Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality. The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey

OBJECTIVES The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. BACKGROUND The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). METHODS Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. RESULTS Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". CONCLUSION This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios

Treatment of articular cartilage lesions of the knee

Treatment of articular cartilage lesions in the knee remains a challenge for the practising orthopaedic surgeon. A wide range of options are currently practised, ranging from conservative measures through various types of operations and, recently, use of growth factors and emerging gene therapy techniques. The end result of these methods is usually a fibrous repair tissue (fibrocartilage), which lacks the biomechanical characteristics of hyaline cartilage that are necessary to withstand the compressive forces distributed across the knee. The fibrocartilage generally deteriorates over time, resulting in a return of the original symptoms and occasionally reported progression to osteoarthritis. Our purpose in this study was to review the aetiology, pathogenesis and treatment options for articular cartilage lesions of the knee. At present, autologous cell therapies, growth factor techniques and biomaterials offer more promising avenues of research to find clinical answers