The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures

Abstract

Objectives: To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position.

Design: Retrospective cohort study, single centered.

Setting: One level 1 trauma center.

Patients: Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006.

Intervention: Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position.

Outcome measures: Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score > or =18 and all those with a femur fracture and an Abbreviated Injury Score chest > or =3.

Results: Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score > or =18. However, for the subgroup of Abbreviated Injury Score chest > or =3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044).

Conclusions: For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.