INORMUS was a huge success at the 2012 Orthopedic Trauma Association International Conference. The INORMUS podium presentation was given special recognition for excellence in international research. A summary of the study is shown below.
International Orthopaedic Multicenter Fracture Study (INORMUS)
Clary J. Foote MD1, Brad Petrisor MD MSc FRCSC1, Joseph Beyene PhD2, PJ Devereaux MD PhD FRCSC2,3, Mandeep Dhillon MD4, Parag Sancheti MD5, Prakesh Kotwal MD6, Theodore Miclau MD7, Mohit Bhandari1,2 MD PhD FRCSC, & the INORMUS Investigators
1Department of Surgery, McMaster University, Hamilton, Ontario, Canada
2Department of Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
3Department of Medicine, McMaster University, Hamilton, Ontario, Canada
4Post Graduate Institute, Chandigarh, India
5Sancheti Institute, Pune, India
6All India Institute of Medical Sciences, Delhi, India
7University of California, San Francisco, California, USA
Background: Injuries from trauma accidents have been rapidly increasing in number worldwide and particularly so in low and middle-income countries. The World Health Organization (WHO) has deemed this epidemic as one of the most important global priorities, calling 2011-2021 the Global Road Traffic Safety Decade. Despite this, there is little empirical data in low and middle-income countries to quantify the burden of fractures and current standard of care to direct research and initiatives.
Methods: We conducted a multicenter, prospective observational study of patients sustaining fractures or dislocations and presenting to orthopaedic fracture units across 14 hospitals in India. Four thousand eight hundred and twenty two patients presenting to the 14 participating hospitals during an eight-week period were enrolled. Primary outcomes included the causes of mortality and complications in a multiple logistic regression model. Secondary outcomes included incidence of fractures by body region and hospital, wait times to fracture stabilization, and timing to irrigation and debridement for open fractures.
Results: Complete in-hospital 30-day follow-up was obtained for 96.7% of patients (4659/4822). The majority of trauma patients were young males (mean age ± standard deviation, 40.8 ± 16.9). Most fractures were caused by road traffic accidents (59.1%), of which the most common mechanism was collision of motorcycles (32%). Almost all patients sustained fractures (97.8%) and one-sixth were open fractures. Nearly half of open fractures were Gustilo grade III. Eighteen percent of patients had fracture stabilization over 3 days while 22% of open fractures (n=689) had irrigation and debridement later than 12 hours. Thirty-day mortality was 1.7% (95% CI, 1.4 – 2.2) and reoperation and infection rates were 6.0% (95% CI, 5.4 – 6.7) and 6.1% (95% CI, 5.6 – 7.0), respectively. Logistic regression analysis determined that the number of nonorthopaedic injuries, fractures, open fracture, time to stabilization, and hospital type were significant predictors of mortality, reoperation, and infection. Open fractures were the strongest predictor of mortality (adjusted Odds Ratio: 3.9, 95% CI, 1.6 – 6.2). Patients presenting to public hospitals had more severe injuries.
Conclusion: There is a growing epidemic of severe fractures in the developing world caused by road traffic accidents. High grade open fractures are very common and many receive delayed care. Orthopaedic injuries and time to treatment are significant predictors of outcomes. Future studies should focus on optimal timing of the treatment of open fractures to produce evidence-based care protocols.