Borderline femur fracture patients: early total care or damage control orthopaedics?

A recent randomized controlled trial (RCT) favours damage control orthopaedics (DCO) over early total care (ETC) in the management of high-energy femoral shaft fracture (FSF) patients with borderline physiology. The purpose of this study was to compare the borderline physiology FSF demographics, management and outcomes of a Level-1 trauma centre, John Hunter Hospital (JHH) with those of the RCT.

A 41-month study of the prospective FSF database was performed. FSF patients were categorized according to the Pape system. Stable (JHH-S) and borderline (JHH-BL) patients' demographics, injury severity, methods of treatment and outcomes were compared with the corresponding groups of the RCT (RCT-S and RCT-BL).

Sixty-six patients met the inclusion criteria of which 45 (68%) were in JHH-S and 21 (32%) were in JHH-BL group. In comparison, there were 121 (73%) RCT-S and 44 (28%) RCT-BL patients in the RCT study population. The demographics and injury severity were similar in the borderline groups, while JHH-S patients were less severely injured. DCO was utilized more frequently in the RCT in both the stable group (JHH-S: 2% versus RCT-S: 41%), and the borderline group (JHH-BL: 14% versus RCT-BL: 48%). The outcomes between the JHH-S and RCT-S groups were comparable, except for intensive care unit (ICU) hours (JHH-S: 20 ± 64 versus RCT-S: 165 ± 187, P < 0.0001) and ventilator hours (JHH-S: 13 ± 46 versus RCT-S: 98 ± 120, P < 0.0001). Among borderline patients, JHH-BL had a tendency to show a lower incidence of both acute respiratory distress syndrome (0% versus 14%) and multiple organ failure (4.8% versus 19.6%). JHH-BL patients had sepsis less frequently (4.8% versus 24.5%, P < 0.05), fewer ICU hours (98 ± 129 versus 436 ± 347, P < 0.0001) and fewer ventilator hours (82 ± 119 versus 337 ± 305, P= 0.0005) compared with the RCT-BL.

The incidence of S and BL patients, demographics and injury severity (among BL patients) is comparable with the RCT. Our current practice of employing predominantly ETC among S (98%) and BL (86%) patients results in shorter ICU and ventilator days, fewer septic complications and a potentially lower incidence of organ failure than in the RCT which had 57% overall utilization of ETC.