A China-Based Exploration of Surgical Timing for Polytrauma with a Focus on Fracture Reconstruction

A China-Based Exploration of Surgical Timing for Polytrauma with a Focus on Fracture Reconstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A China-Based Exploration of Surgical Timing for Polytrauma with a Focus on Fracture Reconstruction Chenning Ding, Mingwang Jia, Xing Han, Jiahui Zhang, Xin Zhao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5388963/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Apr, 2025 Read the published version in World Journal of Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background : For patients with severe polytrauma and fractures, early fracture reconstruction surgery under stable conditions can significantly reduce pulmonary and other complications. However, premature surgical intervention may heighten infection risk, adversely affecting the patient’s prognosis. Consequently, determining the optimal timing of surgery is crucial for patients with multiple traumatic injuries. Given China’s healthcare context, this study will assess injury severity and perform definitive fracture reconstruction at specified post-trauma intervals. Postoperative infection rates, including wound infections, other complication incidences, hospital stay duration, treatment costs, and long-term outcomes will be observed and compared to identify the optimal timing for surgical intervention. This study also aims to develop effective polytrauma management models. By applying accessible criteria and choosing suitable timing for fracture reconstruction, we can better assess patient conditions, reduce complications, and minimize the surgery's "second hit" effect, addressing an important research gap regarding optimal surgical timing for polytrauma in China. Methods : This study collected data on 200 patients treated at our hospital between March 2023 and March 2024, with an average age of 47.24±16.56 years and an average Injury Severity Score (ISS) of 25.85±13.35. A total of 250 fractures received definitive fixation in the initial surgery, including femoral fractures (n=75), spinal fractures (n=46), pelvic ring fractures (n=49), tibial fractures (n=25), acetabular fractures (n=12), humeral fractures (n=12), and other fractures (n=5) (including clavicle, radius and ulna, calcaneus, and patella). Among these patients, 151 underwent single-fracture reconstruction, 42 had two fractures reconstructed, and 5 had three fractures treated during the first surgery. The study protocol excluded patients with absolute contraindications, including bacteremia and infections near the surgical site. Additional inclusion criteria required stable vital signs (temperature 100 mmHg, stable traumatic brain injury status) and blood routine (white blood cell count <22.0×10⁹/L with a neutrophil percentage 50×10⁹/L; hemoglobin >90 g/L). Based on these criteria, historical cohorts were identified and assigned to either an experimental group or a control group. Observed outcomes included postoperative complications, wound healing grades, inflammatory markers, changes in vital signs, length of hospital stay, costs, and long-term follow-up results. Results : Among the patients, 97 underwent surgery after meeting the specified criteria for fracture reconstruction, while 103 received surgery without meeting these criteria. Patients who met the surgical criteria demonstrated superior outcomes, with lower complication rates (including pneumonia and respiratory distress syndrome), improved surgical incision healing, faster postoperative consciousness recovery, shorter overall and ICU stays, reduced hospitalization costs, greater joint mobility at the 9-month follow-up, and higher quality of life assessments compared to those who did not meet the criteria. Among patients who met the criteria, those with spinal fractures experienced better quality of life outcomes, and those with femoral fractures showed improved fracture healing. Conclusions : For polytrauma patients with fractures, performing surgery once surgical requirements are met results in fewer early postoperative pulmonary complications, quicker recovery of consciousness, lower wound infection rates, shorter hospital and ICU stays, reduced costs, and improved postoperative outcomes. This protocol is safe and effective for most polytrauma patients requiring fixation, particularly those with mechanically unstable femoral, pelvic, acetabular, or spinal fractures. Multiple trauma surgical treatment strategy timing of fracture fixation postoperative complications Background Globally, trauma has become the fourth leading threat to human health[ 1 ]and is the leading cause of death among young adults under 44 in China [ 2 ]. During the early stages of in-hospital treatment for polytrauma, life-threatening complications, such as massive hemorrhage, the lethal triad, and septic shock, are common. In later treatment stages, challenges arise from organ failure, wound infections, and fracture reconstruction issues, all of which impact patient outcomes [ 3 ][ 4 ]. Managing polytrauma patients is a complex and dynamic process [ 5 ]. Early definitive treatment is crucial; selecting the optimal timing for surgery and promptly performing fracture reconstruction and limb rehabilitation in severe polytrauma cases can significantly reduce pulmonary and other early complications [ 6 ]. However, in patients whose physiological functions have not yet stabilized, early fracture surgery is associated with severe complications, as excessive surgical intervention may cause further soft tissue injury and blood loss, worsening the patient's condition [ 6 ]. Currently, there are no clear guidelines on the optimal timing for early surgery in polytrauma patients with fractures [ 7 ]. Thus, establishing a clear model for polytrauma management and identifying physiological indicators in severe polytrauma patients to guide fracture reconstruction timing is essential for effective treatment. Internationally, polytrauma management strategies have continued to evolve. The Early Total Care (ETC) approach, introduced in the 1980s, was based on advancements in fracture fixation and anesthesia techniques [ 8 ]. However, ETC’s “second hit” effect—triggering systemic inflammation—led to the development of the Damage Control Orthopedics (DCO) approach [ 9 ]. DCO defers definitive surgery until the patient’s physiological functions stabilize, but it has been associated with poorer recovery and a higher incidence of complications [ 10 ]. Early Appropriate Care (EAC) [ 11 ] aims to perform definitive fracture fixation within 36 hours post-injury, after sufficient resuscitation (lactate < 4.0 mmol/L, base excess ≥-5.5 mmol/L, pH ≥ 7.25). It was later recognized, however, that reducing metabolic acidosis alone should not be the sole criterion for resuscitation success. EAC has faced criticism, as metabolic status, while significant, is not the only factor that should guide treatment [ 12 ]. Recently, the Safe Definitive Surgery (SDS) strategy [ 13 ][ 14 ][ 15 ] was introduced to balance the approaches of Damage Control Orthopedics (DCO) and Early Appropriate Care (EAC). The SDS strategy categorizes patients into marginal, unstable, and extreme groups to determine DCO indications, resulting in a lower complication rate [ 17 ][ 18 ]. However, including “severe thoracic, pelvic, and/or limb injuries” as criteria for unstable or other classifications has led to delays in definitive fixation for some patients, which is not universally endorsed. Patients with severe thoracic injuries face a higher risk of pulmonary complications when definitive fixation is delayed [ 19 ]. Although various institutions have researched parameter definitions for risk factors across two different time periods, there is still a lack of objective criteria for assessing patient status [ 16 ]. Early fixation often has advantages, but the timing must be individualized based on the patient's condition and injury severity. This nuanced approach helps ensure optimal outcomes in complex trauma cases [ 20 ]. In summary, early fracture fixation can significantly reduce pulmonary and other early complications, shorten hospital stays and costs, enhance patient mobility, and alleviate pain and systemic inflammatory response syndrome (SIRS) associated with unstable fractures [ 21 ]. The pathophysiology of polytrauma involves a complex network of interactions: acute hemorrhage and hypoperfusion, along with soft tissue injury, activate the immune system, triggering coagulation and inflammatory responses. Various cellular and humoral defense mechanisms are activated, leading to specific changes within the inflammatory cascade. This defense mechanism represents an exaggerated response to harmful stressors, with inflammation driven by damage-associated molecular patterns (DAMPs) [ 22 ] and pathogen-associated molecular patterns (PAMPs) [ 23 ]. In severe trauma cases, this immune response can become unbalanced [ 24 ], resulting in a systemic inflammatory response. Immune homeostasis is disrupted, and the intense trauma load may trigger acute genetic changes [ 25 ]. Excessive immune cell activation may cause an "inflammatory storm," a response confirmed only in circulating neutrophils (known as the "genetic storm" hypothesis), which may persist throughout hospitalization [ 26 ]. For patients with unstable vital signs or severe trauma, performing extensive surgery prematurely (e.g., complete internal fixation) may trigger a "second hit," where the surgery-induced inflammatory response exacerbates systemic injury, potentially increasing the incidence of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF) [ 27 ]. Unlike other developed Western countries, China’s trauma care system differs significantly from those of Western nations like the United States and Germany, where advantages lie primarily in well-established pre-hospital emergency networks and tiered trauma centers [ 28 ]. China is actively promoting the establishment of regional and tiered trauma centers [ 29 ]. However, challenges in trauma care remain, including uneven distribution of medical resources, inadequate trauma care infrastructure, and insufficient early trauma management and multidisciplinary collaboration. These issues are compounded by systemic institutional limitations, regional disparities, and a lack of standardized training among healthcare professionals [ 30 ]. With advances in resuscitation, inflammation control, and coagulation management, treatment decision-making has become increasingly modular [ 31 ]. However, there are currently no reports on the optimal timing of fracture surgery for polytrauma patients in China. In most Chinese hospitals, the timing of surgery is typically inclined toward Damage Control Orthopedics (DCO) or delayed treatment to avoid secondary surgical injury. Our study is conducted within the practical context of China’s polytrauma management model. In the absence of bacteremia or infection at the surgical site [ 41 ], stable vital signs are a crucial inclusion criterion, requiring patients to maintain stable hemodynamics [ 32 ] and avoid shock. During initial resuscitation, blood pressure in hypotensive patients may be stabilized with vasopressors. Severe traumatic brain injury affects surgery [ 33 ], primarily by influencing vital signs such as respiration, heart rate, and hemodynamics, which increases the risk of intraoperative complications. A stable intracranial condition is defined as one where, after initial treatment (e.g., medication or surgery), there is no significant increase in intracranial bleeding, cerebral edema, or intracranial pressure spikes. It is unnecessary to wait for the patient’s consciousness to recover; stable vital signs alone are sufficient for proceeding with surgery [ 34 ]. For polytrauma patients managed with the DCO strategy or delayed surgery, factors influencing the timing of definitive fixation include skin injuries, visceral organ damage, non-orthopedic surgeries, and fever [ 35 ]. We recommend that febrile patients undergo surgery only when their temperature is below 38.5°C. Additionally, for patients with preoperative temperatures above 38.0°C, the temperature should show a downward trend over the previous two days, indicating temporary control of internal inflammation and suggesting that the patient can tolerate surgery. The SDS strategy includes numerous inflammatory markers [ 16 ], which can be cumbersome and may hinder frontline clinicians’ judgment. We aim to use simple, readily available criteria for patient assessment, with hemoglobin as a key parameter in routine blood tests due to its role in determining surgical tolerance. For elective surgeries, hemoglobin levels should generally be no less than 10 g/dL. Other trauma guidelines suggest maintaining hemoglobin between 7–9 g/dL for polytrauma patients with ongoing bleeding risk [ 36 ]. Considering that some polytrauma patients may experience substantial intraoperative bleeding (e.g., in pelvic fractures), we recommend a preoperative hemoglobin level above 9 g/dL to prevent severe postoperative anemia and hemodynamic instability. For most elective surgeries, a platelet count of at least 50×10^9/L is recommended to ensure sufficient coagulation capacity and minimize bleeding risk [ 37 ]. The white blood cell count and neutrophil percentage are key indicators of inflammation and potential infection, offering a direct assessment that aids in distinguishing infection types, evaluating infection severity, and predicting disease progression [ 38 ][ 39 ]. Currently, no studies correlate polytrauma surgical timing with these indicators. To enable earlier fracture fixation, we recommend that patients meet criteria of a white blood cell count < 22×10⁹/L and a neutrophil percentage < 90% for surgical eligibility. Additionally, if the white blood cell count exceeds 15.0×10⁹/L or the neutrophil percentage is above 85%, both should show a downward trend, signaling temporary control of the inflammatory response and the creation of an optimal surgical window. Methods From March 2023 to March 2024, 200 polytrauma patients with fractures admitted to the emergency surgery department of our hospital were selected. Inclusion criteria for fracture types focused on sites receiving initial definitive fixation rather than temporary fixation. In total, 250 fractures received definitive fixation in the first surgery, including the femur (n = 75), spine (n = 46), pelvic ring (n = 49), tibia (n = 25), acetabulum (n = 12), humerus (n = 12), and other fractures (n = 31) (e.g., clavicle, radius and ulna, calcaneus, scapula, patella). A retrospective study was conducted on patients undergoing initial surgery for single fracture reconstruction (n = 151), two-fracture reconstructions (n = 42), and three-fracture reconstructions (n = 5). Associated injuries included thoracic (n = 143), abdominal (n = 73), and head trauma (n = 123). The Injury Severity Score (ISS) selection criteria were defined. Data recorded included fracture characteristics, ISS, complications, vital signs, consciousness assessment, pain level, inflammatory markers, length of hospital stay, nursing records, surgical procedure names, and long-term follow-up results. Injury Severity Score (ISS) selection criteria were defined. Data recorded included fracture characteristics, ISS, complications, vital signs, consciousness assessment, pain level, inflammatory markers, length of hospital stay, nursing records, surgical procedure names, and long-term follow-up results. inclusion criteria All 200 cases involved polytrauma patients as defined by the 2014 “New Berlin Definition” [ 40 ], which estimates a mortality rate of up to 30% for polytrauma patients. The criteria specify significant injury (≥ 3 AIS points) in at least two distinct anatomical regions, along with at least one of the following five parameters: hypotension (SBP < 90 mmHg), altered consciousness (GCS score 1.4 or APTT > 40 seconds), or age > 70 years. Polytrauma assessment is generally based on the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). Exclusion criteria included fractures from low-energy mechanisms, fractures secondary to tumors, and fractures in skeletally immature patients. Our protocol recommends that patients meet the following preoperative criteria: (1) Stable vital signs: ① Body temperature 100 mmHg, maintained with vasopressors if necessary; ③ Stable traumatic brain injury status, with no signs of increased intracranial bleeding, worsening cerebral edema, or sudden intracranial pressure spikes. (2) Routine blood tests: ① White blood cell count 15.0 × 10⁹/L, it must show a downward trend over the preceding two days; ② Neutrophil percentage 85%, it should also trend downward over the previous two days; ③ Platelet count > 50 × 10⁹/L, with PT (11–14 s) and APTT (25–37 s) within normal limits; ④ Hemoglobin > 90 g/L. (3) No bacteremia and no infection near the surgical site. (4) Exclusion of patients with chronic fractures. Additionally, in both the experimental and control groups, no patients undergoing surgery had bacteremia or infections near the surgical area. Measurements of outcome Complications include sepsis, septicemia, deep vein thrombosis (DVT), multiple organ failure, pneumonia, and acute respiratory distress syndrome (ARDS). Sepsis [ 42 ] is defined as an infection with a confirmed site (e.g., pneumonia, abdominal, or urinary tract infection) and a qSOFA score increase > 2. Septicemia is indicated by a positive blood culture and at least two of the following criteria: temperature > 38.3°C or 90 bpm; tachypnea > 20 breaths per minute or arterial CO₂ partial pressure (PaCO₂) 7.7 mmol/L) without diabetes; acute change in mental status; leukocytosis (WBC count > 12×10⁹/L); leukopenia (WBC count 10% immature cells [ 43 ]. Proximal DVT in the knee joint is diagnosed via ultrasound. Multiple organ failure is defined as the failure of two or more organs for at least three consecutive days, with a score above 4 [ 44 ]. ARDS is characterized by a PaO₂/FiO₂ ratio below 200 for over four consecutive days without pneumonia [ 45 ] and diffuse infiltrates on chest X-ray. Pneumonia is defined by a quantitative culture obtained through bronchoscopy and bronchoalveolar lavage, performed at the discretion of the attending trauma intensivist, typically in response to new pulmonary infiltrates on chest X-ray and purulent sputum, with a temperature above 38°C and/or WBC count over 10,000/mL [ 45 ]. The timing of surgery is crucial for preventing or mitigating the “second hit” effect and can significantly influence its occurrence. Beyond monitoring complications (e.g., multiple organ failure, acute respiratory distress syndrome) to evaluate the “second hit” effect, a range of biomarkers, inflammatory indicators, and vital signs should be considered, including complete blood count (CBC), C-reactive protein (CRP), and procalcitonin (PCT). Changes in vital signs serve as early warning signals of the “second hit” effect. Persistent hypotension, elevated heart rate, tachypnea, and decreased oxygenation are critical indicators. We use the following criteria to assess the severity of the “second hit”: ① Temperature fluctuations: Postoperative temperature elevation is common due to surgical impact; among the 200 cases analyzed, 82.5% (n = 165) exhibited elevated temperature after surgery. Thus, the “temperature trend over the first three postoperative days” can serve as an assessment criterion. ② Level of consciousness: The Glasgow Coma Scale (GCS) score is used to measure consciousness. ③ Blood pressure variations: During resuscitation, unstable hemodynamics are often managed with vasopressors. Changes in vasopressor usage can substitute for direct blood pressure measurements, enabling us to assess stability by tracking vasopressor types and dosages used three days before and after surgery. ④ Respiratory function: Similar to blood pressure monitoring, we assess changes in spontaneous breathing capacity via ventilator usage, providing insight into the surgery’s impact on vital sign recovery. Incision Healing Classification: Postoperative incision healing is monitored based on documented descriptions in medical and nursing records and classified as follows: a. Grade A Healing: The incision site shows no redness, pain, subcutaneous fluid accumulation, infection, inflammation, or adverse reactions such as fat liquefaction. b. Grade B Healing: The incision site exhibits inflammatory responses, including redness, induration, hematoma, or fluid accumulation, but no abscess formation. c. Grade C Healing: The incision site shows clear signs of suppuration, requiring suture removal or incision drainage to clear necrotic tissue. Inflammatory Indicators: Like body temperature, both white blood cell (WBC) count and neutrophil percentage tend to increase postoperatively due to surgical impact. Among the 200 cases analyzed, postoperative WBC count and neutrophil percentage rose in 77.5% (n = 155) and 72.5% (n = 145) of patients compared to preoperative levels. Therefore, we monitor these trends over the first three postoperative days. Additionally, changes in C-reactive protein (CRP) and procalcitonin (PCT) levels before and after surgery are included in the analysis. Long-term follow-up outcomes include three key aspects: ① Fracture healing status at 9 months postoperatively. ② Joint mobility: For injuries in various regions, follow-up assessments are conducted using the Harris Hip Score[ 46 ], Constant Shoulder Score[ 47 ], Knee injury and Osteoarthritis Outcome Score (KOOS)[ 48 ], and the Oswestry Disability Index (for spinal injuries)[ 49 ]. Patients scoring below 70 on the percentile scale are categorized as having “poor joint mobility.” ③ Quality of life: Quality of life is assessed using the FS Post-Fracture Quality of Life Survey, which evaluates physical function, physical role, bodily pain, general health, vitality, social function, role limitations due to emotional issues, and mental health. For ease of interpretation, patients reporting “very poor” or “poor” outcomes in at least four of these eight domains are classified as having “poor quality of life”; otherwise, they are considered to have an acceptable quality of life. Statistical analysis Independent sample t-tests were used to compare continuous variables, while Pearson's chi-square test was applied for categorical variables. Based on adherence to our protocol for surgical timing, the study population was divided into experimental and control groups. Logistic regression models were constructed for binary outcomes. For length of hospital stay (LOS), ICU stay duration, and costs, a generalized linear regression model with a negative binomial distribution was used, as these variables are non-negative integers with a right-skewed distribution. Univariate and multivariate logistic regression, along with negative binomial regression, were applied to identify potential risk factors, including patient age, gender, Injury Severity Score (ISS), fracture type, and other injuries (e.g., head, chest, and abdominal trauma). All analyses were conducted by statisticians not involved in patient treatment, using the SPSS statistical software package. Statistical significance was set at p < 0.05 (two-tailed). Statement of ethical approval This study was approved by the Ethics Committee of Qilu Hospital of Shandong University (approval number: KYLL-202405-044.), Jinan, Shandong, China. Results A retrospective evaluation of 200 cases treated at our hospital between March 2023 and March 2024 was conducted based on established criteria. The cohort included 138 males and 62 females, with an average age of 47.24 ± 16.56 years and a mean Injury Severity Score (ISS) of 25.85 ± 13.35. Among these cases, 123 had head injuries, 143 had chest injuries, and 72 had abdominal injuries. Table 1 provides a statistical analysis of these factors and fracture types, showing that grouping was associated with age and ISS score, while no association was found with other factors. Table 1 Comparisons of Demographic Information in Patients Satisfying vs. Not Satisfying Surgical Criteria All patients(n = 200) protocol-compliant case(n = 97) protocol deviation case(n = 103) p value Male 138 61 77 0.07 Female 62 36 26 - Mean age (years) 47.46 ± 16.56 45.38 ± 16.97 48.79 ± 16.08 0.175 Mean ISS 25.85 ± 13.35 23.47 ± 12.37 28.69 ± 14.05 0.053 femoral fracture 70 28 42 0.078 pelvic fracture 49 23 26 0.801 Spinal fracture 45 21 24 0.780 Acetabular fracture 12 8 4 0.194 Tibial fracture 25 11 14 0.630 Humeral fracture 12 8 4 0.194 Other fractures 28 18 10 0.0702 With head injury 123 61 62 0.627 Without head injury 77 35 42 - With chest injury 143 68 75 0.671 Without chest injury 57 29 28 - With abdominal injury 72 37 35 0.54 Without abdominal injury 128 60 68 - Patients with 1 fracture 151 72 79 0.862 Patients with 2 fractures 42 20 22 - Patients with 3 fractures 5 3 2 - Among patients who met surgical criteria, 40.2% experienced complications, compared to 59.2% in those who did not meet the criteria (p = 0.0072). Pneumonia occurred in 23.7% and 42.7% of these groups, respectively (p = 0.0047, Table 2 ); deep vein thrombosis (DVT) in 22.6% and 26.7% (p = 0.672); and acute respiratory distress syndrome (ARDS) in 3.1% and 15.5% (p = 0.0067). There were 3 cases of sepsis, 4 cases of bacteremia, and 3 cases of multiple organ failure, all occurring in patients who did not meet surgical criteria. Due to the limited number of these cases, statistical analysis was not performed. A multivariate logistic regression model accounted for potential confounding factors such as age, gender, ISS, fracture type, and the type and severity of other system injuries. The analysis showed that both advanced age (p = 0.0074) and higher ISS scores (p = 0.0057) were associated with an increased complication rate. Notably, among patients with postoperative thoracic complications (ARDS and pneumonia), 83.8% (n = 57) had chest injuries. The incidence of thoracic complications was 39.3% in patients with chest injuries, compared to 19.3% in those without (p < 0.01). Additionally, analysis of the association between femoral fractures, pelvic/acetabular fractures, and lower extremity deep vein thrombosis revealed no statistically significant correlation. Table 2 Comparisons of Complication Rates in Patients Meeting vs. Not Meeting Surgical Criteria All patients protocol-compliant case protocol deviation case p value With complications 100 39 61 0.0072 Without complications 100 58 42 Pneumonia 67 23 44 0.0047 Without pneumonia 133 74 59 Deep vein thrombosis (DVT) 49 22 27 0.672 Without deep vein thrombosis (DVT) 151 75 76 Among the 200 patients, 65.5% (n = 131) exhibited a downward trend in temperature within the first three days postoperatively. In the experimental and control groups, this proportion was 68.1% and 66.3%, respectively (p = 0.647, Table 3 ). A total of 12% (n = 24) of patients required vasopressors pre- and post-surgery. Of these, six patients met surgical criteria, with three showing stable blood pressure compared to pre-surgery levels, while three showed no improvement or worsened. In the control group, 18 patients received vasopressors, with six showing improvement and 12 showing no improvement or worsening postoperatively (p = 0.465). Mechanical ventilation was used pre- and postoperatively in 22.5% (n = 45) of patients, including 11 in the experimental group and 34 in the control group. The likelihood of improved spontaneous breathing was 33.3% in the experimental group and 20% in the control group (p = 0.465). Among patients with poor or unchanged consciousness, 30% (n = 60) showed no significant change within the first three days postoperatively. This included 24 patients who met surgical criteria and 36 who did not, with an improvement probability of 66.7% (n = 16) in those meeting criteria and 33.3% (n = 12) in those not meeting criteria (p = 0.0112). No statistically significant differences were found in outcomes other than consciousness recovery. Table 3 Comparisons of changes of vital signs in Patients Satisfying vs. Not Satisfying Surgical Criteria Changes in basic vital signs All patients protocol-compliant case protocol deviation case p value Decreased body temperature 131 64 67 0.647 No decrease in body temperature 69 31 38 - stability of blood pressure 9 3 6 0.465 Unstable blood pressure 15 3 12 - Respiratory improvement 11 5 6 0.326 No Breathing improved 34 10 24 - Improvement in consciousness 28 16 12 0.0112 No improvement in consciousness 32 8 24 Nineteen patients experienced Grade 2 or Grade 3 healing, with 3 cases of Grade 2 and 2 cases of Grade 3 healing in the experimental group, and 5 cases of Grade 2 and 9 cases of Grade 3 healing in the control group. Among these 19 patients, 78.9% had open injuries. Defining Grade 2 and Grade 3 healing as “poor healing,” the incidence of poor healing was 5.2% (n = 5) in the experimental group and 13.6% (n = 14) in the control group (p = 0.0415). Among 176 patients, the three-day postoperative trend in white blood cell (WBC) count and neutrophil percentage was assessed. Within three days post-surgery, the WBC count showed a downward trend in 78.5% (n = 62) of the experimental group and 70.4% (n = 69) of the control group (p = 0.223, Table 4 ). The neutrophil percentage decreased in 74.4% (n = 58) of the experimental group and 72.4% (n = 71) of the control group (p = 0.776). In a comparison of pre- and postoperative CRP levels among 188 patients, 90 showed a decrease and 98 showed an increase, with improvement rates of 63.6% (n = 42) in the experimental group and 50.0% (n = 49) in the control group (p = 0.877). Similarly, for pre- and postoperative PCT levels among 144 patients, the improvement rate was 52.7% (n = 49) in the experimental group and 71.8% (n = 56) in the control group (p = 0.296). None of the inflammatory indicators studied reached statistical significance. The average hospital stay was 18.03 ± 8.50 days in the experimental group and 23.83 ± 15.78 days in the control group (p = 0.0014). The ICU stay duration averaged 8.93 ± 6.42 days in the experimental group and 15.25 ± 12.26 days in the control group (p < 0.001). The average cost was 125,600 ± 85,300 RMB in the experimental group and 212,000 ± 222,000 RMB in the control group (p < 0.001). Table 4 Comparisons of changes of Inflammatory marker or LOS or costs in Patients Satisfying vs. Not Satisfying Surgical Criteria Inflammatory marker changes or length of hospital stay or costs All patients protocol-compliant case protocol deviation case p value Decreased white blood cell count 131 62 69 0.223 No decrease in white blood cell count 46 17 29 - Decreased neutrophil percentage 129 58 71 0. 776 No decrease in neutrophil percentage 48 21 27 - Postoperative decrease in CRP 90 44 46 0.877 Postoperative increase in CRP 98 49 49 - Postoperative decrease in PCT 98 42 56 0.296 Postoperative increase in PCT 46 24 22 - Length of hospital stay (days) 21.02 ± 13.13 18.03 ± 8.50 15.25 ± 12.26 0.0014 ICU length of stay (days) 12.17 ± 10.33 8.93 ± 6.42 15.25 ± 12.26 <0.001 Cost (ten thousand yuan) 17.01 ± 17.51 12.56 ± 8.53 21.2 ± 22.20 <0.001 Long-term Follow-up Outcomes: Due to time constraints and loss to follow-up, only 111 patients were assessed at 9 months postoperatively, with 5 patients deceased. The fracture healing rate was 81.1% (n = 90), with healing rates of 82.4% (n = 42) in the experimental group and 80.0% (n = 48) in the control group. Good joint mobility outcomes were achieved in 50.4% (n = 56) of patients, with 64.0% (n = 32) in the experimental group and 39.3% (n = 24) in the control group (p = 0.0097, Table 5 ). The proportion of patients with an "acceptable quality of life" was 71.9% (n = 41) in the experimental group and 44.4% (n = 24) in the control group (p = 0.0028). Among the 111 patients in the follow-up survey, 41.4% (n = 12) of those with spinal injuries reported a better quality of life, compared to 64.6% (n = 17) of those without spinal injuries (p < 0.05). Severe femoral fractures are often challenging to heal; in the follow-up results, the healing rate for femoral fractures was 68.6% (n = 24), compared to 86.8% (n = 66) for non-femoral fractures (p = 0.022). Table 5 Comparison of Long-term follow-up results vital signs in Patients Satisfying vs. Not Satisfying Surgical Criteria Long-term follow-up results All patients protocol-compliant case protocol deviation case p value Fracture healed 90 42 48 0.920 Fracture not healed 21 9 12 - Good joint mobility 56 32 24 0.0097 Poor joint mobility 55 18 37 - Good quality of life 65 41 24 0.0028 Poor quality of life 46 16 30 - Discussion In China, pre-hospital emergency care primarily relies on independent emergency command centers and large hospitals. The pre-hospital emergency care model is varied and often influenced by individual interests, making objective and scientific triage challenging for hospitals[ 50 ]. In-hospital emergency care is categorized into three types: the multidisciplinary team (MDT) model, led by the critical care unit with participation from other departments; the integrated emergency care model; and the most common approach, involving temporary specialized consultations. Common issues include poor coordination, low efficiency, and a lack of long-term planning. Our emergency care model is based on the integrated approach. Additionally, there is no trauma registry system. Although China has a large and diverse trauma patient population, the lack of data registration significantly limits information availability for scientific research[ 51 ]. The primary goal of our surgical protocol is to optimize the treatment of polytrauma patients by reducing complications and improving postoperative recovery. The efficacy of any treatment protocol relies on the following key characteristics: ① simplicity, ease of recall, and ease of implementation; ② association with consistent outcomes, regardless of the decision-makers involved; and ③ applicability to a broad patient population without altering risk. Vital signs and inflammatory markers are routinely accessible, rapidly obtained, and low-cost, making them well-suited for large-scale use. Moreover, the selected parameters are controllable, maintainable, and monitorable. For instance, hemodynamically unstable patients can be stabilized with medication and monitored via electrocardiography. Studies indicate that in patients with traumatic brain injury (TBI) and fractures, the incidence of delayed fracture healing decreases as TBI severity increases, suggesting that the central nervous system may regulate bone metabolism [ 52 ]. TBI appears to enhance this effect, promoting fracture healing, with similar patterns observed in patients with concomitant spinal cord injuries[ 53 ]. Conversely, limb fractures may negatively regulate brain injury, potentially exacerbating it[ 54 ]. Our study also demonstrates that fracture reconstruction under appropriate conditions can facilitate recovery of consciousness in patients. For patients with severe brain injury and shock, resuscitation should prioritize maintaining blood volume to keep central venous and pulmonary artery pressures within normal ranges rather than dehydration therapy. Once shock is corrected, internal fixation of fractures should be performed as early as possible. Certain types of cranial trauma may serve as absolute contraindications for surgeries in other areas; however, this is not definitive and depends on the likelihood of severe complications, such as elevated intracranial pressure, cerebral edema, or brain herniation, which can affect other vital signs (e.g., heart rate, respiration, blood pressure, temperature), thereby increasing surgical risk and complexity. Resuscitation strategies for polytrauma patients with abdominal injuries include using “open treatment” to prevent and alleviate post-traumatic abdominal compartment syndrome, followed by delayed abdominal wall closure [ 55 ]. Surgeons often delay fracture surgery due to perceived surgical risks, subjecting patients to preventable complications associated with prolonged immobilization. In polytrauma, the timing of fracture fixation should not be based solely on concerns about an open abdomen. Instead, primary consideration should be given to the patient’s physiological stability (e.g., hemodynamics, coagulation, inflammatory response, and infection) in polytrauma patients with fractures and abdominal injuries. When physiological status is stable, attention should focus on the risk of cross-infection between the fracture site and the open abdominal wound. Maintaining sufficient distance between the fracture incision and abdominal or other contaminated wounds allows for early fracture stabilization, promoting recovery while preventing cross-infection. Currently, no reports identify thoracic injuries as absolute contraindications to fracture reconstruction, so emphasis should remain on the patient’s physiological stability. The primary reason for delayed fracture treatment often stems from the trauma surgeon’s judgment [ 56 ]. In cases of severe head or abdominal injury, surgeons may choose to delay treatment even when patients meet resuscitation standards based on inflammatory markers. Literature suggests that patients with delayed fracture fixation have a significantly higher incidence of sepsis[ 57 ]. In these patients, immune system imbalance and increased intestinal permeability make bacterial translocation more likely. Prolonged bed rest and mechanical ventilation due to delayed fixation further extend the risk period, increasing the likelihood of bacterial translocation and infection. Additionally, in patients with open wounds or surgical sites near infected tissue or abscesses, even timely debridement may compromise healing and elevate the risk of sepsis. A reduction in complications is also associated with critical care monitoring and ventilation strategies, which vary according to hospital resuscitation standards. In our study, the limited number of patients with concurrent sepsis and bacteremia prevented us from conclusively determining the relationship between fracture fixation timing and the incidence of sepsis and bacteremia. We advocate for early surgical intervention; however, China’s triage system is underdeveloped, and the in-hospital emergency care model lacks standardized protocols, leading to considerable variability in treatment timing and approaches across regions. Consequently, the Damage Control Orthopedics (DCO) strategy is commonly adopted. Considering China’s healthcare context, our study assesses patient resuscitation levels and physiological status, recommending surgery as soon as surgical criteria are met to reduce complications and enhance the approach’s applicability. This study provides only a preliminary investigation into surgical timing based on clinical experience, and many questions in this area require further exploration. Several limitations should be noted. Our reliance on retrospective data may result in omissions and inaccuracies when assessing postoperative outcomes, such as wound healing classification. To gain a more complete understanding of postoperative infection outcomes, additional prospective research and comprehensive statistical analysis are needed. We included postoperative inflammatory markers and changes in vital signs to assess the “second hit” effect of surgery; however, this approach may not fully capture the impact of the second hit, underscoring the need to establish evaluation criteria for this effect. Additionally, factors associated with deep vein thrombosis warrant further study. Conclusions For polytrauma patients with fractures, those who underwent fracture surgery after meeting the study’s surgical criteria experienced fewer early postoperative pulmonary complications, faster recovery of consciousness, lower incision infection rates, shorter overall and ICU stays, reduced costs, and improved postoperative outcomes compared to those who did not meet the criteria. Our protocol is safe and effective for most polytrauma patients with mechanically unstable femoral, pelvic, acetabular, or spinal fractures requiring fixation. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Qilu Hospital of Shandong University (approval number: KYLL-202405-044.), Jinan, Shandong, China. Competing interest The authors declare no competing interests. Funding: This research received no external funding. Author Contribution Conceptualization: Dr. SangMethodology: Dr. Sang and Dr. DingFormal analysis: Dr. DingInvestigation**: Dr. Jia and Dr. HanData Curation: Dr. DingWriting: Original Draft: Dr. Ding and Dr. ZhangWriting—Review & Editing: Dr. Zhao and Dr. ZhangSupervision: Dr. SangProject Administration: Dr. SangAll authors reviewed the manuscript Acknowledgement The authors would like to thank all individuals who contributed to this work but do not meet the criteria for authorship, including those who provided professional writing assistance or supplied materials. Data Availability The data supporting the findings of this study were collected by the authors. Due to privacy, the data are available from the corresponding author upon reasonable request. References LOZANO R，NAGHAVI M，FOREMAN K，et al．Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010［J］．Lancet， 2012，380( 9859) : 2095-2128． Wang Y, Wang C, Hu P, et al. China trauma treatment statistics 2019: A national retrospective study based on hospitalized cases. Front Public Health. 2023;11:1116828. Published 2023 Feb 24. doi:10.3389/fpubh.2023.1116828 Tisherman SA, Schmicker R, Brasel K, Bulger E, Kerby J, Minei P, et al. De- tailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Ann Surg 2015;261:586–90 PMID: 34048424. Teixeira PGR. Preventable or potentially preventable mortality at a mature trauma center. J Trauma Acute Care Surg 2007;63:1338–47. Sobrino J, Shafi S. Timing and causes of death after injuries. Proceedings 2013;26:120–3. M.J., El, Mekkaoui., R.A., Bassir., M.O., Lamrani. (2023). Early Definitive Care (EDC) VS Damage Control Orthopedics (DCO) in the Management of Femoral Shaft Fractures in Polytrauma Patients. Scholars journal of medical case reports, 11(05):970-975. doi: 10.36347/sjmcr.2023.v11i05.057 Ricardo, J., Roman., Felix, Klingebiel., Sascha, Halvachizadeh., Yannik, Kalbas., Hans-Christoph, Pape. (2023). Clearing of Polytrauma Patients for Early Definitive Fracture Fixation: A Systematic Literature Review. British Journal of Surgery, 110(Supplement_5) doi: 10.1093/bjs/znad178.052 Bone LB, Johnson KD, Weigelt J & Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. Journal of Bone and Joint Surgery. American Volume 1989 71 336–340. Pape HC, Giannoudis P & Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. American Journal of Surgery 2002 183 622–629. Moghtadaei M, Otoukesh B, Pazoki-­Toroudi H, Boddouhi B, Yeganeh A.Evaluation of inflammatory response in patients undergoing surgical treatment forearly and delayed femoral fractures. Arch Med Sci. 2019;15(1):141–145. Giannoudis PV, Tan HB, Perry S, Tzioupis C & Kanakaris NK. The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device. Injury 2010 41(Supplement 2) S57–S61. Pape HC, Andruszkow H, Pfeifer R, Hildebrand F & Barkatali BM. Options and hazards of the early appropriate care protocol for trauma patients with major fractures: towards safe definitive surgery. Injury 2016 47 787–791. Giannoudis PV, Giannoudis VP & Horwitz DS. Time to think outside the box: 'Prompt-Individualised-Safe Management' (PR.I.S.M.) should prevail in patients with multiple injuries. Injury 2017 48 1279–1282. Pape HC, Pfeifer R. Safe definitive orthopaedic surgery (SDS): repeated assessment for tapered application of Early Definitive Care and Damage Control?: an inclusive view of recent advances in polytrauma management. Injury. 2015;46(1):1-3. Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury. 2019;50(10):1656-1670. doi:10.1016/j.injury.2019.09.021 Pfeifer R, Klingebiel FK, Halvachizadeh S, Kalbas Y, Pape HC. How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature. Injury. 2023;54(2):292-317. doi:10.1016/j.injury.2022.11.008 Pape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491-501. Pape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26(11):1478-1484. doi:10.1002/jor.20697 NahmN,ComoJJ,WiliberJH,VallierHA.Earlyappropriatecare:definitivestabilzationffemorarueswihnhursafimuiliyerpatients.JTrauma.2011:71:175-85. Timothy, A., Moore., Natasha, M, Simske., Heather, A., Vallier. (2020). Fracture fixation in the polytrauma patient: Markers that matter. Injury-international Journal of The Care of The Injured, 51 doi: 10.1016/J.INJURY.2019.12.024 Robert, V, O'Toole.Timing of Fracture Fixation. 367-388. Lord JM, Midwinter MJ, Chen YF, et al. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet. 2014;384(9952):1455-1465. doi:10.1016/S0140-6736(14)60687-5 Pape H-C, Remmers D, Grotz M, Kotzerke J, Glinski S, van Griensven M, Dahlweid M, Sznidar S, Tscherne H. Reticuloendothelial system activ- ity and organ failure in multiply injured patients. Archives of Surgery 1999;134:421–7. Billiar TR, Vodovotz Y. Time for trauma immunology. PLoS Med 2017;14:e1002342 [PubMed: 28700602]. Richter M, Krettek C, Otte D, Wiese B, Stalp M, Ernst S, et al. Correlation be- tween crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study. J Trauma 2001;51(1):10–16 JulPMID: 11468457. doi:10.1097/00005373-200107000-00002. Xiao X. Seok J A genomic storm in critically injured humans. J Exp Med 2011;208(13):2581–90. Hans-Christoph, Pape., E., Moore., T., McKinley., Angela, Sauaia. (2022). Pathophysiology in patients with polytrauma.. Injury-international Journal of The Care of The Injured, 53(7):2400-2412. doi: 10.1016/j.injury.2022.04.009 Polytrauma Guideline Update Group. Level 3 guideline on the treatment of patients with severe/multiple injuries : AWMF Register-Nr. 012/019. Eur J Trauma Emerg Surg. 2018;44(Suppl 1):3-271. doi:10.1007/s00068-018-0922-y Liu T, Bai XJ. Trauma care system in China. Chin J Traumatol. 2018;21(2):80-83. doi:10.1016/j.cjtee.2017.06.004 J., M., Zhou., T, B, Wang., B, Jiang. (2022). [Current situation and development of Chinese trauma care system].. 60 12(12):1045-1048. doi: 10.3760/cma.j.cn112139-20220429-00192 Baoguo, Jiang.(2015). The challenges faced in the field of trauma care in China. Chinese journal of surgery, 53(6):401-404. doi:10.3760/CMA.J.ISSN.0529-5815.2015.06.001 Pape HC, Barthels M, van Griensven M, Krettek C, Das Gupta R, Tsch- erne H. Biochemical changes following trauma and skeletal surgery of the lower extremity – quantification of the operative burden. Criti Care Med 2000;28(10):3441–8. Grey, B., Rodseth, R., ALbert, Inkosi. (2018). Early Fracture Stabilisation In The Presence Of Subclinical Hypo-Perfusion. Sumit, Sinha., Raghavendra, Nayak., Sumit, Sinha. (2024). Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability. Clinical Neurology and Neurosurgery, 245:108494-108494. doi: 10.1016/j.clineuro.2024.108494 Christian, Krettek., Robin, G., Simon., Harald, Tscherne. (1998). Management priorities in patients with polytrauma. Langenbeck's Archives of Surgery, 383(3):220-227. doi: 10.1007/S004230050122 Alessandro, Aprato., Davide, RUSCITTI., Roberto, RACCA., Erica, Del, Grosso., Alessandro, Massè. (2024). Which factors influence timing in polytrauma?. Minerva orthopedics, 75(1) doi: 10.23736/s2784-8469.23.04373-0 Marc, Maegele. (2021). The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline.. Journal of Clinical Medicine, 10(2):362-. doi: 10.3390/JCM10020362 Al-Samkari H, Marshall AL, Goodarzi K, Kuter DJ. Romiplostim for the management of perioperative thrombocytopenia. Br J Haematol. 2018;182(1):106-113.doi:10.1111/bjh.15280 García-Escobar A, Vera-Vera S, Tébar-Márquez D, et al. Neutrophil-to-lymphocyte ratio an inflammatory biomarker, and prognostic marker in heart failure, cardiovascular disease and chronic inflammatory diseases: New insights for a potential predictor of anti-cytokine therapy responsiveness. Microvasc Res. 2023;150:104598. doi:10.1016/j.mvr.2023.104598 Wiradi, Suryanegara., Vidi, Posdo, Ahapta, Simarmata. (2022). Sepsis Due to Bacterial Infection: An Analysis based on Ratio Count of Neutrophil – Lymphocyte. Journal of Drug Delivery and Therapeutics, 12(5-S):75-81. doi: 10.22270/jddt.v12i5-s.5632 Pape HC,Lefering R,Butcher N,et al.The definition of polytrauma revisited:an international consensus process and proposal of the new ‘Berlin definition’[J].J Trauma Acute Care Surg,2014,77(5):780-786.DOI:10.1097/ TA.0000000000000453. Astagneau P, Rioux C, Golliot F, Brücker G; INCISO Network Study Group. Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance. J Hosp Infect. 2001;48(4):267-274. doi:10.1053/jhin.2001.1003 Font, M. D., Thyagarajan, B., & Khanna, A. K. (2020). Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making. The Medical clinics of North America, 104(4), 573–585. https://doi.org/10.1016/j.mcna.2020.02.011 DellingerRP,LevyMM,CarletJM,BionJ,ParkerMM,JaeschkeR,etal.InternationalSurvivingSepsisCampaignGuidelinesCommittee. Survivingsepsiscampaign:internationalguidelinesformanagementofseveresepsisandsepticshock2008.CritCareMed.200836:296-327. Durham RM, Moran JJ, Mazuski JE, Shapiro MU, Baue AE, Flint LM.Multiple organ failure in trauma patients. J Trauma. 2003:55:608-16. Harris W H. Traumatic arthritis of the hip after dislocation and acetabular fractures;treatment by mold arthroplasty[J]. J Bone Joint Surg (Am), 1969, 51:737-755. Roos EM, Roos PH,Lohmander LS,et al.Knee injury and Osteoarthritis Outcome Score(KOOS). Development of a self-administered outcome measure. J Orthop Sports Phys Ther,1998,28(2):88-96. Constant C R, Murley A H. A clinical method functional assessment of the shoulder[J]. Clin Orthop Relat Res, 1987, 21(4):160-1 Fibank J, Pynsent P. The Oswestry disability index[J]. Spine,2000,25:2940-2953. American Thoracic Society. Documents approved by ATS Board of Directors,Dec 2004. Guidelines for the management of adults with hospital-acquired,ventilator-associated, and healthcare-associated pneumonia. Am J Respir CritCare Med. 2005;171:388-416. Johnson G. Trauma Triage and Trauma System Performance. West J Emerg Med. 2016;17(3):331-332. doi:10.5811/westjem.2016.2.29900 Jing, Zhou., Tianbing, Wang., Igor, Belenkiy., Timothy, Craig, Hardcastle., Jean-Jacques, Rouby., Baoguo, Jiang. (2021). Management of severe trauma worldwide: implementation of trauma systems in emerging countries: China, Russia and South Africa. Critical Care, 25(1):286-. doi: 10.1186/S13054-021-03681-8） Garbe A, Graef F, Appelt J, et al. Leptin Mediated Pathways Stabilize Posttraumatic Insulin and Osteocalcin Patterns after Long Bone Fracture and Concomitant Traumatic Brain Injury and Thus Influence Fracture Healing in a Combined Murine Trauma Model. Int J Mol Sci. 2020;21(23):9144. Liu W, Chen W, Xie M, et al. Traumatic brain injury stimulates sympathetic tone-mediated bone marrow myelopoiesis to favor fracture healing. Signal Transduct Target Ther. 2023;8(1):260. Mollahosseini M, Ahmadirad H, Goujani R, Khorramdelazad H. The Association Between Traumatic Brain Injury and Accelerated Fracture Healing: A Study on the Effects of Growth Factors and Cytokines. J Mol Neurosci. 2021;71(1):162-168. Roberts DJ, Bobrovitz N, Zygun DA, et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015;79(4):568-579. Vallier HA, Moore TA, Como JJ, et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155. Published 2015 Oct 1. doi:10.1186/s13018-015-0298-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Apr, 2025 Read the published version in World Journal of Emergency Surgery → Version 1 posted Editorial decision: Accepted 07 Apr, 2025 Reviews received at journal 03 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviews received at journal 06 Dec, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviewers invited by journal 11 Nov, 2024 Editor assigned by journal 10 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 04 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5388963","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":381950777,"identity":"d2333392-efa3-438c-8ee6-d75426ee5d79","order_by":0,"name":"Chenning Ding","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Chenning","middleName":"","lastName":"Ding","suffix":""},{"id":381950778,"identity":"39131163-4f4c-4a97-a09c-4c63fae67114","order_by":1,"name":"Mingwang Jia","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Mingwang","middleName":"","lastName":"Jia","suffix":""},{"id":381950779,"identity":"43416e65-b76a-4978-a123-dc330d01f1c9","order_by":2,"name":"Xing Han","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Han","suffix":""},{"id":381950780,"identity":"4dda58a5-bbb6-4f2b-abd6-2c45090c5350","order_by":3,"name":"Jiahui Zhang","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Jiahui","middleName":"","lastName":"Zhang","suffix":""},{"id":381950781,"identity":"a7585f01-a487-46a8-b164-3957ef655b1a","order_by":4,"name":"Xin Zhao","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Zhao","suffix":""},{"id":381950782,"identity":"a061fe6b-d489-492a-bdea-c784a58dc63c","order_by":5,"name":"Xiguang Sang","email":"data:image/png;base64,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","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Xiguang","middleName":"","lastName":"Sang","suffix":""}],"badges":[],"createdAt":"2024-11-04 14:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5388963/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5388963/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13017-025-00607-5","type":"published","date":"2025-04-16T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81050915,"identity":"4216856e-b99e-4741-b38d-7db621fe5a96","added_by":"auto","created_at":"2025-04-21 16:06:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":831805,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5388963/v1/c6d8dbff-e5ab-4de1-b0cf-6b545064fe14.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA China-Based Exploration of Surgical Timing for Polytrauma with a Focus on Fracture Reconstruction\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, trauma has become the fourth leading threat to human health[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]and is the leading cause of death among young adults under 44 in China [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. During the early stages of in-hospital treatment for polytrauma, life-threatening complications, such as massive hemorrhage, the lethal triad, and septic shock, are common. In later treatment stages, challenges arise from organ failure, wound infections, and fracture reconstruction issues, all of which impact patient outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Managing polytrauma patients is a complex and dynamic process [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Early definitive treatment is crucial; selecting the optimal timing for surgery and promptly performing fracture reconstruction and limb rehabilitation in severe polytrauma cases can significantly reduce pulmonary and other early complications [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, in patients whose physiological functions have not yet stabilized, early fracture surgery is associated with severe complications, as excessive surgical intervention may cause further soft tissue injury and blood loss, worsening the patient's condition [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Currently, there are no clear guidelines on the optimal timing for early surgery in polytrauma patients with fractures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Thus, establishing a clear model for polytrauma management and identifying physiological indicators in severe polytrauma patients to guide fracture reconstruction timing is essential for effective treatment.\u003c/p\u003e \u003cp\u003eInternationally, polytrauma management strategies have continued to evolve. The Early Total Care (ETC) approach, introduced in the 1980s, was based on advancements in fracture fixation and anesthesia techniques [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, ETC\u0026rsquo;s \u0026ldquo;second hit\u0026rdquo; effect\u0026mdash;triggering systemic inflammation\u0026mdash;led to the development of the Damage Control Orthopedics (DCO) approach [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. DCO defers definitive surgery until the patient\u0026rsquo;s physiological functions stabilize, but it has been associated with poorer recovery and a higher incidence of complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Early Appropriate Care (EAC) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] aims to perform definitive fracture fixation within 36 hours post-injury, after sufficient resuscitation (lactate\u0026thinsp;\u0026lt;\u0026thinsp;4.0 mmol/L, base excess \u0026ge;-5.5 mmol/L, pH\u0026thinsp;\u0026ge;\u0026thinsp;7.25). It was later recognized, however, that reducing metabolic acidosis alone should not be the sole criterion for resuscitation success. EAC has faced criticism, as metabolic status, while significant, is not the only factor that should guide treatment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, the Safe Definitive Surgery (SDS) strategy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] was introduced to balance the approaches of Damage Control Orthopedics (DCO) and Early Appropriate Care (EAC). The SDS strategy categorizes patients into marginal, unstable, and extreme groups to determine DCO indications, resulting in a lower complication rate [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, including \u0026ldquo;severe thoracic, pelvic, and/or limb injuries\u0026rdquo; as criteria for unstable or other classifications has led to delays in definitive fixation for some patients, which is not universally endorsed. Patients with severe thoracic injuries face a higher risk of pulmonary complications when definitive fixation is delayed [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although various institutions have researched parameter definitions for risk factors across two different time periods, there is still a lack of objective criteria for assessing patient status [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Early fixation often has advantages, but the timing must be individualized based on the patient's condition and injury severity. This nuanced approach helps ensure optimal outcomes in complex trauma cases [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, early fracture fixation can significantly reduce pulmonary and other early complications, shorten hospital stays and costs, enhance patient mobility, and alleviate pain and systemic inflammatory response syndrome (SIRS) associated with unstable fractures [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The pathophysiology of polytrauma involves a complex network of interactions: acute hemorrhage and hypoperfusion, along with soft tissue injury, activate the immune system, triggering coagulation and inflammatory responses. Various cellular and humoral defense mechanisms are activated, leading to specific changes within the inflammatory cascade. This defense mechanism represents an exaggerated response to harmful stressors, with inflammation driven by damage-associated molecular patterns (DAMPs) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and pathogen-associated molecular patterns (PAMPs) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In severe trauma cases, this immune response can become unbalanced [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], resulting in a systemic inflammatory response. Immune homeostasis is disrupted, and the intense trauma load may trigger acute genetic changes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Excessive immune cell activation may cause an \"inflammatory storm,\" a response confirmed only in circulating neutrophils (known as the \"genetic storm\" hypothesis), which may persist throughout hospitalization [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For patients with unstable vital signs or severe trauma, performing extensive surgery prematurely (e.g., complete internal fixation) may trigger a \"second hit,\" where the surgery-induced inflammatory response exacerbates systemic injury, potentially increasing the incidence of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnlike other developed Western countries, China\u0026rsquo;s trauma care system differs significantly from those of Western nations like the United States and Germany, where advantages lie primarily in well-established pre-hospital emergency networks and tiered trauma centers [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. China is actively promoting the establishment of regional and tiered trauma centers [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, challenges in trauma care remain, including uneven distribution of medical resources, inadequate trauma care infrastructure, and insufficient early trauma management and multidisciplinary collaboration. These issues are compounded by systemic institutional limitations, regional disparities, and a lack of standardized training among healthcare professionals [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. With advances in resuscitation, inflammation control, and coagulation management, treatment decision-making has become increasingly modular [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, there are currently no reports on the optimal timing of fracture surgery for polytrauma patients in China. In most Chinese hospitals, the timing of surgery is typically inclined toward Damage Control Orthopedics (DCO) or delayed treatment to avoid secondary surgical injury. Our study is conducted within the practical context of China\u0026rsquo;s polytrauma management model.\u003c/p\u003e \u003cp\u003eIn the absence of bacteremia or infection at the surgical site [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], stable vital signs are a crucial inclusion criterion, requiring patients to maintain stable hemodynamics [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and avoid shock. During initial resuscitation, blood pressure in hypotensive patients may be stabilized with vasopressors. Severe traumatic brain injury affects surgery [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], primarily by influencing vital signs such as respiration, heart rate, and hemodynamics, which increases the risk of intraoperative complications. A stable intracranial condition is defined as one where, after initial treatment (e.g., medication or surgery), there is no significant increase in intracranial bleeding, cerebral edema, or intracranial pressure spikes. It is unnecessary to wait for the patient\u0026rsquo;s consciousness to recover; stable vital signs alone are sufficient for proceeding with surgery [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor polytrauma patients managed with the DCO strategy or delayed surgery, factors influencing the timing of definitive fixation include skin injuries, visceral organ damage, non-orthopedic surgeries, and fever [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. We recommend that febrile patients undergo surgery only when their temperature is below 38.5\u0026deg;C. Additionally, for patients with preoperative temperatures above 38.0\u0026deg;C, the temperature should show a downward trend over the previous two days, indicating temporary control of internal inflammation and suggesting that the patient can tolerate surgery.\u003c/p\u003e \u003cp\u003eThe SDS strategy includes numerous inflammatory markers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which can be cumbersome and may hinder frontline clinicians\u0026rsquo; judgment. We aim to use simple, readily available criteria for patient assessment, with hemoglobin as a key parameter in routine blood tests due to its role in determining surgical tolerance. For elective surgeries, hemoglobin levels should generally be no less than 10 g/dL. Other trauma guidelines suggest maintaining hemoglobin between 7\u0026ndash;9 g/dL for polytrauma patients with ongoing bleeding risk [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Considering that some polytrauma patients may experience substantial intraoperative bleeding (e.g., in pelvic fractures), we recommend a preoperative hemoglobin level above 9 g/dL to prevent severe postoperative anemia and hemodynamic instability. For most elective surgeries, a platelet count of at least 50\u0026times;10^9/L is recommended to ensure sufficient coagulation capacity and minimize bleeding risk [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe white blood cell count and neutrophil percentage are key indicators of inflammation and potential infection, offering a direct assessment that aids in distinguishing infection types, evaluating infection severity, and predicting disease progression [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e][\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, no studies correlate polytrauma surgical timing with these indicators. To enable earlier fracture fixation, we recommend that patients meet criteria of a white blood cell count\u0026thinsp;\u0026lt;\u0026thinsp;22\u0026times;10⁹/L and a neutrophil percentage\u0026thinsp;\u0026lt;\u0026thinsp;90% for surgical eligibility. Additionally, if the white blood cell count exceeds 15.0\u0026times;10⁹/L or the neutrophil percentage is above 85%, both should show a downward trend, signaling temporary control of the inflammatory response and the creation of an optimal surgical window.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrom March 2023 to March 2024, 200 polytrauma patients with fractures admitted to the emergency surgery department of our hospital were selected. Inclusion criteria for fracture types focused on sites receiving initial definitive fixation rather than temporary fixation. In total, 250 fractures received definitive fixation in the first surgery, including the femur (n\u0026thinsp;=\u0026thinsp;75), spine (n\u0026thinsp;=\u0026thinsp;46), pelvic ring (n\u0026thinsp;=\u0026thinsp;49), tibia (n\u0026thinsp;=\u0026thinsp;25), acetabulum (n\u0026thinsp;=\u0026thinsp;12), humerus (n\u0026thinsp;=\u0026thinsp;12), and other fractures (n\u0026thinsp;=\u0026thinsp;31) (e.g., clavicle, radius and ulna, calcaneus, scapula, patella). A retrospective study was conducted on patients undergoing initial surgery for single fracture reconstruction (n\u0026thinsp;=\u0026thinsp;151), two-fracture reconstructions (n\u0026thinsp;=\u0026thinsp;42), and three-fracture reconstructions (n\u0026thinsp;=\u0026thinsp;5). Associated injuries included thoracic (n\u0026thinsp;=\u0026thinsp;143), abdominal (n\u0026thinsp;=\u0026thinsp;73), and head trauma (n\u0026thinsp;=\u0026thinsp;123). The Injury Severity Score (ISS) selection criteria were defined. Data recorded included fracture characteristics, ISS, complications, vital signs, consciousness assessment, pain level, inflammatory markers, length of hospital stay, nursing records, surgical procedure names, and long-term follow-up results. Injury Severity Score (ISS) selection criteria were defined. Data recorded included fracture characteristics, ISS, complications, vital signs, consciousness assessment, pain level, inflammatory markers, length of hospital stay, nursing records, surgical procedure names, and long-term follow-up results.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003einclusion criteria\u003c/h2\u003e \u003cp\u003eAll 200 cases involved polytrauma patients as defined by the 2014 \u0026ldquo;New Berlin Definition\u0026rdquo; [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], which estimates a mortality rate of up to 30% for polytrauma patients. The criteria specify significant injury (\u0026ge;\u0026thinsp;3 AIS points) in at least two distinct anatomical regions, along with at least one of the following five parameters: hypotension (SBP\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg), altered consciousness (GCS score\u0026thinsp;\u0026lt;\u0026thinsp;8), acidosis (BE\u0026thinsp;\u0026ge;\u0026thinsp;6.0), coagulopathy (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.4 or APTT\u0026thinsp;\u0026gt;\u0026thinsp;40 seconds), or age\u0026thinsp;\u0026gt;\u0026thinsp;70 years. Polytrauma assessment is generally based on the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). Exclusion criteria included fractures from low-energy mechanisms, fractures secondary to tumors, and fractures in skeletally immature patients.\u003c/p\u003e \u003cp\u003eOur protocol recommends that patients meet the following preoperative criteria: (1) Stable vital signs: ① Body temperature\u0026thinsp;\u0026lt;\u0026thinsp;38.5℃; if above 38.0℃, it should show a downward trend over the previous two days; ② Systolic blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;100 mmHg, maintained with vasopressors if necessary; ③ Stable traumatic brain injury status, with no signs of increased intracranial bleeding, worsening cerebral edema, or sudden intracranial pressure spikes. (2) Routine blood tests: ① White blood cell count\u0026thinsp;\u0026lt;\u0026thinsp;22.0 \u0026times; 10⁹/L; if\u0026thinsp;\u0026gt;\u0026thinsp;15.0 \u0026times; 10⁹/L, it must show a downward trend over the preceding two days; ② Neutrophil percentage\u0026thinsp;\u0026lt;\u0026thinsp;90%; if\u0026thinsp;\u0026gt;\u0026thinsp;85%, it should also trend downward over the previous two days; ③ Platelet count\u0026thinsp;\u0026gt;\u0026thinsp;50 \u0026times; 10⁹/L, with PT (11\u0026ndash;14 s) and APTT (25\u0026ndash;37 s) within normal limits; ④ Hemoglobin\u0026thinsp;\u0026gt;\u0026thinsp;90 g/L. (3) No bacteremia and no infection near the surgical site. (4) Exclusion of patients with chronic fractures. Additionally, in both the experimental and control groups, no patients undergoing surgery had bacteremia or infections near the surgical area.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurements of outcome\u003c/h3\u003e\n\u003cp\u003eComplications include sepsis, septicemia, deep vein thrombosis (DVT), multiple organ failure, pneumonia, and acute respiratory distress syndrome (ARDS). Sepsis [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] is defined as an infection with a confirmed site (e.g., pneumonia, abdominal, or urinary tract infection) and a qSOFA score increase\u0026thinsp;\u0026gt;\u0026thinsp;2. Septicemia is indicated by a positive blood culture and at least two of the following criteria: temperature\u0026thinsp;\u0026gt;\u0026thinsp;38.3\u0026deg;C or \u0026lt;\u0026thinsp;36.0\u0026deg;C; tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;90 bpm; tachypnea\u0026thinsp;\u0026gt;\u0026thinsp;20 breaths per minute or arterial CO₂ partial pressure (PaCO₂)\u0026thinsp;\u0026lt;\u0026thinsp;32 mmHg; hyperglycemia (blood glucose\u0026thinsp;\u0026gt;\u0026thinsp;7.7 mmol/L) without diabetes; acute change in mental status; leukocytosis (WBC count\u0026thinsp;\u0026gt;\u0026thinsp;12\u0026times;10⁹/L); leukopenia (WBC count\u0026thinsp;\u0026lt;\u0026thinsp;4\u0026times;10⁹/L); or a normal WBC count with \u0026gt;\u0026thinsp;10% immature cells [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Proximal DVT in the knee joint is diagnosed via ultrasound. Multiple organ failure is defined as the failure of two or more organs for at least three consecutive days, with a score above 4 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. ARDS is characterized by a PaO₂/FiO₂ ratio below 200 for over four consecutive days without pneumonia [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and diffuse infiltrates on chest X-ray. Pneumonia is defined by a quantitative culture obtained through bronchoscopy and bronchoalveolar lavage, performed at the discretion of the attending trauma intensivist, typically in response to new pulmonary infiltrates on chest X-ray and purulent sputum, with a temperature above 38\u0026deg;C and/or WBC count over 10,000/mL [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe timing of surgery is crucial for preventing or mitigating the \u0026ldquo;second hit\u0026rdquo; effect and can significantly influence its occurrence. Beyond monitoring complications (e.g., multiple organ failure, acute respiratory distress syndrome) to evaluate the \u0026ldquo;second hit\u0026rdquo; effect, a range of biomarkers, inflammatory indicators, and vital signs should be considered, including complete blood count (CBC), C-reactive protein (CRP), and procalcitonin (PCT).\u003c/p\u003e \u003cp\u003eChanges in vital signs serve as early warning signals of the \u0026ldquo;second hit\u0026rdquo; effect. Persistent hypotension, elevated heart rate, tachypnea, and decreased oxygenation are critical indicators. We use the following criteria to assess the severity of the \u0026ldquo;second hit\u0026rdquo;: ① Temperature fluctuations: Postoperative temperature elevation is common due to surgical impact; among the 200 cases analyzed, 82.5% (n\u0026thinsp;=\u0026thinsp;165) exhibited elevated temperature after surgery. Thus, the \u0026ldquo;temperature trend over the first three postoperative days\u0026rdquo; can serve as an assessment criterion. ② Level of consciousness: The Glasgow Coma Scale (GCS) score is used to measure consciousness. ③ Blood pressure variations: During resuscitation, unstable hemodynamics are often managed with vasopressors. Changes in vasopressor usage can substitute for direct blood pressure measurements, enabling us to assess stability by tracking vasopressor types and dosages used three days before and after surgery. ④ Respiratory function: Similar to blood pressure monitoring, we assess changes in spontaneous breathing capacity via ventilator usage, providing insight into the surgery\u0026rsquo;s impact on vital sign recovery.\u003c/p\u003e \u003cp\u003eIncision Healing Classification: Postoperative incision healing is monitored based on documented descriptions in medical and nursing records and classified as follows: a. Grade A Healing: The incision site shows no redness, pain, subcutaneous fluid accumulation, infection, inflammation, or adverse reactions such as fat liquefaction. b. Grade B Healing: The incision site exhibits inflammatory responses, including redness, induration, hematoma, or fluid accumulation, but no abscess formation. c. Grade C Healing: The incision site shows clear signs of suppuration, requiring suture removal or incision drainage to clear necrotic tissue.\u003c/p\u003e \u003cp\u003eInflammatory Indicators: Like body temperature, both white blood cell (WBC) count and neutrophil percentage tend to increase postoperatively due to surgical impact. Among the 200 cases analyzed, postoperative WBC count and neutrophil percentage rose in 77.5% (n\u0026thinsp;=\u0026thinsp;155) and 72.5% (n\u0026thinsp;=\u0026thinsp;145) of patients compared to preoperative levels. Therefore, we monitor these trends over the first three postoperative days. Additionally, changes in C-reactive protein (CRP) and procalcitonin (PCT) levels before and after surgery are included in the analysis.\u003c/p\u003e \u003cp\u003eLong-term follow-up outcomes include three key aspects: ① Fracture healing status at 9 months postoperatively. ② Joint mobility: For injuries in various regions, follow-up assessments are conducted using the Harris Hip Score[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], Constant Shoulder Score[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], Knee injury and Osteoarthritis Outcome Score (KOOS)[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and the Oswestry Disability Index (for spinal injuries)[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Patients scoring below 70 on the percentile scale are categorized as having \u0026ldquo;poor joint mobility.\u0026rdquo; ③ Quality of life: Quality of life is assessed using the FS Post-Fracture Quality of Life Survey, which evaluates physical function, physical role, bodily pain, general health, vitality, social function, role limitations due to emotional issues, and mental health. For ease of interpretation, patients reporting \u0026ldquo;very poor\u0026rdquo; or \u0026ldquo;poor\u0026rdquo; outcomes in at least four of these eight domains are classified as having \u0026ldquo;poor quality of life\u0026rdquo;; otherwise, they are considered to have an acceptable quality of life.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIndependent sample t-tests were used to compare continuous variables, while Pearson's chi-square test was applied for categorical variables. Based on adherence to our protocol for surgical timing, the study population was divided into experimental and control groups. Logistic regression models were constructed for binary outcomes. For length of hospital stay (LOS), ICU stay duration, and costs, a generalized linear regression model with a negative binomial distribution was used, as these variables are non-negative integers with a right-skewed distribution. Univariate and multivariate logistic regression, along with negative binomial regression, were applied to identify potential risk factors, including patient age, gender, Injury Severity Score (ISS), fracture type, and other injuries (e.g., head, chest, and abdominal trauma). All analyses were conducted by statisticians not involved in patient treatment, using the SPSS statistical software package. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatement of ethical approval\u003c/h3\u003e\n\u003cp\u003e This study was approved by the Ethics Committee of Qilu Hospital of Shandong University (approval number: KYLL-202405-044.), Jinan, Shandong, China.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA retrospective evaluation of 200 cases treated at our hospital between March 2023 and March 2024 was conducted based on established criteria. The cohort included 138 males and 62 females, with an average age of 47.24\u0026thinsp;\u0026plusmn;\u0026thinsp;16.56 years and a mean Injury Severity Score (ISS) of 25.85\u0026thinsp;\u0026plusmn;\u0026thinsp;13.35. Among these cases, 123 had head injuries, 143 had chest injuries, and 72 had abdominal injuries. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a statistical analysis of these factors and fracture types, showing that grouping was associated with age and ISS score, while no association was found with other factors.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of Demographic Information in Patients Satisfying vs. Not Satisfying Surgical Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients(n\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprotocol-compliant case(n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprotocol deviation case(n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.46\u0026thinsp;\u0026plusmn;\u0026thinsp;16.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.79\u0026thinsp;\u0026plusmn;\u0026thinsp;16.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean ISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.85\u0026thinsp;\u0026plusmn;\u0026thinsp;13.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.47\u0026thinsp;\u0026plusmn;\u0026thinsp;12.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.69\u0026thinsp;\u0026plusmn;\u0026thinsp;14.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemoral fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epelvic fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.780\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcetabular fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTibial fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.630\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHumeral fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0702\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith head injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout head injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith chest injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout chest injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith abdominal injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout abdominal injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with 1 fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with 2 fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with 3 fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong patients who met surgical criteria, 40.2% experienced complications, compared to 59.2% in those who did not meet the criteria (p\u0026thinsp;=\u0026thinsp;0.0072). Pneumonia occurred in 23.7% and 42.7% of these groups, respectively (p\u0026thinsp;=\u0026thinsp;0.0047, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); deep vein thrombosis (DVT) in 22.6% and 26.7% (p\u0026thinsp;=\u0026thinsp;0.672); and acute respiratory distress syndrome (ARDS) in 3.1% and 15.5% (p\u0026thinsp;=\u0026thinsp;0.0067). There were 3 cases of sepsis, 4 cases of bacteremia, and 3 cases of multiple organ failure, all occurring in patients who did not meet surgical criteria. Due to the limited number of these cases, statistical analysis was not performed. A multivariate logistic regression model accounted for potential confounding factors such as age, gender, ISS, fracture type, and the type and severity of other system injuries. The analysis showed that both advanced age (p\u0026thinsp;=\u0026thinsp;0.0074) and higher ISS scores (p\u0026thinsp;=\u0026thinsp;0.0057) were associated with an increased complication rate.\u003c/p\u003e \u003cp\u003eNotably, among patients with postoperative thoracic complications (ARDS and pneumonia), 83.8% (n\u0026thinsp;=\u0026thinsp;57) had chest injuries. The incidence of thoracic complications was 39.3% in patients with chest injuries, compared to 19.3% in those without (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, analysis of the association between femoral fractures, pelvic/acetabular fractures, and lower extremity deep vein thrombosis revealed no statistically significant correlation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of Complication Rates in Patients Meeting vs. Not Meeting Surgical Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprotocol-compliant case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprotocol deviation case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep vein thrombosis (DVT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout deep vein thrombosis (DVT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the 200 patients, 65.5% (n\u0026thinsp;=\u0026thinsp;131) exhibited a downward trend in temperature within the first three days postoperatively. In the experimental and control groups, this proportion was 68.1% and 66.3%, respectively (p\u0026thinsp;=\u0026thinsp;0.647, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A total of 12% (n\u0026thinsp;=\u0026thinsp;24) of patients required vasopressors pre- and post-surgery. Of these, six patients met surgical criteria, with three showing stable blood pressure compared to pre-surgery levels, while three showed no improvement or worsened. In the control group, 18 patients received vasopressors, with six showing improvement and 12 showing no improvement or worsening postoperatively (p\u0026thinsp;=\u0026thinsp;0.465). Mechanical ventilation was used pre- and postoperatively in 22.5% (n\u0026thinsp;=\u0026thinsp;45) of patients, including 11 in the experimental group and 34 in the control group. The likelihood of improved spontaneous breathing was 33.3% in the experimental group and 20% in the control group (p\u0026thinsp;=\u0026thinsp;0.465). Among patients with poor or unchanged consciousness, 30% (n\u0026thinsp;=\u0026thinsp;60) showed no significant change within the first three days postoperatively. This included 24 patients who met surgical criteria and 36 who did not, with an improvement probability of 66.7% (n\u0026thinsp;=\u0026thinsp;16) in those meeting criteria and 33.3% (n\u0026thinsp;=\u0026thinsp;12) in those not meeting criteria (p\u0026thinsp;=\u0026thinsp;0.0112). No statistically significant differences were found in outcomes other than consciousness recovery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of changes of vital signs in Patients Satisfying vs. Not Satisfying Surgical Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChanges in basic vital signs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprotocol-compliant case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprotocol deviation case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased body temperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo decrease in body temperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estability of blood pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnstable blood pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Breathing improved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement in consciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo improvement in consciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNineteen patients experienced Grade 2 or Grade 3 healing, with 3 cases of Grade 2 and 2 cases of Grade 3 healing in the experimental group, and 5 cases of Grade 2 and 9 cases of Grade 3 healing in the control group. Among these 19 patients, 78.9% had open injuries. Defining Grade 2 and Grade 3 healing as \u0026ldquo;poor healing,\u0026rdquo; the incidence of poor healing was 5.2% (n\u0026thinsp;=\u0026thinsp;5) in the experimental group and 13.6% (n\u0026thinsp;=\u0026thinsp;14) in the control group (p\u0026thinsp;=\u0026thinsp;0.0415).\u003c/p\u003e \u003cp\u003eAmong 176 patients, the three-day postoperative trend in white blood cell (WBC) count and neutrophil percentage was assessed. Within three days post-surgery, the WBC count showed a downward trend in 78.5% (n\u0026thinsp;=\u0026thinsp;62) of the experimental group and 70.4% (n\u0026thinsp;=\u0026thinsp;69) of the control group (p\u0026thinsp;=\u0026thinsp;0.223, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The neutrophil percentage decreased in 74.4% (n\u0026thinsp;=\u0026thinsp;58) of the experimental group and 72.4% (n\u0026thinsp;=\u0026thinsp;71) of the control group (p\u0026thinsp;=\u0026thinsp;0.776). In a comparison of pre- and postoperative CRP levels among 188 patients, 90 showed a decrease and 98 showed an increase, with improvement rates of 63.6% (n\u0026thinsp;=\u0026thinsp;42) in the experimental group and 50.0% (n\u0026thinsp;=\u0026thinsp;49) in the control group (p\u0026thinsp;=\u0026thinsp;0.877). Similarly, for pre- and postoperative PCT levels among 144 patients, the improvement rate was 52.7% (n\u0026thinsp;=\u0026thinsp;49) in the experimental group and 71.8% (n\u0026thinsp;=\u0026thinsp;56) in the control group (p\u0026thinsp;=\u0026thinsp;0.296). None of the inflammatory indicators studied reached statistical significance.\u003c/p\u003e \u003cp\u003eThe average hospital stay was 18.03\u0026thinsp;\u0026plusmn;\u0026thinsp;8.50 days in the experimental group and 23.83\u0026thinsp;\u0026plusmn;\u0026thinsp;15.78 days in the control group (p\u0026thinsp;=\u0026thinsp;0.0014). The ICU stay duration averaged 8.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42 days in the experimental group and 15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26 days in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The average cost was 125,600\u0026thinsp;\u0026plusmn;\u0026thinsp;85,300 RMB in the experimental group and 212,000\u0026thinsp;\u0026plusmn;\u0026thinsp;222,000 RMB in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of changes of Inflammatory marker or LOS or costs in Patients Satisfying vs. Not Satisfying Surgical Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflammatory marker changes or length of hospital stay or costs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprotocol-compliant case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprotocol deviation case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased white blood cell count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo decrease in white blood cell count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased neutrophil percentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0. 776\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo decrease in neutrophil percentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative decrease in CRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative increase in CRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative decrease in PCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative increase in PCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.02\u0026thinsp;\u0026plusmn;\u0026thinsp;13.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.03\u0026thinsp;\u0026plusmn;\u0026thinsp;8.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.17\u0026thinsp;\u0026plusmn;\u0026thinsp;10.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost (ten thousand yuan)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.01\u0026thinsp;\u0026plusmn;\u0026thinsp;17.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;22.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLong-term Follow-up Outcomes: Due to time constraints and loss to follow-up, only 111 patients were assessed at 9 months postoperatively, with 5 patients deceased. The fracture healing rate was 81.1% (n\u0026thinsp;=\u0026thinsp;90), with healing rates of 82.4% (n\u0026thinsp;=\u0026thinsp;42) in the experimental group and 80.0% (n\u0026thinsp;=\u0026thinsp;48) in the control group. Good joint mobility outcomes were achieved in 50.4% (n\u0026thinsp;=\u0026thinsp;56) of patients, with 64.0% (n\u0026thinsp;=\u0026thinsp;32) in the experimental group and 39.3% (n\u0026thinsp;=\u0026thinsp;24) in the control group (p\u0026thinsp;=\u0026thinsp;0.0097, Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The proportion of patients with an \"acceptable quality of life\" was 71.9% (n\u0026thinsp;=\u0026thinsp;41) in the experimental group and 44.4% (n\u0026thinsp;=\u0026thinsp;24) in the control group (p\u0026thinsp;=\u0026thinsp;0.0028).\u003c/p\u003e \u003cp\u003eAmong the 111 patients in the follow-up survey, 41.4% (n\u0026thinsp;=\u0026thinsp;12) of those with spinal injuries reported a better quality of life, compared to 64.6% (n\u0026thinsp;=\u0026thinsp;17) of those without spinal injuries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Severe femoral fractures are often challenging to heal; in the follow-up results, the healing rate for femoral fractures was 68.6% (n\u0026thinsp;=\u0026thinsp;24), compared to 86.8% (n\u0026thinsp;=\u0026thinsp;66) for non-femoral fractures (p\u0026thinsp;=\u0026thinsp;0.022).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Long-term follow-up results vital signs in Patients Satisfying vs. Not Satisfying Surgical Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-term follow-up results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprotocol-compliant case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprotocol deviation case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture healed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture not healed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood joint mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor joint mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn China, pre-hospital emergency care primarily relies on independent emergency command centers and large hospitals. The pre-hospital emergency care model is varied and often influenced by individual interests, making objective and scientific triage challenging for hospitals[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In-hospital emergency care is categorized into three types: the multidisciplinary team (MDT) model, led by the critical care unit with participation from other departments; the integrated emergency care model; and the most common approach, involving temporary specialized consultations. Common issues include poor coordination, low efficiency, and a lack of long-term planning. Our emergency care model is based on the integrated approach. Additionally, there is no trauma registry system. Although China has a large and diverse trauma patient population, the lack of data registration significantly limits information availability for scientific research[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary goal of our surgical protocol is to optimize the treatment of polytrauma patients by reducing complications and improving postoperative recovery. The efficacy of any treatment protocol relies on the following key characteristics: ① simplicity, ease of recall, and ease of implementation; ② association with consistent outcomes, regardless of the decision-makers involved; and ③ applicability to a broad patient population without altering risk. Vital signs and inflammatory markers are routinely accessible, rapidly obtained, and low-cost, making them well-suited for large-scale use. Moreover, the selected parameters are controllable, maintainable, and monitorable. For instance, hemodynamically unstable patients can be stabilized with medication and monitored via electrocardiography.\u003c/p\u003e \u003cp\u003eStudies indicate that in patients with traumatic brain injury (TBI) and fractures, the incidence of delayed fracture healing decreases as TBI severity increases, suggesting that the central nervous system may regulate bone metabolism [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. TBI appears to enhance this effect, promoting fracture healing, with similar patterns observed in patients with concomitant spinal cord injuries[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Conversely, limb fractures may negatively regulate brain injury, potentially exacerbating it[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Our study also demonstrates that fracture reconstruction under appropriate conditions can facilitate recovery of consciousness in patients. For patients with severe brain injury and shock, resuscitation should prioritize maintaining blood volume to keep central venous and pulmonary artery pressures within normal ranges rather than dehydration therapy. Once shock is corrected, internal fixation of fractures should be performed as early as possible. Certain types of cranial trauma may serve as absolute contraindications for surgeries in other areas; however, this is not definitive and depends on the likelihood of severe complications, such as elevated intracranial pressure, cerebral edema, or brain herniation, which can affect other vital signs (e.g., heart rate, respiration, blood pressure, temperature), thereby increasing surgical risk and complexity.\u003c/p\u003e \u003cp\u003eResuscitation strategies for polytrauma patients with abdominal injuries include using \u0026ldquo;open treatment\u0026rdquo; to prevent and alleviate post-traumatic abdominal compartment syndrome, followed by delayed abdominal wall closure [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Surgeons often delay fracture surgery due to perceived surgical risks, subjecting patients to preventable complications associated with prolonged immobilization. In polytrauma, the timing of fracture fixation should not be based solely on concerns about an open abdomen. Instead, primary consideration should be given to the patient\u0026rsquo;s physiological stability (e.g., hemodynamics, coagulation, inflammatory response, and infection) in polytrauma patients with fractures and abdominal injuries. When physiological status is stable, attention should focus on the risk of cross-infection between the fracture site and the open abdominal wound. Maintaining sufficient distance between the fracture incision and abdominal or other contaminated wounds allows for early fracture stabilization, promoting recovery while preventing cross-infection. Currently, no reports identify thoracic injuries as absolute contraindications to fracture reconstruction, so emphasis should remain on the patient\u0026rsquo;s physiological stability.\u003c/p\u003e \u003cp\u003eThe primary reason for delayed fracture treatment often stems from the trauma surgeon\u0026rsquo;s judgment [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. In cases of severe head or abdominal injury, surgeons may choose to delay treatment even when patients meet resuscitation standards based on inflammatory markers.\u003c/p\u003e \u003cp\u003eLiterature suggests that patients with delayed fracture fixation have a significantly higher incidence of sepsis[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. In these patients, immune system imbalance and increased intestinal permeability make bacterial translocation more likely. Prolonged bed rest and mechanical ventilation due to delayed fixation further extend the risk period, increasing the likelihood of bacterial translocation and infection. Additionally, in patients with open wounds or surgical sites near infected tissue or abscesses, even timely debridement may compromise healing and elevate the risk of sepsis. A reduction in complications is also associated with critical care monitoring and ventilation strategies, which vary according to hospital resuscitation standards. In our study, the limited number of patients with concurrent sepsis and bacteremia prevented us from conclusively determining the relationship between fracture fixation timing and the incidence of sepsis and bacteremia.\u003c/p\u003e \u003cp\u003eWe advocate for early surgical intervention; however, China\u0026rsquo;s triage system is underdeveloped, and the in-hospital emergency care model lacks standardized protocols, leading to considerable variability in treatment timing and approaches across regions. Consequently, the Damage Control Orthopedics (DCO) strategy is commonly adopted. Considering China\u0026rsquo;s healthcare context, our study assesses patient resuscitation levels and physiological status, recommending surgery as soon as surgical criteria are met to reduce complications and enhance the approach\u0026rsquo;s applicability.\u003c/p\u003e \u003cp\u003eThis study provides only a preliminary investigation into surgical timing based on clinical experience, and many questions in this area require further exploration. Several limitations should be noted. Our reliance on retrospective data may result in omissions and inaccuracies when assessing postoperative outcomes, such as wound healing classification. To gain a more complete understanding of postoperative infection outcomes, additional prospective research and comprehensive statistical analysis are needed. We included postoperative inflammatory markers and changes in vital signs to assess the \u0026ldquo;second hit\u0026rdquo; effect of surgery; however, this approach may not fully capture the impact of the second hit, underscoring the need to establish evaluation criteria for this effect. Additionally, factors associated with deep vein thrombosis warrant further study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor polytrauma patients with fractures, those who underwent fracture surgery after meeting the study\u0026rsquo;s surgical criteria experienced fewer early postoperative pulmonary complications, faster recovery of consciousness, lower incision infection rates, shorter overall and ICU stays, reduced costs, and improved postoperative outcomes compared to those who did not meet the criteria. Our protocol is safe and effective for most polytrauma patients with mechanically unstable femoral, pelvic, acetabular, or spinal fractures requiring fixation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Qilu Hospital of Shandong University (approval number: KYLL-202405-044.), Jinan, Shandong, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Dr. SangMethodology: Dr. Sang and Dr. DingFormal analysis: Dr. DingInvestigation**: Dr. Jia and Dr. HanData Curation: Dr. DingWriting: Original Draft: Dr. Ding and Dr. ZhangWriting\u0026mdash;Review \u0026amp; Editing: Dr. Zhao and Dr. ZhangSupervision: Dr. SangProject Administration: Dr. SangAll authors reviewed the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all individuals who contributed to this work but do not meet the criteria for authorship, including those who provided professional writing assistance or supplied materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study were collected by the authors. Due to privacy, the data are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLOZANO R，NAGHAVI M，FOREMAN K，et al．Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010［J］．Lancet， 2012，380( 9859) : 2095-2128．\u003c/li\u003e\n \u003cli\u003eWang Y, Wang C, Hu P, et al. China trauma treatment statistics 2019: A national retrospective study based on hospitalized cases. Front Public Health. 2023;11:1116828. Published 2023 Feb 24. doi:10.3389/fpubh.2023.1116828\u003c/li\u003e\n \u003cli\u003eTisherman SA, Schmicker R, Brasel K, Bulger E, Kerby J, Minei P, et al. De- tailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Ann Surg 2015;261:586\u0026ndash;90 PMID: 34048424.\u003c/li\u003e\n \u003cli\u003eTeixeira PGR. Preventable or potentially preventable mortality at a mature trauma center. J Trauma Acute Care Surg 2007;63:1338\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eSobrino J, Shafi S. Timing and causes of death after injuries. Proceedings 2013;26:120\u0026ndash;3.\u003c/li\u003e\n \u003cli\u003eM.J., El, Mekkaoui., R.A., Bassir., M.O., Lamrani. (2023). Early Definitive Care (EDC) VS Damage Control Orthopedics (DCO) in the Management of Femoral Shaft Fractures in Polytrauma Patients. Scholars journal of medical case reports, 11(05):970-975. doi: 10.36347/sjmcr.2023.v11i05.057\u003c/li\u003e\n \u003cli\u003eRicardo, J., Roman., Felix, Klingebiel., Sascha, Halvachizadeh., Yannik, Kalbas., Hans-Christoph, Pape. (2023). Clearing of Polytrauma Patients for Early Definitive Fracture Fixation: A Systematic Literature Review. British Journal of Surgery, 110(Supplement_5) doi: 10.1093/bjs/znad178.052\u003c/li\u003e\n \u003cli\u003eBone LB, Johnson KD, Weigelt J \u0026amp; Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. Journal of Bone and Joint Surgery. American Volume 1989 71 336\u0026ndash;340.\u003c/li\u003e\n \u003cli\u003ePape HC, Giannoudis P \u0026amp; Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. American Journal of Surgery 2002 183 622\u0026ndash;629.\u003c/li\u003e\n \u003cli\u003eMoghtadaei M, Otoukesh B, Pazoki-\u0026shy;Toroudi H, Boddouhi B, Yeganeh A.Evaluation of inflammatory response in patients undergoing surgical treatment forearly and delayed femoral fractures. Arch Med Sci. 2019;15(1):141\u0026ndash;145.\u003c/li\u003e\n \u003cli\u003eGiannoudis PV, Tan HB, Perry S, Tzioupis C \u0026amp; Kanakaris NK. The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device. Injury 2010 41(Supplement 2) S57\u0026ndash;S61.\u003c/li\u003e\n \u003cli\u003ePape HC, Andruszkow H, Pfeifer R, Hildebrand F \u0026amp; Barkatali BM. Options and hazards of the early appropriate care protocol for trauma patients with major fractures: towards safe definitive surgery. Injury 2016 47 787\u0026ndash;791.\u003c/li\u003e\n \u003cli\u003eGiannoudis PV, Giannoudis VP \u0026amp; Horwitz DS. Time to think outside the box: \u0026apos;Prompt-Individualised-Safe Management\u0026apos; (PR.I.S.M.) should prevail in patients with multiple injuries. Injury 2017 48 1279\u0026ndash;1282.\u003c/li\u003e\n \u003cli\u003ePape HC, Pfeifer R. Safe definitive orthopaedic surgery (SDS): repeated assessment for tapered application of Early Definitive Care and Damage Control?: an inclusive view of recent advances in polytrauma management. Injury. 2015;46(1):1-3.\u003c/li\u003e\n \u003cli\u003ePape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury. 2019;50(10):1656-1670. doi:10.1016/j.injury.2019.09.021\u003c/li\u003e\n \u003cli\u003ePfeifer R, Klingebiel FK, Halvachizadeh S, Kalbas Y, Pape HC. How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature. Injury. 2023;54(2):292-317. doi:10.1016/j.injury.2022.11.008\u003c/li\u003e\n \u003cli\u003ePape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491-501.\u003c/li\u003e\n \u003cli\u003ePape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26(11):1478-1484. doi:10.1002/jor.20697\u003c/li\u003e\n \u003cli\u003eNahmN,ComoJJ,WiliberJH,VallierHA.Earlyappropriatecare:definitivestabilzationffemorarueswihnhursafimuiliyerpatients.JTrauma.2011:71:175-85.\u003c/li\u003e\n \u003cli\u003eTimothy, A., Moore., Natasha, M, Simske., Heather, A., Vallier. (2020). Fracture fixation in the polytrauma patient: Markers that matter. Injury-international Journal of The Care of The Injured, 51 doi: 10.1016/J.INJURY.2019.12.024\u003c/li\u003e\n \u003cli\u003eRobert, V, O\u0026apos;Toole.Timing of Fracture Fixation. 367-388.\u003c/li\u003e\n \u003cli\u003eLord JM, Midwinter MJ, Chen YF, et al. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet. 2014;384(9952):1455-1465. doi:10.1016/S0140-6736(14)60687-5\u003c/li\u003e\n \u003cli\u003ePape H-C, Remmers D, Grotz M, Kotzerke J, Glinski S, van Griensven M, Dahlweid M, Sznidar S, Tscherne H. Reticuloendothelial system activ- ity and organ failure in multiply injured patients. Archives of Surgery 1999;134:421\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eBilliar TR, Vodovotz Y. Time for trauma immunology. PLoS Med 2017;14:e1002342 [PubMed: 28700602].\u003c/li\u003e\n \u003cli\u003eRichter M, Krettek C, Otte D, Wiese B, Stalp M, Ernst S, et al. Correlation be- tween crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study. J Trauma 2001;51(1):10\u0026ndash;16 JulPMID: 11468457. doi:10.1097/00005373-200107000-00002.\u003c/li\u003e\n \u003cli\u003eXiao X. Seok J A genomic storm in critically injured humans. J Exp Med 2011;208(13):2581\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eHans-Christoph, Pape., E., Moore., T., McKinley., Angela, Sauaia. (2022). Pathophysiology in patients with polytrauma.. Injury-international Journal of The Care of The Injured, 53(7):2400-2412. doi: 10.1016/j.injury.2022.04.009\u003c/li\u003e\n \u003cli\u003ePolytrauma Guideline Update Group. Level 3 guideline on the treatment of patients with severe/multiple injuries : AWMF Register-Nr. 012/019. Eur J Trauma Emerg Surg. 2018;44(Suppl 1):3-271. doi:10.1007/s00068-018-0922-y\u003c/li\u003e\n \u003cli\u003eLiu T, Bai XJ. Trauma care system in China. Chin J Traumatol. 2018;21(2):80-83. doi:10.1016/j.cjtee.2017.06.004\u003c/li\u003e\n \u003cli\u003eJ., M., Zhou., T, B, Wang., B, Jiang. (2022). [Current situation and development of Chinese trauma care system].. 60 12(12):1045-1048. doi: 10.3760/cma.j.cn112139-20220429-00192\u003c/li\u003e\n \u003cli\u003eBaoguo, Jiang.(2015). The challenges faced in the field of trauma care in China. Chinese journal of surgery, 53(6):401-404. doi:10.3760/CMA.J.ISSN.0529-5815.2015.06.001\u003c/li\u003e\n \u003cli\u003ePape HC, Barthels M, van Griensven M, Krettek C, Das Gupta R, Tsch- erne H. Biochemical changes following trauma and skeletal surgery of the lower extremity \u0026ndash; quantification of the operative burden. Criti Care Med 2000;28(10):3441\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eGrey, B., Rodseth, R., ALbert, Inkosi. (2018). Early Fracture Stabilisation In The Presence Of Subclinical Hypo-Perfusion.\u003c/li\u003e\n \u003cli\u003eSumit, Sinha., Raghavendra, Nayak., Sumit, Sinha. (2024). Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability. Clinical Neurology and Neurosurgery, 245:108494-108494. doi: 10.1016/j.clineuro.2024.108494\u003c/li\u003e\n \u003cli\u003eChristian, Krettek., Robin, G., Simon., Harald, Tscherne. (1998). Management priorities in patients with polytrauma. Langenbeck\u0026apos;s Archives of Surgery, 383(3):220-227. doi: 10.1007/S004230050122\u003c/li\u003e\n \u003cli\u003eAlessandro, Aprato., Davide, RUSCITTI., Roberto, RACCA., Erica, Del, Grosso., Alessandro, Mass\u0026egrave;. (2024). Which factors influence timing in polytrauma?. Minerva orthopedics, 75(1) doi: 10.23736/s2784-8469.23.04373-0\u003c/li\u003e\n \u003cli\u003eMarc, Maegele. (2021). The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline.. Journal of Clinical Medicine, 10(2):362-. doi: 10.3390/JCM10020362\u003c/li\u003e\n \u003cli\u003eAl-Samkari H, Marshall AL, Goodarzi K, Kuter DJ. Romiplostim for the management of perioperative thrombocytopenia. Br J Haematol. 2018;182(1):106-113.doi:10.1111/bjh.15280\u003c/li\u003e\n \u003cli\u003eGarc\u0026iacute;a-Escobar A, Vera-Vera S, T\u0026eacute;bar-M\u0026aacute;rquez D, et al. Neutrophil-to-lymphocyte ratio an inflammatory biomarker, and prognostic marker in heart failure, cardiovascular disease and chronic inflammatory diseases: New insights for a potential predictor of anti-cytokine therapy responsiveness. Microvasc Res. 2023;150:104598. doi:10.1016/j.mvr.2023.104598\u003c/li\u003e\n \u003cli\u003eWiradi, Suryanegara., Vidi, Posdo, Ahapta, Simarmata. (2022). Sepsis Due to Bacterial Infection: An Analysis based on Ratio Count of Neutrophil \u0026ndash; Lymphocyte. Journal of Drug Delivery and Therapeutics, 12(5-S):75-81. doi: 10.22270/jddt.v12i5-s.5632\u003c/li\u003e\n \u003cli\u003ePape HC,Lefering R,Butcher N,et al.The definition of polytrauma revisited:an international consensus process and proposal of the new \u0026lsquo;Berlin definition\u0026rsquo;[J].J Trauma Acute Care Surg,2014,77(5):780-786.DOI:10.1097/ TA.0000000000000453.\u003c/li\u003e\n \u003cli\u003eAstagneau P, Rioux C, Golliot F, Br\u0026uuml;cker G; INCISO Network Study Group. Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance. J Hosp Infect. 2001;48(4):267-274. doi:10.1053/jhin.2001.1003\u003c/li\u003e\n \u003cli\u003eFont, M. D., Thyagarajan, B., \u0026amp; Khanna, A. K. (2020). Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making. The Medical clinics of North America, 104(4), 573\u0026ndash;585. https://doi.org/10.1016/j.mcna.2020.02.011\u003c/li\u003e\n\u003cli\u003eDellingerRP,LevyMM,CarletJM,BionJ,ParkerMM,JaeschkeR,etal.InternationalSurvivingSepsisCampaignGuidelinesCommittee.\u003cbr/\u003eSurvivingsepsiscampaign:internationalguidelinesformanagementofseveresepsisandsepticshock2008.CritCareMed.200836:296-327.\u003c/li\u003e\n \u003cli\u003eDurham RM, Moran JJ, Mazuski JE, Shapiro MU, Baue AE, Flint LM.Multiple organ failure in trauma patients. J Trauma. 2003:55:608-16.\u003c/li\u003e\n \u003cli\u003eHarris W H. Traumatic arthritis of the hip after dislocation and acetabular fractures;treatment by mold arthroplasty[J]. J Bone Joint Surg (Am), 1969, 51:737-755.\u003c/li\u003e\n \u003cli\u003eRoos EM, Roos PH,Lohmander LS,et al.Knee injury and Osteoarthritis Outcome Score(KOOS). Development of a self-administered outcome measure. J Orthop Sports Phys Ther,1998,28(2):88-96.\u003c/li\u003e\n \u003cli\u003eConstant C R, Murley A H. A clinical method functional assessment of the shoulder[J]. Clin Orthop Relat Res, 1987, 21(4):160-1\u003c/li\u003e\n \u003cli\u003eFibank J, Pynsent P. The Oswestry disability index[J]. Spine,2000,25:2940-2953.\u003c/li\u003e\n \u003cli\u003eAmerican Thoracic Society. Documents approved by ATS Board of Directors,Dec 2004. Guidelines for the management of adults with hospital-acquired,ventilator-associated, and healthcare-associated pneumonia. Am J Respir CritCare Med. 2005;171:388-416.\u003c/li\u003e\n \u003cli\u003eJohnson G. Trauma Triage and Trauma System Performance. West J Emerg Med. 2016;17(3):331-332. doi:10.5811/westjem.2016.2.29900\u003c/li\u003e\n \u003cli\u003eJing, Zhou., Tianbing, Wang., Igor, Belenkiy., Timothy, Craig, Hardcastle., Jean-Jacques, Rouby., Baoguo, Jiang. (2021). Management of severe trauma worldwide: implementation of trauma systems in emerging countries: China, Russia and South Africa. Critical Care, 25(1):286-. doi: 10.1186/S13054-021-03681-8）\u003c/li\u003e\n \u003cli\u003eGarbe A, Graef F, Appelt J, et al. Leptin Mediated Pathways Stabilize Posttraumatic Insulin and Osteocalcin Patterns after Long Bone Fracture and Concomitant Traumatic Brain Injury and Thus Influence Fracture Healing in a Combined Murine Trauma Model. Int J Mol Sci. 2020;21(23):9144.\u003c/li\u003e\n \u003cli\u003eLiu W, Chen W, Xie M, et al. Traumatic brain injury stimulates sympathetic tone-mediated bone marrow myelopoiesis to favor fracture healing. Signal Transduct Target Ther. 2023;8(1):260.\u003c/li\u003e\n \u003cli\u003eMollahosseini M, Ahmadirad H, Goujani R, Khorramdelazad H. The Association Between Traumatic Brain Injury and Accelerated Fracture Healing: A Study on the Effects of Growth Factors and Cytokines. J Mol Neurosci. 2021;71(1):162-168.\u003c/li\u003e\n \u003cli\u003eRoberts DJ, Bobrovitz N, Zygun DA, et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015;79(4):568-579.\u003c/li\u003e\n \u003cli\u003eVallier HA, Moore TA, Como JJ, et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155. Published 2015 Oct 1. doi:10.1186/s13018-015-0298-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multiple trauma, surgical treatment strategy, timing of fracture fixation, postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-5388963/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5388963/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: For patients with severe polytrauma and fractures, early fracture reconstruction surgery under stable conditions can significantly reduce pulmonary and other complications. However, premature surgical intervention may heighten infection risk, adversely affecting the patient’s prognosis. Consequently, determining the optimal timing of surgery is crucial for patients with multiple traumatic injuries. Given China’s healthcare context, this study will assess injury severity and perform definitive fracture reconstruction at specified post-trauma intervals. Postoperative infection rates, including wound infections, other complication incidences, hospital stay duration, treatment costs, and long-term outcomes will be observed and compared to identify the optimal timing for surgical intervention. This study also aims to develop effective polytrauma management models. By applying accessible criteria and choosing suitable timing for fracture reconstruction, we can better assess patient conditions, reduce complications, and minimize the surgery's \"second hit\" effect, addressing an important research gap regarding optimal surgical timing for polytrauma in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This study collected data on 200 patients treated at our hospital between March 2023 and March 2024, with an average age of 47.24±16.56 years and an average Injury Severity Score (ISS) of 25.85±13.35. A total of 250 fractures received definitive fixation in the initial surgery, including femoral fractures (n=75), spinal fractures (n=46), pelvic ring fractures (n=49), tibial fractures (n=25), acetabular fractures (n=12), humeral fractures (n=12), and other fractures (n=5) (including clavicle, radius and ulna, calcaneus, and patella). Among these patients, 151 underwent single-fracture reconstruction, 42 had two fractures reconstructed, and 5 had three fractures treated during the first surgery. The study protocol excluded patients with absolute contraindications, including bacteremia and infections near the surgical site. Additional inclusion criteria required stable vital signs (temperature \u0026lt;38.5°C with a downward trend, systolic blood pressure \u0026gt;100 mmHg, stable traumatic brain injury status) and blood routine (white blood cell count \u0026lt;22.0×10⁹/L with a neutrophil percentage \u0026lt;90%, both trending downward; platelet count \u0026gt;50×10⁹/L; hemoglobin \u0026gt;90 g/L). Based on these criteria, historical cohorts were identified and assigned to either an experimental group or a control group. Observed outcomes included postoperative complications, wound healing grades, inflammatory markers, changes in vital signs, length of hospital stay, costs, and long-term follow-up results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among the patients, 97 underwent surgery after meeting the specified criteria for fracture reconstruction, while 103 received surgery without meeting these criteria. Patients who met the surgical criteria demonstrated superior outcomes, with lower complication rates (including pneumonia and respiratory distress syndrome), improved surgical incision healing, faster postoperative consciousness recovery, shorter overall and ICU stays, reduced hospitalization costs, greater joint mobility at the 9-month follow-up, and higher quality of life assessments compared to those who did not meet the criteria. Among patients who met the criteria, those with spinal fractures experienced better quality of life outcomes, and those with femoral fractures showed improved fracture healing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: For polytrauma patients with fractures, performing surgery once surgical requirements are met results in fewer early postoperative pulmonary complications, quicker recovery of consciousness, lower wound infection rates, shorter hospital and ICU stays, reduced costs, and improved postoperative outcomes. This protocol is safe and effective for most polytrauma patients requiring fixation, particularly those with mechanically unstable femoral, pelvic, acetabular, or spinal fractures.\u003c/p\u003e","manuscriptTitle":"A China-Based Exploration of Surgical Timing for Polytrauma with a Focus on Fracture Reconstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 11:01:52","doi":"10.21203/rs.3.rs-5388963/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-07T16:38:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T14:03:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59304939052677438763741709975575289040","date":"2025-04-02T12:24:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-06T10:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247270544787386931782769152883293191410","date":"2024-11-11T16:41:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-11T12:23:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-10T16:43:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-07T00:45:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Emergency Surgery","date":"2024-11-04T14:34:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8164276b-7a16-4610-80b7-a740a8ee7cca","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:01:57+00:00","versionOfRecord":{"articleIdentity":"rs-5388963","link":"https://doi.org/10.1186/s13017-025-00607-5","journal":{"identity":"world-journal-of-emergency-surgery","isVorOnly":false,"title":"World Journal of Emergency Surgery"},"publishedOn":"2025-04-16 15:57:52","publishedOnDateReadable":"April 16th, 2025"},"versionCreatedAt":"2024-11-25 11:01:52","video":"","vorDoi":"10.1186/s13017-025-00607-5","vorDoiUrl":"https://doi.org/10.1186/s13017-025-00607-5","workflowStages":[]},"version":"v1","identity":"rs-5388963","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5388963","identity":"rs-5388963","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}