Nationwide Analysis of Cardiopulmonary Outcomes After Multiple Long Bone Fracture Fixation

Multiple long bone lower extremity fractures repaired with intramedullary nail (IMN) fixation have been associated with notable cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, acute respiratory distress syndrome (ARDS), and pneumonia. Minimal data exist regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that include both tibial and femoral injuries. We aimed to compare the cardiopulmonary outcomes after simultaneous versus staged IMN fixation.

The American College of Surgeons' Trauma Quality Improvement Program database was queried to identify patients who sustained multiple long bone lower extremity fractures between January 2016 and December 2019. Patients were split into two cohorts: simultaneous fixation (fixation of all fractures in the same operation/calendar day) and staged fixation (two or more operations each >24 hours apart).

In total, 202,777 records of patients with tibial and/or femoral fractures were identified in the Trauma Quality Improvement Program database; 3,202 patients met the inclusion criteria. In total, 75.9% underwent simultaneous IMN fixation of two or more long bones, and 24.1% received staged fixation. The groups were similar across multiple variables; however, the staged fixation group was older (42 vs. 37, P < 0.0001) and had a significantly higher rate of ventilator associated pneumonia, ARDS, and acute kidney injury. The staged group had a longer time to surgery (16 vs. 39.5 hours, P < 0.0001) and hospital length of stay (17 vs. 11 days, P < 0.0001).

After propensity score matching, simultaneous fixation of multiple long bone lower extremity fractures was not associated with increased cardiopulmonary events, including ARDS, ventilator associated pneumonia, and acute kidney injury. Given these findings, simultaneous IMN fixation should be considered because it was not associated with an increased risk of cardiopulmonary complications in the high-risk patient.