” Dr. Phillips said.

In addition to their findings regarding cardiopulmonary events, an unexpected outcome measure was that injury severity scores for the two groups (simultaneous versus staged) were very similar. “We had assumed that staged patients would be significantly more injured,” Dr. Phillips said. “Therefore, by comparing similarly injured groups, we can draw appropriate conclusions in our analyses.”

A clinical takeaway is that “simultaneous fixation should be employed for treatment of multiple lower-extremity long-bone fractures when clinically feasible,” Dr. Phillips said. “Simultaneous fixation was shown to be superior in our study, regarding patient outcomes for fractures of two lower-extremity long bones.” However, he added, “For trauma patients with three or four lower-extremity long-bone fractures, we cannot generalize our results, as this group only comprised 5.4 percent of our sample.”

Dr. Phillips proposed possible next steps arising from these findings: “For orthopaedic trauma surgeons to consider implementing the practice of simultaneous IMN fixation for trauma patients with two lower-extremity long-bone fractures, this practice change should be considered for local and national guidelines. For research purposes, it would be interesting to reevaluate in 5 to 7 years to determine if a greater number of simultaneous fixations were carried out and if the patient outcomes continued to be significantly better than their staged counterparts.”

Limitations to the study, Dr. Phillips said, include its retrospective nature: The TQIP database is retrospective, and the most recent data available were through December 2019.

Paper 014 will be presented during Trauma II, 11 a.m. on Tuesday in West, Room 2020.

Dr. Phillips’s coauthors of “Nationwide Analysis of Cardiopulmonary Outcomes after Multiple Long Bone Fracture Fixation” are Gable Moffitt, MD; Alistair J. Chapman, MD, FACS; Jessica Parker, MS; Steffen Pounders; Chelsea Fisk; and Laura Krech, MPH.

Terry Stanton is the former senior medical writer for AAOS Now.