Hypothesis: In severely the injured, there has been a move away from early total care to staged physiological and anatomic reconstruction, damage control orthopaedics (DCO). This seeks to limit the magnitude of the second hit insult resulting from operative treatment after trauma, deferring complex reconstructive work until a later stage. For femoral shaft fracture, this entails initial external fixation, to provide early skeletal stabilisation, and subsequent conversion to an intramedullary nail (IMN).

Materials and Methods: Patients with femoral shaft fracture, who underwent primary IMN or DCO between 1996 and 2002 were identified from our database. Those with New Injury Severity Score (NISS) < 20 were excluded. The systemic inflammatory response (SIRS) and Marshall multi-organ failure scores (MMOFS) were calculated every 12h for 4 days. These systems have been previously correlated with outcome and complications in critical care.

Results: 174 patients were included. The mean SIRS score was higher at each time period post operatively in the IMN group (p < 0.01). The MMOFS was slightly higher at each point in the DCO group, (only sig. at 48h). There was a higher incidence of pneumonia and mortality (significant p < 0.02), ARDS and MOF (both n.s.) in the DCO group, this being attributable to the higher incidence of head and thoracic injury (AIS severity 2 or more). The mean peak post-operative SIRS score was significantly higher in the IMN group than in the DCO group, both at primary procedure and conversion, as was the time with SIRS score above 1. The pre-op and peak post-op SIRS score correlated with the peak post op MMOFS score (p 0.0002). The conversion pre-op SIRS score correlated with post-operative peak SIRS score and MMOFS score (p 0.0001). On average, a significant rise in the MMOFS score did not occur following the conversion procedure.

Conclusion: It would appear that despite having significantly more severe injuries, patients in the DCO group had a smaller, shorter postoperative systemic inflammatory response and suffered only slightly more pronounced organ failure than the IMN group. They did suffer more complications, but this was only significant for pneumonia. DCO patients undergoing conversion whilst their SIRS score was raised suffered the most pronounced subsequent inflammatory response and rise in organ failure score.