Cadmore media player playing audio Continuous Improvement In Optimizing The Timing Of Axial, Hip, And Femoral Fracture Fixation
Audio Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the audio. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Transcript
Result Count
of
Search
Segments
Result Count
of
Search
Name:
Continuous Improvement In Optimizing The Timing Of Axial, Hip, And Femoral Fracture Fixation
Description:
Continuous Improvement In Optimizing The Timing Of Axial, Hip, And Femoral Fracture Fixation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e5f0c8d1-7abc-4a76-8b61-ece36d4ff3d3/thumbnails/e5f0c8d1-7abc-4a76-8b61-ece36d4ff3d3.jpg
Duration:
T00H39M00S
Embed URL:
https://stream.cadmore.media/player/e5f0c8d1-7abc-4a76-8b61-ece36d4ff3d3
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e5f0c8d1-7abc-4a76-8b61-ece36d4ff3d3/BJJ Podcast - April 2023 (HV).mp3?sv=2019-02-02&sr=c&sig=IX1aKyPWMqYHVQrLbPARELrYPVbBCaHWd2wfuKKU5%2B4%3D&st=2024-11-22T02%3A52%3A13Z&se=2024-11-22T04%3A57%3A13Z&sp=r
Upload Date:
2023-04-25T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Welcome everyone to one of our BJJ podcasts for the month of April. I'm Andrew Duckworth and a warm welcome from your team here at The Bone and Joint Journal. We'd like to thank all of you for your continued comments and support for our journal podcast series, as well as a big thanks to our many authors and colleagues who've taken part. The topic of our podcast today, I think will be a real interest to so many of our listeners and readers and likely relevant to most of our clinical practices. So today I'm delighted to welcome back the amazing Dr.
Heather Vallier from Cleveland to discuss her excellent annotation in the Journal of this month entitled 'Continuous improvement in optimizing the timing of axial hip and femoral fracture fixation what practices does recent science support?' Welcome back, Heather. It's so great to have you with us today. Thank you so much for having me. It's a real honor to join you for this podcast and, and of course one of my, one of most favorite topics to discuss. So I look forward to our exchange.
That's great. Thanks Heather. So maybe to kick us off, you know, sort of for those who've read the annotation already, which I'm sure they have, you know, you, you point out to begin with that there's been great advances in our knowledge over the roles of early total care versus, you know, damage control orthopedics for the multiply injured patients over the past few decades. So maybe just for our listeners, can you give us a brief overview of, of how you feel, our feel, our knowledge has sort of progressed over that time and how the debate may be has evolved as well?
Yeah, absolutely. I think this is a critical importance to understand it and really have this, this piece of orthopedic history nailed down as, as orthopedic trauma surgeons because it affects so much the way that we think about things and the way that we approach things today. We understand where our mentors and earlier surgeons were 30 to 40 years ago, and so I think we can appreciate that kind of throughout the, the 1980s there was some delving into the timing of fixation and recognizing particularly with respect to the femoral shaft that early stabilization really helped people to get up and get out of bed, and recognize improvements in pulmonary function and the reduction in pulmonary and thrombotic complications when people were fixed earlier, which was usually defined as within 24 hours of injury.
I think for lack of a better way of, of studying it, it was mostly retrospective work. But emphasizing those things and then noting that you know, if you look at like the Larry Bone et al study published in 1989 where they did a randomized trial of patients who underwent primary intramedullary nailing of the femur within 24 hours of injury versus 48 hours after injury. And they had a, a group with isolated femoral fractures in a group with injuries to other systems, and it was very profound. The outcomes measured by complications as total in that early hospitalization course or pulmonary complications, hospital length of stay, cost of care, profoundly better for the people who were fixed early and even better for the people with multiple injuries, which I think was really it kind of shook things up at the time.
I know I'd like to have conversations with some of my old mentors all of whom are retired now. They look back on this and think, wow, that was really radical at the time, and it, it wasn't widely accepted, not for many years. And so there were a handful of pioneers who were kind of pushing that envelope to do this and, and seeing some value. And those that were able to publish about it to speak to others at meetings and to kind of share these ideas. It seems to me there were pockets of activity, mostly in Europe and in North America, where at a handful of centers this was starting to happen and somewhat slower based on, you know, today we take for granted, you know, sending a, a text message, just communicating with people around the world in seconds all the time.
And this took months and years really to disseminate good information back then because of the limited communications technology. And so kind of throughout the nineties, it seems there was more of an emphasis I think in the United States and in other countries in pushing that envelope and not just approaching the femoral shaft early, but saying, hey this is a great thing. We'll just get in there and we're excited and we'll have these marathon OR sessions and just fix all the fractures. And what some people were starting to notice is that there were a handful of patients that didn't do as well.
Yeah. And there was really no mention on standardizing resuscitation or how we were assessing these patients. And of course there were advanced trauma life support algorithms that were really in their infancy. And, and so there was some attention to how to provide pre-hospital care and care upon arrival, but not so much in terms of nuances of resuscitation and when would someone be ready to safely undergo fixation. And so these long OR sessions kind of led to a handful of people that were having multiple organ failure and problems, even though those were problems that we attributed having them lay in bed and not have their femur and other fractures fixed.
And so it was a little confusing, but hands off to heads off to Chris Pape and other colleagues who really pulled us into question kind of in the early nineties and throughout the nineties, both on a, a biochemical basis and sort of looking at what the inflammatory markers were that were, seen in, in someone in their physiology of that early course of care, whether they were treated with early definitive stabilization of the femur or not. And then also the questions about chest injury. And so, you know, I like the, I like the study that, that Pape and his colleagues did that was published back in 1993 because it really called it into question, you know, do we fix these femurs primarily?
And is it because I have a chest injury that they're doing poorly, or is it cause we're fixing the femur too early that they're doing poorly? We know now that it's really a little bit of both depending on where that person is at in their pathway of resuscitation. And although that wasn't part of the dialogue back then it raised that important question that maybe we just need to exercise caution around that group. And I think there were a lot of camps that formed one camp that said, oh, well we're not gonna fix those very severe chest injury patients with the femur early. We're gonna wait.
And then some who said, no, we're gonna do it anyway cause we think it's okay. And there wasn't really a middle ground right away, which is now what we would consider damage control. There was even some foray into, what about reaming? Maybe it's because we're reaming the femur that that's doing it. And so the little more of the basic science and the clinical study of reaming and the effects on the whole thing that transpired, and I think we really came back to is the idea of providing some provisional stability. Yeah.
And you know, a lot of the residents right now, they, they take it for granted and say, oh, do some damage control. Well, that wasn't even a term that was used in surgery until in the nineties when the, the general surgeons took it up first. You know, the guys at Shock Trauma in, in Maryland, published about it with their experience using some provisional external fixation with femur to stabilize those patients that they felt were in a high risk group for having problems with early definitive management of the femur. And so they looked at, you know, people with a very severe head injury, people with a very severe chest injury, people who were otherwise hemodynamically unstable, and they suggested that, hey, doing this external fixation and then converting it to a nail in several days.
It seems like it's a safe way to go. Maybe we should do that, and so I feel like this pendulum kind of swung over to the early total care camp and we apply it to all fractures. Then it kind of came back to damage control, yet it wasn't really clear as to what are the indications for doing that. People had ideas based on their own experiences or the experiences at their center or what they talked with their colleagues about, but there wasn't a lot of good science behind it. And so I think that in the early obs , there was a, a study published in 2000 by Cole et al where they, they showed that in a retrospective cohort of, I wanna say it was about 45 patients, so not a big group.
Those patients had multiple system injuries and had a femoral shaft fracture. And the patients that had a recorded lactate level of less than 2.5 had half the incidence of early complications of those who had a lactate level that was higher. Yet this study's problematic because they really didn't control from the types and severities of the other injuries. It's a very small group, and they also didn't say, when was lactate even measured and what was happening? Was it worsening?
Was it getting better? Do we even know? People spotted that because of the way the timing was when all of this damage control bit was being talked about. And so it kind of got established that like, oh, well the lactate's more than 2.5. No go. We're just gonna do damage control. We'll wait it out.
And so it was relatively cursory evidence if, if, if you could even call it that when you go back and look at that paper, I always challenge people like try to do as much reading. I'm far from perfect. I'm, I'm, I'm, I'm a bit of an, an orthopedic nerd. I'd love to love to read and think about these things, but there's just such a, a wealth of knowledge and in some of these old papers, I think if you don't read them ourselves and you just read the abstract or you listen to what someone told you, it's real easy to not know what was actually happening.
What are the takeaways and what are the limitations of that work? Suffice to say it put us in a place where there was a lot of opportunity to try to look at parameters, to establish safe guidelines for definitive fixation, and then conversely to say, well, when can we employ a damage control strategy? Because, we know that that provides better stability to a femur, for example, than does skeletal traction, and certainly then does just bedrest with, with no skeletal stability at all. Yeah. And so to try to find that, that middle ground yet to know, we really want to get people over into that other camp.
And I think that there were a number of of a large series of patients with femur fractures kind of in the following 10 years, that showed that most people can safely go to the OR and have their femurs stabilized primarily within the first say, 24 hours. Another point of contention with me, cause it's just like, yeah, for lack of a better thing, that's early. If it's within 24, yet what we really wanna know, is who are these people? Like, where are they at? And, and it, it does have to do a lot with resuscitation and there's a handful of other things that play in, but resuscitation of that metabolic acidosis that comes from hyperoxygenation due to, due to hemorrhage primarily.
And so correcting of that. And then also what is the best time course? Is it 24, is it longer? And so kind of dissecting that out a little bit and then to say, well, what about all these other fractures? I mean, it's not just the femurs. There's a number of things and we, we like to study the femur cause it's fun to nail femurs and they're pretty common and it's a, you can get a lot of 'em to look at, but there's a lot of other orthopedic injuries that relegate a person to bedrest and recumbency until they're reduced and stabilize.
And so I think that that physiologically affects a person the same way. Yeah, no, absolutely. Had you had that, I think that's such a wonderful overview, not just for this area but of of, of knowing how we've got to where we are with so many of the things we do day to day. And I, I agree and you encourage your trainees to do this, is that, you know, you know, we, we, how we got to where we are in care now is so important in terms of learning those pathways. And actually what's interesting, like you say, is that some things which are dogma and what we do are based on what we would classify now as very limited evidence really, and actually quite limited methodological design.
But I think the, even for this in particular, how we've come to where we are now is so important. And to, to understand those past papers, I think is so important. And I think you sort of touched upon it, there is this idea of, of how we've evolved to sort of earlier appropriate care now, isn't it? This is the sort of the concept that, that people have evolved to, haven't they? Yeah, and, and I think that the, at the time our, our group, you know, was blessed to work with colleagues who performed all of the orthopedic trauma care spine trauma colleagues, both from the neurosurgery side and the orthopedic side of things.
Anesthesiologists and critical care specialists and our general trauma colleagues with advanced training in Traumatology. We really wanted to kind of put our heads together and try to look at our prior experience for several years. What were we doing? What was working? What wasn't working? Yeah. What patients were we maybe operating on too much too soon and, and how can we learn from that going forward?
And so after a lot of, a lot of time coming up with some, some topics of study and a lot of data to review over several years to to look at our high energy patients with multiple system injury and some of these fractures of interest, like I mentioned, not just the femur, and say, well, we can look at them all separately, but maybe we can pool them and let's kind of get some ideas about that looking at all of the laboratory values for the first four days after they arrived, looking at their vital signs at speci specified time points after they arrived, characterizing the severity and types of injuries to other systems, and then hiring a, a mathematician to work with us who also has a, a PhD in biostatistics who is able to kind of process this.
And, and what we were hoping to come away with are some guidelines. If there are laboratory values, injury types, things where we could create an algorithm to guide care safely to reduce the number of complications we were having, which we classified as anything in that first hospital course, which are primarily pulmonary complications thrombotic complications, infectious complications, and handful of other things in there. And, and so our institution had a rate that that bucket of about 22% so pretty high. Yeah, number of patients we're having some type of complication.
We're hopeful to cut it in half. And we asked the mathematician to predict if he could, based on where someone was at physiologically given a constellation of injuries, what would be our ability as a system to cut our complication rate in half. And that was sort of the basis for developing the EC parameters because he was able to identify that the, the critical items in those patients, either having a complication or not was sort of threefold. One was the amount of acidosis they had when you went to the OR, and so that all makes sense now.
At the time, we didn't realize it plays a pretty critical role, so you could measure it, you know, via lactate, base access, pH. They're all similar. The lactate, of course, is easier to get the measurement based on a venous sample and, and also more specific to metabolic acidosis that's originating from the hypoxygenation associated with hemorrhage from trauma. But that, how quickly was that acidosis improving, especially the rate of improvement in the first eight hours? Cause we notices that the people who were dying, not just in the trauma bay, but in the, in the hospital, most all of them, they never corrected their acidosis.
And it may have been that their system was so badly taxed. They may have been languishing on the side of the road for several hours place. Maybe we weren't on the ball with the resuscitation when they arrived, but if they really weren't corrected within the first 24 hours they died, they didn't survive. And so that was very illustrative to us. Cause you know, we look at these cases month to month and even in conferences. But really to look at a, a several year span of our data as a whole, that taught us a lot about how heavily that piece weighed on not just their survival, but also their readiness to go to the OR.
The next piece was the severity of of chest injury. And so, you know, we look at people with really severe chest injuries like a diaphragmatic rupture or hemothorax on one side in a massive pneumothorax on the other side, you know, things like this where they have very severe chest injuries, also put them at high risk for complication. We can't change that. They either have a chest injury or they don't. We treat the chest injury, but part of treating the chest injury is actually. Resuscitating them appropriately and then providing expeditious skeletal fixations so we can sit them upright.
Yeah. So that's an important piece. And then the third part of our look into our own work was the timing of the definitive fixation. And we noticed that patients that were fixed within the first 48 hours, really did incredibly better than those that were fixed longer. And you can say, well, this is just a retrospective cohort and there's a bias because we emphasized early fixation. We did mostly for the femur, not as much for the other fractures of interest, which gave us a little bit of meat to work with in the group as a whole.
But also because the people that made it that long, they either were resuscitated, or they weren't for them to survive. And in, in 48 hours, we started to notice a lot of decline in pulmonary function. And I think anybody that's been in, in orthopedic practice recognizes this. We know this in our elder folks with hip fractures. You get them fixed and we get them up. And so it, it all makes sense that physiologically that gets compounded by bed rest and oxygenation of a lot of pain.
All amplifies these things and so the data we looked at closely suggested that around the 40 outer marks of four zero was when someone's physiology really started to decline. Yeah. So our effort was, was kind of threefold to say, well, we believe that these fractures should be stabilized either definitively. Or if there's a reason not to with some type of damage controlled strategy for those fractures that are amenable within 40 hours of injury, and that the resuscitation parameters, I'll say more about in a second are very important and we can establish some cutoffs where it seems to be safe to proceed.
But the chest injury, since we can't change it, we acknowledge that they're ultimately in a higher risk category. Yet we should proceed with expeditious fixation despite that, if they've had an adequate level of resuscitation. Yeah. Now with a lot of advanced math that is beyond my personal capabilities, we're able to look at refinements of the parameters to say, well, where's the real catchpoint? On the, the complications going up.
Is it, is it at around, we thought it would be around two or 2.5 of a lactate just based on that old work and sort of historical practices, right? Yeah. But in our dataset it was, it was actually much different than that. Our patients were able to tolerate a much higher level of acidosis, although it needed to be improving. And so the, that's how we developed where we called the early appropriate care parameters in that EAC was really used to try to get away from the early care, yeah, idea in that it might be, if you need to fixation, it might be a damage control tactic, but it was really to try to do what was appropriate for the person.
At that point in time. Yeah, no, that absolutely. And that sort of leads us into, cause you've mentioned it already, Heather, is, is about those resuscitation parameters in terms of, you know, the, there's been a a lot more work on that over time. What do you, you know, and I know it's debated, but is there a generalized, generalized agreement that exists in terms of those, those important laboratory parameters that we should be using? What, what would your take home from that data be?
Yeah sadly, there's, there's limitations to the approach that we took for sure. I mean, it was just one center's work, and so it's heavily biased by the historical practices that our group, and so you can't really get away from that. And, and in a, in a more public world, if we had another, you know, eight or 10 large trauma centers that did a similar type of thing, I think we could get a, a better handle on it. Definitely. Having said that, the parameters now have been prospectively used for many years and have really cut the complications in half.
But would they be cut in half again? Yeah, they probably could. I think with further refinement, maybe attention to patient age or nuances of cardiac and renal function. Maybe subtle differences in terms of the anticipated operative burden. How much surgery are you planning to do? How long of a procedure is it? How much blood loss do you anticipate with that procedure? Because all of these things are gonna play a role, but we weren't equipped to nuance that outta the dataset.
And so for several years after we did our EAC work and even prospectively tested it and published about that, there were trauma centers that were kind of picking it up, but tailoring it based on their clientele and, and one of the big hangups is that a lot of places don't have enough spine surgeons and or a history of really emphasizing expeditious spine fracture stabilization. And so those couple of things have really impaired some large trauma center's ability to try to use these EAC parameters to apply it to other injuries.
So maybe they're using it for the femur and maybe for the pelvic ring, but not for other things. Yeah. Similarly, I think acetabular fractures and to a lesser extent pelvic ring injuries are a little bit problematic cuz even in large trauma centers there's often 1, 2, 3, only a handful of people that are really capable of, of managing those injuries. And certainly no one surgeon is available every day of the week.
And so I think there's system issues that have led to difficulty in implementing. The other piece really to think about is, that concurrent with this, there were other parameters proposed. So you can look at the clinical grading system proposed by Pape and colleagues. And, and so that was first published around 2000 in a very intelligent effort to look at things that we know matter. And they say, well, if someone's got a severe abdominal injury, severe chest injury, certainly that's gonna put him into a different category and that system was based on creating four categories of readiness for, for surgery, and it was, it was initially proposed just for femoral shaft fractures, right?
And so there's stable patients. There's borderline patients, unstable patients and in extremis patients, and recognizing as someone in a stable category, certainly we believe in expeditious fixation of the femur, which was at the time, again, defined as 24 hours after injury. And so looking at the vital signs, looking at their, their, their temperature was actually a separate category looking at measurements of, of acidosis. Looking at injuries to other body systems. Pelvis was one category, and chest and abdomen were another category.
And, and saying, well, we'd like for the patient to have three of the four labels of those categories of parameters to be stable or borderline or unstable, to designate them into that row. And then if they're unstable or in extremis a damage control strategy should be employed, or if not possible, definitive management should be deferred. Yeah. And so the unstable category in the extremist categories, I think that patients that would fall into those groups would probably be pretty unwell.
And either they're gonna die from their injuries, or they're gonna be resuscitated probably within the first 24 hours based on, you know what, what you and I see in our practices, right? But that borderline group's a little tricky. You can have people that are in that group, maybe just because they had an extremely severe chest injury. Yeah. Yet their acidosis isn't really that bad. And so do we need to be additionally concerned about the timing of stabilizing the femur or the method used, maybe not as much.
And so I think that that was a the, that clinical grading system was based on experience, but really not on research data per se. Yeah. It was studied afterward. And the borderline group, you know, there was a publication of randomizing patients to a damage control strategy with external fixation versus primary, intramedullary nailing for patients in the borderline group. But a relatively small group. I wanna say it was about a hundred and 65 patients treated over several years at like 10 hospitals, and they showed no difference in pneumonia or embolism or other things.
A part of it might have been cause it was a small group of patients. They did see a difference in acute lung injury, which isn't a term that many surgeons are familiar with, but what it is, is it's an alteration in the oxygenation ratio. So it suggests that there's not as much oxygen being delivered in patients that have that yet it didn't translate into more severe complications that we could record. And so I think that that's interesting in that patients treated with damage control had less acute lung injury.
So suggesting a safe or more favorable pro- profile for borderline patients in their study. But still. I think the translation of that into practice is problematic because we're not necessarily measuring those oxygenation, ratios or familiar with them. Yeah. In practice. Furthermore the men, the mention that I made about the clinical grading system and how it, it inherently puts patients into different categories or it's problematic cause they may have some features in any of those four groups yet they may be clinically really, we would say, oh, that person seems to be pretty stable.
They're looking in pretty good shape. Yeah, I think they're okay to go. So it's in, in, in practice it's a little bit problematic and there's been some refinement of it over the years, and I think a lot of it is, is similar to what we came upon with the EAC. The EAC just had a little more science behind it to start off because it's not as though those other things don't matter. It's just we were trying to be very rigorous about what we could say about how they mattered in terms of someone's clinical course.
Absolutely, absolutely. And I think that sort of takes us nice, it sort of. What you've said throughout is though what probably one of the key factors in these patients is their resuscitation and actually getting that, that resuscitation. Right. And, and where are we in terms of what's your sort of feeling about not only transfusion protocols and where we are with that, but also related very much to that is the assessment of coagulopathy and that, and the development of that. What, what, what, where, where are we now with that, do you think?
I find that to be a really interesting area, but it's, it's tricky to study, you know, as you know, because not all hospitals are using it and it's had, it's had various uptake or not. Like some places use TEG or they use ROTEM. Yeah. And they use it all the time, which is kind of good because if they're using it, they all just get a lot of measurements. We can learn more about it. Yeah, absolutely.
But then there's some places who are doing it, not at all, or it depends on which anesthesiologist is working and then they're using ROTEM or TEG and so there's no consistency whatsoever in the United States, and I think that there's a little bit of data coming forward, but, but again, problematic because they, they seem to function similarly in, in measuring the person's capability of, of making clot. So key in another factor. And so I wanna step back for just a second and say, you know, coagulopathy is one of the criticisms that the whole EAC work received by a number of other groups.
And I think that that's a very good point being raised. How come you're doing this but you're not even including that? And we studied it quite a bit. But it ran so consistent with correction of the acidosis that we didn't feel and our, our mathematician felt that it would have a bit of a multicollinearity problem. Yeah. By including it with the other parameters into the, into the model. And so because it corrected at the same time as everything else, we didn't study it specifically.
Yeah. Yet I think that this is a very interesting field because with nuanced factor replacement, I think we can fine tune resuscitation and I suspect in the next five to 10 years, it will probably be relatively common practice. Yes. That we do this for people, particularly those who are on some type of a massive transfusion protocol, so that the, the resuscitation will be really specifically directed to what their needs are, and that will be more efficient and more, more, more complete.
Yeah, absolutely. And it'll be more tailored to that yeah, absolutely that makes sense. So if we, something else that we, I thought was really interesting about the, your annotation was, you, you know, you, you, a lot of what we've talked about already is, is not solely, but it's based on the idea of the long bone fracture, particularly the femur wasn't it? And, and, and the fixation of that. But then it, it is really interesting how you've, you, you move on to the idea of not just, not just the femur and other unstable fractures where it be, you know, spine fractures, pelvic ring, acetabular fractures and, and, and fractures, of the proximal femur.
And I, I thought it was really interesting how that, you know, that link and how that, that area has evolved over time. You know, we, we do that with, we know that with now with our elderly hip fracture patients. And as you talk about our periprosthetic fracture patients now, which is growing and it's really interesting, the analogies there that actually overlap really isn't there. And I, I think it's just gonna continue to be borne out as we do this further, you know, all the periprosthetic fractures and they may be distal femoral fractures adjacent to, a total knee, or even proximal tibia, but to have a similar bearing on that person cause they can't get up and move.
Yeah. And so my gut is that this'll be studied more and more and refined, and that for elder patients, they may have lower thresholds where we consider it safe because they have less cardiopulmonary or renal reserve to begin with. And so that's an area that I think we need more study to look at the physiology concurrent with what we're doing. And I'm hopeful that if we can get large centers who agree to share data and to just record it going forward to see where the problem spots are, then we can propose algorithms and study them perspectively and then continue to refine them.
Cause I, I think there's a lot of opportunity there. And so, it's a good thing and it, it, it just makes sense, you know, these, they're all affecting the person the same way. And so I've had people ask, well, what about the tibia shaft? We should throw a nail on that. It's like, well, yeah, it's the same ideas. It is causing some pain, but we can put a splint on that. Yeah. And that, that's all right.
The person can sit up and bend. So it's, it's really not the same. And that, that is nice. I'm glad you're thinking about it, but my opinion is that it'll never really affect people. No. Physiologically the same way. No, absolutely.
Absolutely. And something else you, I thought was, Interesting. And I, I know it's something that, you know, probably we've all been taught in the past, which is, you know, you say that historically, you know, it was, it was proposed that, you know that the early surgery, the concern would be clot disruption, that actually, that you can actually dis- disrupt the clot and it would cause excessive surgical bleeding and prolonged operating times. But you, as you said in your annotation, that that's pretty much been debunked now, is that right?
Yeah, that's absolutely right. Yeah, and it's, it's a funny thing I, I I make, just, just to regret us a little bit into personal anecdote, because you know, when I was in my residency training in the nineties I noticed a lot of emphasis on femur and, and so less emphasis on pelvis and acetabular, we did have patients that would occasionally have organ failure. Some of them would die and they'd be laying in traction and just kind of waiting it out to have their you know, tea with posterior wall acetablumum fracture stabilized was kinda complicated and their lungs weren't doing so well. Then occasionally they didn't make it.
And then as I did my trauma fellowship, you know, right after that I noticed there were more injuries at that hospital in Seattle and it was very busy and there was an emphasis on let's get all of these people to the OR where they have a pelvic ring acetabular fractures as long as we felt they were ready. Again, it wasn't a consistent resuscitation protocol, but most of the patients were getting pretty aggressive critical care medicine from the get-go. Yeah. And so almost all those patients were stabilized right away, and it was very noticeable to me.
The difference in how well people were doing. And I just kept saying like, these all should be stabilized, but it's not the standard practice. And talking with some of the faculty there in other places, there was a, there was an appetite to try to push the envelope. And then saying respond. And so, you know, having colleagues around me who kind of felt the same way was easy to study our work and to ultimately push for the EAC protocol. And I think that we need to do more of that as it pertains to folks with periprosthetic fractures and, and all, and I'm hopeful that now that we have electronic medical records, more research infrastructure in place to do collaborative work, to collect the identified data to share it.
And I think, you know, you guys with National Health Service, are way ahead of us because you have a lot more experience with standardized pathways and with data sharing and collection mechanisms to look at these things because that's how we're really gonna do better. Yeah. With what we do. By, by creating expectations and then anticipating that we're gonna have to have our systems respond to this. And so maybe there's, if there's trauma centers that are always busy and they don't have surgeons that can do periprosthetic work, or they can do acetabular fractures or manage thoracolumbar spine fracture dislocation in the first day following.
Maybe they shouldn't be a major trauma center. Maybe they sh they, we should find ways to combine them. And I think that we need some level of governmental intervention in conjunction with us, in our professional societies to try to push this, to continue to get better with what we're doing. But, there is a lot of reticence in the United States and, and I'm just gonna call out these behaviors because people will say like, oh no, no, that doesn't happen. But it does. And it's mostly based around individuals who want to keep those cases.
Cause they enjoy doing 'em and they make money doing them. Or hospital systems who say, well we don't wanna transfer him away. We have a guy on Thursday, he'll be here in a few days. He can do it because they don't wanna lose the revenue. That's not right. Yeah. We need to take the best care of people that we can and I think until we call out behaviors like that, and until we unify on our statements of purpose. And in wanting to do this and to figure it out, when to safely best treat people, then we're still gonna flounder a little longer than we need to.
No, absolutely. And I, I suppose that's a good opportunity, cuz I, I, I just for our listeners, I don't often do this, but I wanted to read out a couple of sentences that you wrote, which I thought were brilliant, which was "Striving beyond individual provider and institutional borders and interests is imperative to maintaining sustainable systems of care with optimal clinical outcomes. It also is essential to career longevity, yet these practices are easily contemplated and said, then delivered". I think that's so, so poi- I think it's so beautifully put, Heather, I think in terms of you have those factors you've all talked about, you have to consider it and actually ultimately at the end of it, it's the patient, isn't it?
It's the patient care, which is the, the, the utmost importance. And I suppose that's sort of, sort of to finish up maybe, where do you think we're sort of for the future, you know, where are we headed in terms of, you know, not only the systems which you've, you've all alluded to, but where, where are the big things research wise that we need to look at, do you think moving forward? Yeah. So in addition to the, the systems management and, and the algorithms like we talked about, I think we're specifically focusing on some of the, the geriatric multiply injured patients as well as those with the isolated injuries.
Cuz our, our populations are aging, our people are living longer than they used to, and the complexity of injuries continues to go up. And so I think really looking at that and for nuancing these algorithms based on their physiology, which is partly their age, but more their, their cardiac, pulmonary, renal function at baseline, and how do we measure that? And then there's been a lot of interest now for, I, I would say probably to 30 years on genetics. In looking at the genetics of inflammation and thus, how does it respond to resuscitation?
How does it respond to musculoskeletal care? And, and so those studies are really difficult to do because there's just so many variables. And so until the availability of those genetic markers, our, our ability to measure them and to record them and to understand what to do with them improves. I think that's gonna be a while in the making, they're, they're expensive and many of the tests aren't available right away. And so I think that's interesting, but I don't see it as impacting the way we do things in the near future.
Sure. But if we have more emphasis on the elderly and just nuances of their baseline status and, and how to, how to tweak their resuscitation and their readiness based on that I think that will help. And then I think concurrent with that, one of the things we need to do more with is knowing how long are we gonna have that person in the operating room, and how much of a tax is that on their, their body in terms of blood loss? In addition to the OR time, because now we're seeing all these things with like, oh, well, we're gonna go all plate nail two implant constructs, where, and it's certainly, you and I both know, not every person with a periprosthetic fracture needs all that.
Yeah. But what do they need? And so I think it, it adds another layer of complexity on it, which I think will be interesting. My gut is that in many of the centers in the United States there's a lot of activity going, weight nail, multiple plates on, on all of these people. It's probably a little bit too much, a little bit too much surgery. And it seems like maybe it's not necessarily affecting their weight variability as much as you claim that it would.
Yeah. And so kind of calling that out and really asking people to justify what they're doing is gonna be important and then after that the piece that we didn't really touch on at all is the, the rehab, and that's just been so badly neglected. I'm eager in the next five to 10 years to see some big improvements. Yeah. In, in rehabilitation because, it's one thing to put the parts back together, but it's another thing to say, Hey, this is a person with a life. Yeah.
And there is so much left to be desired in most cases, to address their, their social needs, their mental health needs, their you know, even economic issues particularly in the first three to six months to help them to get over the hump and make a huge difference. Yeah. In how they do, and not only that, but the, the lives of the people around them, their family members and other colleagues. Yeah. No, absolutely.
Heather and I, I think I know you have done, and continue to do a lot of work in that area and I think it's such an integral part that we often, like you say, you certainly in the past, we forget about, we just, you know, we think you fix the person back up and, and that's them fixed, but there's so much more to do after that, isn't there? And that's, that's really important has probably has as a profound effect as any operation probably can as well. So, yeah, no. Well, Heather, I think that's such, such a great, great chat.
So great chatting to you. A real big thanks for joining me today and, and putting a spotlight and a real, really good history of how it's evolved over time in this area and a really important, relevant issue in our specialty and, and, and for, especially for the, the multiply injured patient. It was really informative and always so nice to talk to you. Back at you, Andrew. It's really the pleasure is all mine. Such an honor to to chat with you and be part of this important podcast.
Thank you so much Heather. And so to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media and a like, and feel free to tweet or post about anything we've discussed here today. And thanks again for joining us. Take care, everyone.
Segment:0 .
Welcome everyone to one of our BJJ podcasts for the month of April. I'm Andrew Duckworth and a warm welcome from your team here at The Bone and Joint Journal. We'd like to thank all of you for your continued comments and support for our journal podcast series, as well as a big thanks to our many authors and colleagues who've taken part. The topic of our podcast today, I think will be a real interest to so many of our listeners and readers and likely relevant to most of our clinical practices. So today I'm delighted to welcome back the amazing Dr.
Heather Vallier from Cleveland to discuss her excellent annotation in the Journal of this month entitled 'Continuous improvement in optimizing the timing of axial hip and femoral fracture fixation what practices does recent science support?' Welcome back, Heather. It's so great to have you with us today. Thank you so much for having me. It's a real honor to join you for this podcast and, and of course one of my, one of most favorite topics to discuss. So I look forward to our exchange.
That's great. Thanks Heather. So maybe to kick us off, you know, sort of for those who've read the annotation already, which I'm sure they have, you know, you, you point out to begin with that there's been great advances in our knowledge over the roles of early total care versus, you know, damage control orthopedics for the multiply injured patients over the past few decades. So maybe just for our listeners, can you give us a brief overview of, of how you feel, our feel, our knowledge has sort of progressed over that time and how the debate may be has evolved as well?
Yeah, absolutely. I think this is a critical importance to understand it and really have this, this piece of orthopedic history nailed down as, as orthopedic trauma surgeons because it affects so much the way that we think about things and the way that we approach things today. We understand where our mentors and earlier surgeons were 30 to 40 years ago, and so I think we can appreciate that kind of throughout the, the 1980s there was some delving into the timing of fixation and recognizing particularly with respect to the femoral shaft that early stabilization really helped people to get up and get out of bed, and recognize improvements in pulmonary function and the reduction in pulmonary and thrombotic complications when people were fixed earlier, which was usually defined as within 24 hours of injury.
I think for lack of a better way of, of studying it, it was mostly retrospective work. But emphasizing those things and then noting that you know, if you look at like the Larry Bone et al study published in 1989 where they did a randomized trial of patients who underwent primary intramedullary nailing of the femur within 24 hours of injury versus 48 hours after injury. And they had a, a group with isolated femoral fractures in a group with injuries to other systems, and it was very profound. The outcomes measured by complications as total in that early hospitalization course or pulmonary complications, hospital length of stay, cost of care, profoundly better for the people who were fixed early and even better for the people with multiple injuries, which I think was really it kind of shook things up at the time.
I know I'd like to have conversations with some of my old mentors all of whom are retired now. They look back on this and think, wow, that was really radical at the time, and it, it wasn't widely accepted, not for many years. And so there were a handful of pioneers who were kind of pushing that envelope to do this and, and seeing some value. And those that were able to publish about it to speak to others at meetings and to kind of share these ideas. It seems to me there were pockets of activity, mostly in Europe and in North America, where at a handful of centers this was starting to happen and somewhat slower based on, you know, today we take for granted, you know, sending a, a text message, just communicating with people around the world in seconds all the time.
And this took months and years really to disseminate good information back then because of the limited communications technology. And so kind of throughout the nineties, it seems there was more of an emphasis I think in the United States and in other countries in pushing that envelope and not just approaching the femoral shaft early, but saying, hey this is a great thing. We'll just get in there and we're excited and we'll have these marathon OR sessions and just fix all the fractures. And what some people were starting to notice is that there were a handful of patients that didn't do as well.
Yeah. And there was really no mention on standardizing resuscitation or how we were assessing these patients. And of course there were advanced trauma life support algorithms that were really in their infancy. And, and so there was some attention to how to provide pre-hospital care and care upon arrival, but not so much in terms of nuances of resuscitation and when would someone be ready to safely undergo fixation. And so these long OR sessions kind of led to a handful of people that were having multiple organ failure and problems, even though those were problems that we attributed having them lay in bed and not have their femur and other fractures fixed.
And so it was a little confusing, but hands off to heads off to Chris Pape and other colleagues who really pulled us into question kind of in the early nineties and throughout the nineties, both on a, a biochemical basis and sort of looking at what the inflammatory markers were that were, seen in, in someone in their physiology of that early course of care, whether they were treated with early definitive stabilization of the femur or not. And then also the questions about chest injury. And so, you know, I like the, I like the study that, that Pape and his colleagues did that was published back in 1993 because it really called it into question, you know, do we fix these femurs primarily?
And is it because I have a chest injury that they're doing poorly, or is it cause we're fixing the femur too early that they're doing poorly? We know now that it's really a little bit of both depending on where that person is at in their pathway of resuscitation. And although that wasn't part of the dialogue back then it raised that important question that maybe we just need to exercise caution around that group. And I think there were a lot of camps that formed one camp that said, oh, well we're not gonna fix those very severe chest injury patients with the femur early. We're gonna wait.
And then some who said, no, we're gonna do it anyway cause we think it's okay. And there wasn't really a middle ground right away, which is now what we would consider damage control. There was even some foray into, what about reaming? Maybe it's because we're reaming the femur that that's doing it. And so the little more of the basic science and the clinical study of reaming and the effects on the whole thing that transpired, and I think we really came back to is the idea of providing some provisional stability. Yeah.
And you know, a lot of the residents right now, they, they take it for granted and say, oh, do some damage control. Well, that wasn't even a term that was used in surgery until in the nineties when the, the general surgeons took it up first. You know, the guys at Shock Trauma in, in Maryland, published about it with their experience using some provisional external fixation with femur to stabilize those patients that they felt were in a high risk group for having problems with early definitive management of the femur. And so they looked at, you know, people with a very severe head injury, people with a very severe chest injury, people who were otherwise hemodynamically unstable, and they suggested that, hey, doing this external fixation and then converting it to a nail in several days.
It seems like it's a safe way to go. Maybe we should do that, and so I feel like this pendulum kind of swung over to the early total care camp and we apply it to all fractures. Then it kind of came back to damage control, yet it wasn't really clear as to what are the indications for doing that. People had ideas based on their own experiences or the experiences at their center or what they talked with their colleagues about, but there wasn't a lot of good science behind it. And so I think that in the early obs , there was a, a study published in 2000 by Cole et al where they, they showed that in a retrospective cohort of, I wanna say it was about 45 patients, so not a big group.
Those patients had multiple system injuries and had a femoral shaft fracture. And the patients that had a recorded lactate level of less than 2.5 had half the incidence of early complications of those who had a lactate level that was higher. Yet this study's problematic because they really didn't control from the types and severities of the other injuries. It's a very small group, and they also didn't say, when was lactate even measured and what was happening? Was it worsening?
Was it getting better? Do we even know? People spotted that because of the way the timing was when all of this damage control bit was being talked about. And so it kind of got established that like, oh, well the lactate's more than 2.5. No go. We're just gonna do damage control. We'll wait it out.
And so it was relatively cursory evidence if, if, if you could even call it that when you go back and look at that paper, I always challenge people like try to do as much reading. I'm far from perfect. I'm, I'm, I'm, I'm a bit of an, an orthopedic nerd. I'd love to love to read and think about these things, but there's just such a, a wealth of knowledge and in some of these old papers, I think if you don't read them ourselves and you just read the abstract or you listen to what someone told you, it's real easy to not know what was actually happening.
What are the takeaways and what are the limitations of that work? Suffice to say it put us in a place where there was a lot of opportunity to try to look at parameters, to establish safe guidelines for definitive fixation, and then conversely to say, well, when can we employ a damage control strategy? Because, we know that that provides better stability to a femur, for example, than does skeletal traction, and certainly then does just bedrest with, with no skeletal stability at all. Yeah. And so to try to find that, that middle ground yet to know, we really want to get people over into that other camp.
And I think that there were a number of of a large series of patients with femur fractures kind of in the following 10 years, that showed that most people can safely go to the OR and have their femurs stabilized primarily within the first say, 24 hours. Another point of contention with me, cause it's just like, yeah, for lack of a better thing, that's early. If it's within 24, yet what we really wanna know, is who are these people? Like, where are they at? And, and it, it does have to do a lot with resuscitation and there's a handful of other things that play in, but resuscitation of that metabolic acidosis that comes from hyperoxygenation due to, due to hemorrhage primarily.
And so correcting of that. And then also what is the best time course? Is it 24, is it longer? And so kind of dissecting that out a little bit and then to say, well, what about all these other fractures? I mean, it's not just the femurs. There's a number of things and we, we like to study the femur cause it's fun to nail femurs and they're pretty common and it's a, you can get a lot of 'em to look at, but there's a lot of other orthopedic injuries that relegate a person to bedrest and recumbency until they're reduced and stabilize.
And so I think that that physiologically affects a person the same way. Yeah, no, absolutely. Had you had that, I think that's such a wonderful overview, not just for this area but of of, of knowing how we've got to where we are with so many of the things we do day to day. And I, I agree and you encourage your trainees to do this, is that, you know, you know, we, we, how we got to where we are in care now is so important in terms of learning those pathways. And actually what's interesting, like you say, is that some things which are dogma and what we do are based on what we would classify now as very limited evidence really, and actually quite limited methodological design.
But I think the, even for this in particular, how we've come to where we are now is so important. And to, to understand those past papers, I think is so important. And I think you sort of touched upon it, there is this idea of, of how we've evolved to sort of earlier appropriate care now, isn't it? This is the sort of the concept that, that people have evolved to, haven't they? Yeah, and, and I think that the, at the time our, our group, you know, was blessed to work with colleagues who performed all of the orthopedic trauma care spine trauma colleagues, both from the neurosurgery side and the orthopedic side of things.
Anesthesiologists and critical care specialists and our general trauma colleagues with advanced training in Traumatology. We really wanted to kind of put our heads together and try to look at our prior experience for several years. What were we doing? What was working? What wasn't working? Yeah. What patients were we maybe operating on too much too soon and, and how can we learn from that going forward?
And so after a lot of, a lot of time coming up with some, some topics of study and a lot of data to review over several years to to look at our high energy patients with multiple system injury and some of these fractures of interest, like I mentioned, not just the femur, and say, well, we can look at them all separately, but maybe we can pool them and let's kind of get some ideas about that looking at all of the laboratory values for the first four days after they arrived, looking at their vital signs at speci specified time points after they arrived, characterizing the severity and types of injuries to other systems, and then hiring a, a mathematician to work with us who also has a, a PhD in biostatistics who is able to kind of process this.
And, and what we were hoping to come away with are some guidelines. If there are laboratory values, injury types, things where we could create an algorithm to guide care safely to reduce the number of complications we were having, which we classified as anything in that first hospital course, which are primarily pulmonary complications thrombotic complications, infectious complications, and handful of other things in there. And, and so our institution had a rate that that bucket of about 22% so pretty high. Yeah, number of patients we're having some type of complication.
We're hopeful to cut it in half. And we asked the mathematician to predict if he could, based on where someone was at physiologically given a constellation of injuries, what would be our ability as a system to cut our complication rate in half. And that was sort of the basis for developing the EC parameters because he was able to identify that the, the critical items in those patients, either having a complication or not was sort of threefold. One was the amount of acidosis they had when you went to the OR, and so that all makes sense now.
At the time, we didn't realize it plays a pretty critical role, so you could measure it, you know, via lactate, base access, pH. They're all similar. The lactate, of course, is easier to get the measurement based on a venous sample and, and also more specific to metabolic acidosis that's originating from the hypoxygenation associated with hemorrhage from trauma. But that, how quickly was that acidosis improving, especially the rate of improvement in the first eight hours? Cause we notices that the people who were dying, not just in the trauma bay, but in the, in the hospital, most all of them, they never corrected their acidosis.
And it may have been that their system was so badly taxed. They may have been languishing on the side of the road for several hours place. Maybe we weren't on the ball with the resuscitation when they arrived, but if they really weren't corrected within the first 24 hours they died, they didn't survive. And so that was very illustrative to us. Cause you know, we look at these cases month to month and even in conferences. But really to look at a, a several year span of our data as a whole, that taught us a lot about how heavily that piece weighed on not just their survival, but also their readiness to go to the OR.
The next piece was the severity of of chest injury. And so, you know, we look at people with really severe chest injuries like a diaphragmatic rupture or hemothorax on one side in a massive pneumothorax on the other side, you know, things like this where they have very severe chest injuries, also put them at high risk for complication. We can't change that. They either have a chest injury or they don't. We treat the chest injury, but part of treating the chest injury is actually. Resuscitating them appropriately and then providing expeditious skeletal fixations so we can sit them upright.
Yeah. So that's an important piece. And then the third part of our look into our own work was the timing of the definitive fixation. And we noticed that patients that were fixed within the first 48 hours, really did incredibly better than those that were fixed longer. And you can say, well, this is just a retrospective cohort and there's a bias because we emphasized early fixation. We did mostly for the femur, not as much for the other fractures of interest, which gave us a little bit of meat to work with in the group as a whole.
But also because the people that made it that long, they either were resuscitated, or they weren't for them to survive. And in, in 48 hours, we started to notice a lot of decline in pulmonary function. And I think anybody that's been in, in orthopedic practice recognizes this. We know this in our elder folks with hip fractures. You get them fixed and we get them up. And so it, it all makes sense that physiologically that gets compounded by bed rest and oxygenation of a lot of pain.
All amplifies these things and so the data we looked at closely suggested that around the 40 outer marks of four zero was when someone's physiology really started to decline. Yeah. So our effort was, was kind of threefold to say, well, we believe that these fractures should be stabilized either definitively. Or if there's a reason not to with some type of damage controlled strategy for those fractures that are amenable within 40 hours of injury, and that the resuscitation parameters, I'll say more about in a second are very important and we can establish some cutoffs where it seems to be safe to proceed.
But the chest injury, since we can't change it, we acknowledge that they're ultimately in a higher risk category. Yet we should proceed with expeditious fixation despite that, if they've had an adequate level of resuscitation. Yeah. Now with a lot of advanced math that is beyond my personal capabilities, we're able to look at refinements of the parameters to say, well, where's the real catchpoint? On the, the complications going up.
Is it, is it at around, we thought it would be around two or 2.5 of a lactate just based on that old work and sort of historical practices, right? Yeah. But in our dataset it was, it was actually much different than that. Our patients were able to tolerate a much higher level of acidosis, although it needed to be improving. And so the, that's how we developed where we called the early appropriate care parameters in that EAC was really used to try to get away from the early care, yeah, idea in that it might be, if you need to fixation, it might be a damage control tactic, but it was really to try to do what was appropriate for the person.
At that point in time. Yeah, no, that absolutely. And that sort of leads us into, cause you've mentioned it already, Heather, is, is about those resuscitation parameters in terms of, you know, the, there's been a a lot more work on that over time. What do you, you know, and I know it's debated, but is there a generalized, generalized agreement that exists in terms of those, those important laboratory parameters that we should be using? What, what would your take home from that data be?
Yeah sadly, there's, there's limitations to the approach that we took for sure. I mean, it was just one center's work, and so it's heavily biased by the historical practices that our group, and so you can't really get away from that. And, and in a, in a more public world, if we had another, you know, eight or 10 large trauma centers that did a similar type of thing, I think we could get a, a better handle on it. Definitely. Having said that, the parameters now have been prospectively used for many years and have really cut the complications in half.
But would they be cut in half again? Yeah, they probably could. I think with further refinement, maybe attention to patient age or nuances of cardiac and renal function. Maybe subtle differences in terms of the anticipated operative burden. How much surgery are you planning to do? How long of a procedure is it? How much blood loss do you anticipate with that procedure? Because all of these things are gonna play a role, but we weren't equipped to nuance that outta the dataset.
And so for several years after we did our EAC work and even prospectively tested it and published about that, there were trauma centers that were kind of picking it up, but tailoring it based on their clientele and, and one of the big hangups is that a lot of places don't have enough spine surgeons and or a history of really emphasizing expeditious spine fracture stabilization. And so those couple of things have really impaired some large trauma center's ability to try to use these EAC parameters to apply it to other injuries.
So maybe they're using it for the femur and maybe for the pelvic ring, but not for other things. Yeah. Similarly, I think acetabular fractures and to a lesser extent pelvic ring injuries are a little bit problematic cuz even in large trauma centers there's often 1, 2, 3, only a handful of people that are really capable of, of managing those injuries. And certainly no one surgeon is available every day of the week.
And so I think there's system issues that have led to difficulty in implementing. The other piece really to think about is, that concurrent with this, there were other parameters proposed. So you can look at the clinical grading system proposed by Pape and colleagues. And, and so that was first published around 2000 in a very intelligent effort to look at things that we know matter. And they say, well, if someone's got a severe abdominal injury, severe chest injury, certainly that's gonna put him into a different category and that system was based on creating four categories of readiness for, for surgery, and it was, it was initially proposed just for femoral shaft fractures, right?
And so there's stable patients. There's borderline patients, unstable patients and in extremis patients, and recognizing as someone in a stable category, certainly we believe in expeditious fixation of the femur, which was at the time, again, defined as 24 hours after injury. And so looking at the vital signs, looking at their, their, their temperature was actually a separate category looking at measurements of, of acidosis. Looking at injuries to other body systems. Pelvis was one category, and chest and abdomen were another category.
And, and saying, well, we'd like for the patient to have three of the four labels of those categories of parameters to be stable or borderline or unstable, to designate them into that row. And then if they're unstable or in extremis a damage control strategy should be employed, or if not possible, definitive management should be deferred. Yeah. And so the unstable category in the extremist categories, I think that patients that would fall into those groups would probably be pretty unwell.
And either they're gonna die from their injuries, or they're gonna be resuscitated probably within the first 24 hours based on, you know what, what you and I see in our practices, right? But that borderline group's a little tricky. You can have people that are in that group, maybe just because they had an extremely severe chest injury. Yeah. Yet their acidosis isn't really that bad. And so do we need to be additionally concerned about the timing of stabilizing the femur or the method used, maybe not as much.
And so I think that that was a the, that clinical grading system was based on experience, but really not on research data per se. Yeah. It was studied afterward. And the borderline group, you know, there was a publication of randomizing patients to a damage control strategy with external fixation versus primary, intramedullary nailing for patients in the borderline group. But a relatively small group. I wanna say it was about a hundred and 65 patients treated over several years at like 10 hospitals, and they showed no difference in pneumonia or embolism or other things.
A part of it might have been cause it was a small group of patients. They did see a difference in acute lung injury, which isn't a term that many surgeons are familiar with, but what it is, is it's an alteration in the oxygenation ratio. So it suggests that there's not as much oxygen being delivered in patients that have that yet it didn't translate into more severe complications that we could record. And so I think that that's interesting in that patients treated with damage control had less acute lung injury.
So suggesting a safe or more favorable pro- profile for borderline patients in their study. But still. I think the translation of that into practice is problematic because we're not necessarily measuring those oxygenation, ratios or familiar with them. Yeah. In practice. Furthermore the men, the mention that I made about the clinical grading system and how it, it inherently puts patients into different categories or it's problematic cause they may have some features in any of those four groups yet they may be clinically really, we would say, oh, that person seems to be pretty stable.
They're looking in pretty good shape. Yeah, I think they're okay to go. So it's in, in, in practice it's a little bit problematic and there's been some refinement of it over the years, and I think a lot of it is, is similar to what we came upon with the EAC. The EAC just had a little more science behind it to start off because it's not as though those other things don't matter. It's just we were trying to be very rigorous about what we could say about how they mattered in terms of someone's clinical course.
Absolutely, absolutely. And I think that sort of takes us nice, it sort of. What you've said throughout is though what probably one of the key factors in these patients is their resuscitation and actually getting that, that resuscitation. Right. And, and where are we in terms of what's your sort of feeling about not only transfusion protocols and where we are with that, but also related very much to that is the assessment of coagulopathy and that, and the development of that. What, what, what, where, where are we now with that, do you think?
I find that to be a really interesting area, but it's, it's tricky to study, you know, as you know, because not all hospitals are using it and it's had, it's had various uptake or not. Like some places use TEG or they use ROTEM. Yeah. And they use it all the time, which is kind of good because if they're using it, they all just get a lot of measurements. We can learn more about it. Yeah, absolutely.
But then there's some places who are doing it, not at all, or it depends on which anesthesiologist is working and then they're using ROTEM or TEG and so there's no consistency whatsoever in the United States, and I think that there's a little bit of data coming forward, but, but again, problematic because they, they seem to function similarly in, in measuring the person's capability of, of making clot. So key in another factor. And so I wanna step back for just a second and say, you know, coagulopathy is one of the criticisms that the whole EAC work received by a number of other groups.
And I think that that's a very good point being raised. How come you're doing this but you're not even including that? And we studied it quite a bit. But it ran so consistent with correction of the acidosis that we didn't feel and our, our mathematician felt that it would have a bit of a multicollinearity problem. Yeah. By including it with the other parameters into the, into the model. And so because it corrected at the same time as everything else, we didn't study it specifically.
Yeah. Yet I think that this is a very interesting field because with nuanced factor replacement, I think we can fine tune resuscitation and I suspect in the next five to 10 years, it will probably be relatively common practice. Yes. That we do this for people, particularly those who are on some type of a massive transfusion protocol, so that the, the resuscitation will be really specifically directed to what their needs are, and that will be more efficient and more, more, more complete.
Yeah, absolutely. And it'll be more tailored to that yeah, absolutely that makes sense. So if we, something else that we, I thought was really interesting about the, your annotation was, you, you know, you, you, a lot of what we've talked about already is, is not solely, but it's based on the idea of the long bone fracture, particularly the femur wasn't it? And, and, and the fixation of that. But then it, it is really interesting how you've, you, you move on to the idea of not just, not just the femur and other unstable fractures where it be, you know, spine fractures, pelvic ring, acetabular fractures and, and, and fractures, of the proximal femur.
And I, I thought it was really interesting how that, you know, that link and how that, that area has evolved over time. You know, we, we do that with, we know that with now with our elderly hip fracture patients. And as you talk about our periprosthetic fracture patients now, which is growing and it's really interesting, the analogies there that actually overlap really isn't there. And I, I think it's just gonna continue to be borne out as we do this further, you know, all the periprosthetic fractures and they may be distal femoral fractures adjacent to, a total knee, or even proximal tibia, but to have a similar bearing on that person cause they can't get up and move.
Yeah. And so my gut is that this'll be studied more and more and refined, and that for elder patients, they may have lower thresholds where we consider it safe because they have less cardiopulmonary or renal reserve to begin with. And so that's an area that I think we need more study to look at the physiology concurrent with what we're doing. And I'm hopeful that if we can get large centers who agree to share data and to just record it going forward to see where the problem spots are, then we can propose algorithms and study them perspectively and then continue to refine them.
Cause I, I think there's a lot of opportunity there. And so, it's a good thing and it, it, it just makes sense, you know, these, they're all affecting the person the same way. And so I've had people ask, well, what about the tibia shaft? We should throw a nail on that. It's like, well, yeah, it's the same ideas. It is causing some pain, but we can put a splint on that. Yeah. And that, that's all right.
The person can sit up and bend. So it's, it's really not the same. And that, that is nice. I'm glad you're thinking about it, but my opinion is that it'll never really affect people. No. Physiologically the same way. No, absolutely.
Absolutely. And something else you, I thought was, Interesting. And I, I know it's something that, you know, probably we've all been taught in the past, which is, you know, you say that historically, you know, it was, it was proposed that, you know that the early surgery, the concern would be clot disruption, that actually, that you can actually dis- disrupt the clot and it would cause excessive surgical bleeding and prolonged operating times. But you, as you said in your annotation, that that's pretty much been debunked now, is that right?
Yeah, that's absolutely right. Yeah, and it's, it's a funny thing I, I I make, just, just to regret us a little bit into personal anecdote, because you know, when I was in my residency training in the nineties I noticed a lot of emphasis on femur and, and so less emphasis on pelvis and acetabular, we did have patients that would occasionally have organ failure. Some of them would die and they'd be laying in traction and just kind of waiting it out to have their you know, tea with posterior wall acetablumum fracture stabilized was kinda complicated and their lungs weren't doing so well. Then occasionally they didn't make it.
And then as I did my trauma fellowship, you know, right after that I noticed there were more injuries at that hospital in Seattle and it was very busy and there was an emphasis on let's get all of these people to the OR where they have a pelvic ring acetabular fractures as long as we felt they were ready. Again, it wasn't a consistent resuscitation protocol, but most of the patients were getting pretty aggressive critical care medicine from the get-go. Yeah. And so almost all those patients were stabilized right away, and it was very noticeable to me.
The difference in how well people were doing. And I just kept saying like, these all should be stabilized, but it's not the standard practice. And talking with some of the faculty there in other places, there was a, there was an appetite to try to push the envelope. And then saying respond. And so, you know, having colleagues around me who kind of felt the same way was easy to study our work and to ultimately push for the EAC protocol. And I think that we need to do more of that as it pertains to folks with periprosthetic fractures and, and all, and I'm hopeful that now that we have electronic medical records, more research infrastructure in place to do collaborative work, to collect the identified data to share it.
And I think, you know, you guys with National Health Service, are way ahead of us because you have a lot more experience with standardized pathways and with data sharing and collection mechanisms to look at these things because that's how we're really gonna do better. Yeah. With what we do. By, by creating expectations and then anticipating that we're gonna have to have our systems respond to this. And so maybe there's, if there's trauma centers that are always busy and they don't have surgeons that can do periprosthetic work, or they can do acetabular fractures or manage thoracolumbar spine fracture dislocation in the first day following.
Maybe they shouldn't be a major trauma center. Maybe they sh they, we should find ways to combine them. And I think that we need some level of governmental intervention in conjunction with us, in our professional societies to try to push this, to continue to get better with what we're doing. But, there is a lot of reticence in the United States and, and I'm just gonna call out these behaviors because people will say like, oh no, no, that doesn't happen. But it does. And it's mostly based around individuals who want to keep those cases.
Cause they enjoy doing 'em and they make money doing them. Or hospital systems who say, well we don't wanna transfer him away. We have a guy on Thursday, he'll be here in a few days. He can do it because they don't wanna lose the revenue. That's not right. Yeah. We need to take the best care of people that we can and I think until we call out behaviors like that, and until we unify on our statements of purpose. And in wanting to do this and to figure it out, when to safely best treat people, then we're still gonna flounder a little longer than we need to.
No, absolutely. And I, I suppose that's a good opportunity, cuz I, I, I just for our listeners, I don't often do this, but I wanted to read out a couple of sentences that you wrote, which I thought were brilliant, which was "Striving beyond individual provider and institutional borders and interests is imperative to maintaining sustainable systems of care with optimal clinical outcomes. It also is essential to career longevity, yet these practices are easily contemplated and said, then delivered". I think that's so, so poi- I think it's so beautifully put, Heather, I think in terms of you have those factors you've all talked about, you have to consider it and actually ultimately at the end of it, it's the patient, isn't it?
It's the patient care, which is the, the, the utmost importance. And I suppose that's sort of, sort of to finish up maybe, where do you think we're sort of for the future, you know, where are we headed in terms of, you know, not only the systems which you've, you've all alluded to, but where, where are the big things research wise that we need to look at, do you think moving forward? Yeah. So in addition to the, the systems management and, and the algorithms like we talked about, I think we're specifically focusing on some of the, the geriatric multiply injured patients as well as those with the isolated injuries.
Cuz our, our populations are aging, our people are living longer than they used to, and the complexity of injuries continues to go up. And so I think really looking at that and for nuancing these algorithms based on their physiology, which is partly their age, but more their, their cardiac, pulmonary, renal function at baseline, and how do we measure that? And then there's been a lot of interest now for, I, I would say probably to 30 years on genetics. In looking at the genetics of inflammation and thus, how does it respond to resuscitation?
How does it respond to musculoskeletal care? And, and so those studies are really difficult to do because there's just so many variables. And so until the availability of those genetic markers, our, our ability to measure them and to record them and to understand what to do with them improves. I think that's gonna be a while in the making, they're, they're expensive and many of the tests aren't available right away. And so I think that's interesting, but I don't see it as impacting the way we do things in the near future.
Sure. But if we have more emphasis on the elderly and just nuances of their baseline status and, and how to, how to tweak their resuscitation and their readiness based on that I think that will help. And then I think concurrent with that, one of the things we need to do more with is knowing how long are we gonna have that person in the operating room, and how much of a tax is that on their, their body in terms of blood loss? In addition to the OR time, because now we're seeing all these things with like, oh, well, we're gonna go all plate nail two implant constructs, where, and it's certainly, you and I both know, not every person with a periprosthetic fracture needs all that.
Yeah. But what do they need? And so I think it, it adds another layer of complexity on it, which I think will be interesting. My gut is that in many of the centers in the United States there's a lot of activity going, weight nail, multiple plates on, on all of these people. It's probably a little bit too much, a little bit too much surgery. And it seems like maybe it's not necessarily affecting their weight variability as much as you claim that it would.
Yeah. And so kind of calling that out and really asking people to justify what they're doing is gonna be important and then after that the piece that we didn't really touch on at all is the, the rehab, and that's just been so badly neglected. I'm eager in the next five to 10 years to see some big improvements. Yeah. In, in rehabilitation because, it's one thing to put the parts back together, but it's another thing to say, Hey, this is a person with a life. Yeah.
And there is so much left to be desired in most cases, to address their, their social needs, their mental health needs, their you know, even economic issues particularly in the first three to six months to help them to get over the hump and make a huge difference. Yeah. In how they do, and not only that, but the, the lives of the people around them, their family members and other colleagues. Yeah. No, absolutely.
Heather and I, I think I know you have done, and continue to do a lot of work in that area and I think it's such an integral part that we often, like you say, you certainly in the past, we forget about, we just, you know, we think you fix the person back up and, and that's them fixed, but there's so much more to do after that, isn't there? And that's, that's really important has probably has as a profound effect as any operation probably can as well. So, yeah, no. Well, Heather, I think that's such, such a great, great chat.
So great chatting to you. A real big thanks for joining me today and, and putting a spotlight and a real, really good history of how it's evolved over time in this area and a really important, relevant issue in our specialty and, and, and for, especially for the, the multiply injured patient. It was really informative and always so nice to talk to you. Back at you, Andrew. It's really the pleasure is all mine. Such an honor to to chat with you and be part of this important podcast.
Thank you so much Heather. And so to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media and a like, and feel free to tweet or post about anything we've discussed here today. And thanks again for joining us. Take care, everyone.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html audio player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the audio player are generally tabs, one of which shows a scrolling transcript of the audio and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the audio player is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the audio by opening up an explore dialog which contains an about tab which contains rich metadata about the media, a segments tab which contains further information about the audio, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
E: Explore Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Form Title Embed Media
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the media.
You can press A to open the Accessibility Dialog.
This describes many other keyboard shortcuts for media controls.
Exit Clip Mode
The video is currently set-up to show just a clip from 0:00 to video end. You have requested to see a portion of the media outside of the clip.
Click OK to switch to the full media or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode