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22 expert zone
Hans-Christoph Pape
Damage control orthopedics:
a response
In issue 1/06 of AO Dialogue, Robert Meek and Peter
O´Brien from Vancouver, Canada again raised the question
of whether or not damage control orthopedic surgery is the
best strategy to adopt for patients with multiple orthopedic
injuries. The article was based on the “John Border Memo-
rial lecture” given by Robert Meek at the annual meeting of
the Orthopaedic Trauma Association in 2005. During this
lecture, Meek presented recalculations of raw data from a
2002 publication of mine, which described management
changes for polytrauma patients undertaken in my previous
institution [1].
These recalculations were wrong and misleading. I therefore
wrote an explanatory letter which appeared in the winter
issue of the OTA newsletter. Additionally, the same infor-
mation was published in March 2006 [2].
I was therefore surprised to find a reiteration of these accu-
sations in the AO Dialogue, published after my explanatory
letters, but without any reference to these responses. Since
the readers of AO Dialogue may not have the chance to re-
search the original data, please find the information below:
In the publication from 2002 [1], we reported management
changes in Germany regarding the treatment of major frac-
tures over a period of almost 20 years. The manuscript is
a description of the management changes performed at
Hannover Medical School under the guidance of Harold
Tscherne, and was written in honor of his retirement after
30 years of leadership. It was not designed to prove the value
of DCO. Patients who were treated during the latest time
period (DCO era, 1993-2000 in the paper) developed less
ARDS when treated by initial external fixation (DCO) and
secondary nailing compared with those treated by initial
intramedullary nailing (ETC). This was shown by means
of an odds ratio of ARDS and by comparison of the ARDS
incidence between the subgroups. The patient selection sup-
porting the data is as follows:
In the group who received intramedullary nails (ETC), pa-
tients were excluded if the nail was inserted in a retrograde
fashion. Retrograde nailing is a special entity and is used for
distal fractures, bilateral fractures or floating knee injuries.
Also, the exclusion of these patients is important because
the systemic and pulmonary effects of retrograde nailing are
poorly described. The ARDS incidence in patients who had
antegrade nails (n=99 out of 110 in the DCO era) was 15.1%,
as indicated in the abstract (15 out of 99 patients). It is im-
portant to note that table VII has been designed to illustrate
the general reduction in the rate of complication over time,
rather than portray a relationship between the complication
rate and the method of fracture management.
In the group with initial external fixation (DCO), we ex-
cluded those patients in whom the indication for the exter-
nal fixateur was based on the severity of head injury only (ie
was unrelated to other orthopedic injuries): 14 patients with
head injuries received an external fixateur. In 13 of these
cases, the timing of the definitive surgery did not depend
 23

Reported incidence of ARDS and odds ratio regarding the development of ARDS in the publication from 2002
(Abstract and Discussion)

Treatment ARDS incidence reported ARDS incidence reported Relative percentage

(0dds ratio) of ARDS

– DCO era ETC era DCO era

External fixation 9.1% 97.4% 22.1%

IM nailing 15.1% 54.6% 26.4%

Table 1

on the influence of the orthopedic surgeon, but was delayed
because of the severity of head injury. In one patient receiv-
ing an external fixateur, the control head CT showed an im-
provement of the head injury. This resulted in conversion to
an intramedullary nail the following day, thus leaving 55
out of 68 patients for evaluation. In these, the ARDS inci-
dence was 9.1% (5 out of 55), as indicated in the abstract.
The reported data on the difference of ARDS incidence dur-
ing the DCO era are as follows: ( Table 1).
Robert Meek recalculated the data from Table VII in the
2002 article, which describes the general improvements in
the rates of complications in all patients over time. He then
used all available patients for a given time period as the de-
nominator for his recalculations. In contrast, we excluded
patients with severe head trauma and those with retrograde
nails. The table below lists the comparison between the re-
ported (Pape) and recalculated (Meek) data of ARDS inci-
dences and the denominators used ( Table 2).
I agree that the publication from 2002 could have been clear-
er had we included the inclusion criteria as a separate table.
However, there is no need to reconsider our conclusions from
the 2002 publication. Also, one may wonder whether it is
rational to question a broad concept based solely on the criti-
cism of a single publication.
Moreover, as pointed out in the comment in the AO dialogue
by Trentz, other centers have also changed their management
strategy over the last decade. As listed in Table 3 , reports on
DCO have been present throughout the world in recent years
[3–14].
Dr Meek and Dr O’Brien state that the idea of the patient
being “too sick to operate is not a new one”. While this may
be true, I do not think that returning to an old concept of
fixing every fracture in every patient is the right course of
action.
Moreover, I believe that one must take into account the ef-
fect of the system of trauma care, as it differs throughout the
world. Specifically, there are striking differences in orga-
nization which may contribute to the confusion that arises
from the interpretation of study data from Europe and study
data from Canada and North America: In the North Ameri-
can/Canadian system, the management of the polytrauma
patient is not handled by the orthopedic surgeon. A general
surgeon inspects the patient in the ED, performs the clinical
examination and then consults the orthopedic surgeon for

Comparison of data based on denominators used in our publication in 2002 and the ones used for
recalculating the raw data by Robert Meek

– ARDS Incidence ARDS Incidence

Treatment of femur fractures Pape’s data (denominators used ) Recalculated data (Meek)
(denominators: all patients)
Ex fixation 9.1% (5/55) no ex fix for head trauma 22.1% (15/68) all patients

IM nailing 15.1% (15/99) no retrograde nails 26.4% (29/110) all patients

Table 2
 3 | 06
24

fractures of the pelvis and the extremities. The general sur-

Care of femoral shaft fractures in Germany
geon weighs the general injury severity and decides which
(Rixen et al; data from the German Trauma registry)
surgical procedures can be undertaken. He does or does not
clear the patient for surgery to be undertaken by the ortho- Polytrauma patients with femur shaft fractures 1465
pedic surgeon ( Fig 1). Osteosynthesis <24 hours 1465
Due to these differences in organization of the trauma sys-
External fixation 47.0%
tem, it is not surprising that general surgeons rather than
Nailing 41.1%
orthopedic surgeons were the first to report the benefits of
a limited surgery approach in the severely injured. Over Plating 11.9%
the last decade, the idea of limiting surgery in view of a life
Table 4
threatening condition has become common practice in the
general surgery community [15–21].
The important question to be asked is the following: What
happens to a patient who is not cleared for definitive stabi- In contrast to the North American/Canadian system, the
lization of his fractures? Does he receive traction? Will the orthopedic trauma surgeon in Switzerland, Germany and
fractures be stabilized by a cast? Does any one of these pa- the UK performs many of the tasks of the general surgeon.
tients receive an external fixateur? Are the patients included In most institutions, the surgeon examines, evaluates, and
in the study only those who have been cleared for surgery by manages the patient in the emergency room. He/she then
the general surgeon? If so, absolutely no discussion would collects the injury data and the physiologic parameters and
be necessary, since throughout the world these patients categorizes the patient accordingly. He/she determines the
would appear to be treated in a similar fashion. priority of the different injuries, determines the timing of
The same issue has been addressed in a previous publication surgery, and proceeds with fracture stabilization him/her-
by Ziran et al. “Common to all studies, including the pres- self as part of the resuscitation protocol.
ent one, is the inherent difficulty of determining the effects According to the established treatment protocols in most Eu-
of delays in fixation. Because trauma centers reporting such ropean trauma centers, long bone fractures undergo imme-
studies have favored early fixation in those with multiple in- diate intramedullary nailing if the overall cardiopulmonary
juries, patients who are not stabilized within 48 to 72 hours condition allows it. In polytraumatized patients who have
tend to be delayed for reasons pertaining to their physiologic an unstable cardiopulmonary condition, it is advised that
condition. These patients tend to be more severely injured long bone fractures are stabilized with an external fixateur.
and therefore may not be comparable with those whose con- This approach has recently been described in detail by two
dition allows early fixation [22]”. studies:
1. Taeger et al report a prospective survey of polytrauma pa-
tients submitted to a damage control approach. They con-
vincingly report a low incidence of ARDS and multiple
Author Country Reference organ failure, when following this approach [8].
2. Rixen et al describe the “reality of fracture care in Ger-
many” and includes data from 1,465 polytrauma patients.
Scalea and Nowotarski USA (1,2) It is interesting to note that this report from the German
John and Ertel Germany (3) Trauma Registry clearly documents that all patients had
Labeu and van Erbs Belgium (4) their femur fractures stabilized within 24 hours [23].
Rixen and Bouillon Germany (15)
( Table 4). There was no patient in whom traction was per-
Olson USA (5)
formed or a cast was applied for temporary stabilization.
Taeger and Nast Kolb Germany (6) This may elucidate how different the trauma systems affect
Giannoudis Great Britain (9) the question of timing.
Roberts USA (10) I believe that future studies comparing the outcome in the
treatment of major fractures should include these issues and
Prior and Reilly USA (11)
that the number of patients who underwent no fracture sta-
Nast Kolb Germany (11)
bilization should be documented.
Roise Norway (12) I would like to thank the AO for the opportunity to add my
Keel and Trentz Switzerland (13) comments to the discussion. Moreover, I would like to thank
the AO for its ongoing funding and support which has enabled
Table 3
us to investigate many urgent questions regarding this topic.
expert zone 25

Canada/USA Rescue Switzerland/Germany/UK

General surgeon Orthopedic trauma surgeon

Attending general surgeon Emergency room Attending orthopedic surgeon
– admits patient – expects patient
– manages diagnostics – manages diagnostics
– evaluates physiologic parameters – weighs physiologic parameters
– consults ortho trauma – takes patient to OR for fracture care

General surgeon Operating room Orthopedic trauma surgeon

– operates on truncal injuries Timing of fracture fixation decides on management/timing
– decides if patient is cleared for of injuries and performs surgery
fracture fixation by orthopedic surgeon

Anesthesia Anesthesia
General Surgery ICU Orthopedic trauma surgery
ICU

Figure 1 Organization of patient management in different trauma systems

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Hans-Christoph Pape
Director - Division of Trauma
Department of Orthopaedic Surgery
Pittsburgh, PA USA
papehc@upmc.edu
hcpape@web.de