Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures

Multiple long bone lower extremity fractures are a debilitating traumatic injury that carries long-term morbidity and mortality implications. For the orthopedic surgeon, intramedullary nailing (IMN) represents a common method of fixation for both tibial and femoral fractures [1,2,3]. Its benefits over other surgical techniques, such as plating, include improved long-term functional outcomes (quality of life, reduced angular deformity), superior mechanical stability, and rates of union as high as 99% [1,2,3,4,5]. Its frequency of use in femoral fractures has been long established [6,7,8,9,10], and the landmark SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) trial found 80% of tibial fractures were ultimately treated by IMN as well [11].

Intramedullary Nailing is used in both a primary (simultaneous) and staged approach in multiply fractured trauma patients with relative parity. In the SPRINT trial 42% of patients with tibial fractures treated with IMN had a staged fixation of an additional separate lower extremity fracture [11]. Distribution is slightly less for femoral fractures, where 25% of patients undergo a staged approach [12]. Despite the prevalence of IMN, there is no current consensus regarding the staging of surgical management in patients who have sustained multiple lower extremity long bone fractures. Aggregate data encompassing multiple fracture combinations of femur and/or tibia remains sparse. Patients with concomitant femoral and tibial fractures are often excluded from analyses, although this injury pattern is not uncommon. A 2020 study found 264 of 1805 fractures were femoral and tibial, a rate of nearly 15% [13]. Exclusion of patients with a combination of lower extremity fractures represents a gap in the current literature, one that this study aims to fill.

Fixation of multiple lower extremity long bone fractures with IMN fixation is associated with significant cardiopulmonary risk and may result in mortality. During intramedullary instrumentation of the femur and tibia, marrow contents and intramedullary fat may be released into the bloodstream, posing significant harm to the polytraumatized patient [13,14]. It is well-documented that IMN fixation in femoral fractures can result in a secondary systemic inflammatory response, causing an increased risk for FES, pneumonia, ARDS, multiple organ failure, and death [14,15]. This leads to an overwhelming proinflammatory immunological response in an already-vulnerable patient [13]. Increased ISS, thoracic trauma, elevated lactate, hypotension on presentation, and increased transfusion rates have been linked to an increased risk of pulmonary complications in both tibia and femur fracture patients as well [13]. Risk of ARDS following IMN fixation of femoral shaft fractures has been reported at up to 15% [13]. Incidence of respiratory failure in patients with single femoral shaft fractures ranges from 10% to as high as 75% [15,16]. Recent research has reinforced this risk in the tibia fracture patient, especially in the setting of bilateral tibia fractures [13,17]. A second tibia fracture was observed to be an independent risk factor for pulmonary organ failure [17]. As such, the operative course of care must be chosen with precision to prevent downstream catastrophic events.

Out of caution for theoretically increased cardiopulmonary risk, which is exacerbated for the trauma patient with diminished respiratory reserve [18], some surgeons opt for a staged approach [19]. However, there is scarce data regarding the actual cardiopulmonary burden associated with simultaneous versus staged fixation of multiple lower extremity long bone fractures that includes both femoral and tibial injuries. No standardized guidelines exist to direct treatment when patients present with this injury pattern. Therefore, it is unknown whether a simultaneous or staged approach is superior in the reduction of cardiopulmonary complications. Clearer understanding of the true risks of simultaneous versus staged IMN fixation is necessary to optimize patient care and prevent the morbidity and mortality conferred by cardiopulmonary events, in addition to the very real burden of recovering from these debilitating traumatic injuries. The surgical team must balance the perceived risks of both simultaneous and staged fixation techniques alongside the patient's clinical status and examination of objective clinical data, such as lactate levels, to determine how to proceed.

In this retrospective study, we identified whether simultaneous IMN fixation of multiple lower extremity long bone fractures led to increased cardiopulmonary complications when compared to a staged approach. We utilized a statewide trauma database, the Michigan Trauma Quality Improvement Program (MTQIP). This research serves as a descriptive study to inform surgeons as to which polytraumatized patients may benefit from staged management over simultaneous fixation, and vice versa. We hypothesized that simultaneous fixation would result in increased cardiopulmonary complications. This study was approved by our institution's IRB (Institutional Review Board) and the IRB of a large public university.

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