Plasma concentrations of pro- and anti-inflammatory cytokines and outcome prediction in elderly hip fracture patients

The role of cytokines in acute and chronic postsurgical pain after major musculoskeletal surgeries in a quaternary pediatric center

STUDY OBJECTIVE

To determine if baseline cytokines/chemokines and their changes over postoperative days 0-2 (POD0-2) predict acute and chronic postsurgical pain (CPSP) after major surgery.

DESIGN

Prospective, observational, longitudinal nested study.

SETTING

University-affiliated quaternary children's hospital.

PATIENTS

Subjects (≥8 years old) with idiopathic scoliosis undergoing spine fusion or pectus excavatum undergoing Nuss procedure.

MEASUREMENTS

Demographics, surgical, psychosocial measures, pain scores, and opioid use over POD0-2 were collected. Cytokine concentrations were analyzed in serial blood samples collected before and up to two weeks after surgery, using Luminex bead arrays. After data preparation, relationships between pre- and post-surgical cytokine concentrations with acute (% time in moderate-severe pain over POD0-2) and chronic (pain score > 3/10 beyond 3 months post-surgery) post-surgical pain were analyzed using univariable and multivariable regression analyses with adjustment for covariates and mixed effects models were used to associate longitudinal cytokine concentrations with pain outcomes.

MAIN RESULTS

Analyses included 3,164 repeated measures of 16 cytokines/chemokines from 112 subjects (median age 15.3, IQR 13.5-17.0, 54.5 % female, 59.8 % pectus). Acute postsurgical pain was associated with higher baseline concentrations of GM-CSF (β = 0.95, SE 0.31; p = 0.003), IL-1β (β = 0.84, SE 0.36; p = 0.02), IL-2 (β = 0.78, SE 0.34; p = 0.03), and IL-12 p70 (β = 0.88, SE 0.40; p = 0.03) and longitudinal postoperative elevations in GM-CSF (β = 1.38, SE 0.57; p = 0.03), IFNγ (β = 1.36, SE 0.6; p = 0.03), IL-1β (β = 1.25, SE 0.59; p = 0.03), IL-7 (β = 1.65, SE 0.7; p = 0.02), and IL-12 p70 (β = 1.17, SE 0.58; p = 0.04). In contrast, CPSP was associated with lower baseline concentration of IL-8 (β = -0.39, SE 0.17; p = 0.02), and the risk of developing CPSP was elevated in patients with lower longitudinal postoperative concentrations of IL-6 (β = -0.57, SE 0.26; p = 0.03), IL-8 (β = -0.68, SE 0.24; p = 0.006), and IL-13 (β = -0.48, SE 0.22; p = 0.03). Covariates female (vs. male) sex and surgery type (pectus surgery vs. spine) were associated with higher odds for CPSP in baseline adjusted cytokine-CPSP association models for IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, TNFα, and IL-8, IL-10, respectively.

CONCLUSION

We identified pro-inflammatory cytokine profiles associated with higher risk of acute postoperative pain. Interestingly, pleiotropic cytokine IL-6, chemokine IL-8 (which promotes neutrophil infiltration and monocyte differentiation), and monocyte-released anti-inflammatory cytokine IL-13, were associated with lower CPSP risk. Our results suggest heterogenous outcomes of cytokine/chemokine signaling that can both promote and protect against post-surgical pain. These may serve as predictive and prognostic biomarkers of pain outcomes following surgery.

Development of a nomogram for deep vein thrombosis in patients with tibial plateau fractures based on systemic Immune-inflammation index

In recent years, the incidence of tibial plateau fractures (TPF) has been on the rise. Deep vein thrombosis (DVT) may lead to poor prognosis in patients. The systemic immune-inflammation index(SII) are novel biomarkers of inflammation, and this study aims to verify their predictive effect and construct the nomogram model. This study used binary logistic regression analysis to predict the predictive effect of SII on the occurrence of DVT in tibial plateau fracture patients. And use R studio to construct nomogram model. The results showed that Age (1.03 [1, 1.06], p = 0.032), SII (3.57 [1.68, 7.61], p = 0.04), and NC (7.22 [3.21, 16.26], p < 0.001) were independent predictive factors for DVT. The nomogram demonstrated good predictive performance with small errors in both the training and validation groups, and most clinical patients could benefit from them. The nomogram constructed based on SII can assist clinicians in early assessment of the probability of DVT occurrence.

Serum levels of IL-6 and IL-10 on admission correlate with complications in elderly patients with hip fracture

OBJECTIVES

Ageing may cause a progressive pro-inflammatory environment and alter functionality of different immune-cell populations. The aim of the present study is to examine the influence of certain serum immunological parameters on hospitalization stay and complications in patients who have suffered a hip fracture.

PATIENTS AND METHODS

A prospective study was carried out with 87 patients (63 women) presenting with either trochanteric femoral fracture or Garden IV displaced subcapital fracture. The average age was 84.43 ± 9, ranging from 65 to 104 years old. Data regarding different comorbidities were recorded at the time of arrival. The morning after patient's admission peripheral blood samples were obtained and a series of immunological parameters were determined: leukocyte formula, platelets count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), IL-6 and IL-10 levels, T-lymphocytes count, number of cells/mm3 and percentages of CD3, CD4, CD8, CD3-/CD16/56+ (NK cells), and CD3-/CD19+ (B cells).

RESULTS

IL-6 serum levels presented a positive and significant correlation with higher levels of CRP (p < 0.001), IL-10 (p = 0.002), and higher percentages of NK CD56+ cells (p = 0.046). IL-6 serum levels at hospitalization presented a positive and significant correlation with a longer hospitalization stay (p = 0.037). Hospitalization increased by 0.231 days for every 1 pg/mL above the IL-6 mean value (40.43 pg/mL). Lower serum IL-10 levels on admission were associated with the appearance of symptomatic urinary tract infection during hospitalization (p = 0.032). Higher number of CD19+ cells/mm3 presented a significant relationship with pneumonia (p = 0.018) and symptomatic urinary tract infection (p = 0.0019).

CONCLUSIONS

IL-6 serum levels on admission showed a positive and significant correlation with a longer hospitalization stay in elderly patients presenting with hip fracture. Lower levels of IL-10 in peripheral blood on admission were associated with symptomatic urinary tract infections. A higher number of CD19+ cells/mm³ was significantly associated with pneumonia and symptomatic urinary tract infection. These immunological variables on admission may serve as risk indicators of complications during hospitalization.

Sustained IL-6 and sTNF-αR1 levels after hip fracture predict 5-year mortality: A prospective cohort study from the Baltimore Hip Studies

BACKGROUND

Persistent inflammation is associated with adverse health outcomes, but its impact on mortality has not been investigated previously among hip fracture patients. This article aims to investigate the influence of changes in levels of cytokines in the 2 months after a hip fracture repair on 5-year mortality.

METHODS

This is a prospective cohort study from the Baltimore Hip Studies (BHS) with 191 community-dwelling older men and women (≥65 years) who had recently undergone surgical repair of an acute hip fracture, with recruitment from May 2006 to June 2011. Plasma interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor1 (sTNFα-R1), and interleukin-1 receptor agonist (IL-1RA) were obtained within 22 days of admission and at 2 months. All-cause mortality over 5 years was determined. Logistic regression analysis tested the associations between the cytokines' trajectories and mortality over 5 years, adjusted for covariates (age, sex, education, body mass index, lower extremity physical activities of daily living, and Charlson comorbidity index).

RESULTS

High levels of IL-6 and sTNFα-R1 at baseline with small or no decline at 2 months were associated with higher odds of 5-year mortality compared with those with lower levels at baseline and greater decline at 2 months after adjustment for age, and other potential confounders (OR = 4.71, p = 0.01 for IL-6; OR = 15.03, p = 0.002 for sTNFα-R1). Similar results that failed to reach significance were found for IL-1RA (OR = 2.40, p = 0.18). Those with higher levels of cytokines at baseline with greater decline did not have significantly greater mortality than the reference group, those with lower levels at baseline and greater decline.

CONCLUSION

Persistent elevation of plasma IL-6 and sTNFα-R1 levels within the first 2 months after hospital admission in patients with hip fracture is associated with higher 5-year mortality. These patients may benefit from enhanced care and earlier intensive interventions to reduce the risk of death.

Association between admission inflammatory indicators and 3-year mortality risk in geriatric patients after hip fracture surgery: a retrospective cohort study

Background

Recent research indicates that the monocyte lymphocyte ratio (MLR), neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), C-reactive protein (CRP), and systemic immune-inflammation index (SII) may serve as valuable predictors of early postoperative mortality in elderly individuals with hip fractures. The primary objective of the study was to examine the association between preoperative MLR, NLR, PLR, CRP, and SII levels and 3-year mortality risk in geriatric patients after hip fracture surgery.

Patients and methods

The study included patients aged 65 years or older who underwent hip fracture surgery between November 2018 and November 2019. Admission levels of MLR, NLR, PLR, CRP, and SII were measured. The median follow-up period was 3.1 years. Cox proportional hazards models were used to calculate the hazard ratio (HR) for mortality with adjusting for potential covariates. Time-dependent receiver operating characteristic (ROC) curves were employed to assess the predictive capability of inflammatory indicators for mortality.

Results

A total of 760 patients completed the follow-up (79.4 ± 7.8 years, 71.1% female). A higher preoperative MLR was found to be significantly associated with an increased 3-year postoperative mortality risk (HR 1.811, 95% CI 1.047-3.132, P = 0.034). However, no significant correlations were observed between preoperative NLR, PLR, CRP, SII and 3-year mortality. The areas under the ROC curve (AUCs) of MLR for predicting 30-day, 120-day, 1-year, and 3-year mortality were 0.74 (95% CI 0.53-0.95), 0.70 (95% CI 0.57-0.83), 0.67 (95% CI 0.60-0.74), and 0.61 (95% CI 0.56-0.66), respectively.

Conclusion

Preoperative MLR is a useful inflammatory marker for predicting 3-year mortality in elderly hip fracture patients, but its predictive ability diminishes over time.

Postoperative Myocardial Injury and Inflammatory Biomarkers in Patients Undergoing Vascular Surgery: A Subanalysis of the Platelet Reactivity and Postoperative Myocardial Injury after Major Vascular Surgery (PROMISE) Study

BACKGROUND

Postoperative myocardial injury (PMI) is associated with morbidity and mortality, but the aetiology remains unclear. We studied whether PMI is associated with perioperative systemic inflammation. The objective is the examination of the relationship between inflammatory biomarkers (Interleukin 6[IL-6], C-reactive protein [CRP]) and PMI, detected by elevated cardiac troponin (cTn), in patients undergoing elective open abdominal aortic surgery.

METHODS

This prospective, single-center, observational cohort study included 54 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. IL-6 and CRP were measured preoperatively, directly after surgery, 24 hr and 48 hr postoperatively. The primary outcome was cTn release assessed by a fifth-generation high-sensitive cTn assay. Multivariable generalized linear regression models were used to evaluate the association between inflammatory biomarkers and cTn concentrations.

RESULTS

Fifteen patients (27.8%) developed PMI. IL-6 directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.28 [1.07-1.54], P = 0.009) and 1.75 [1.18-2.59], P = 0.006, respectively). Also, CRP directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.25 [1.06-1.47], P = 0.009) and 1.61 [1.1-2.33], P = 0.013, respectively). No association was found between IL-6 or CRP and cTn concentrations when measured at 48 hr postsurgery.

CONCLUSIONS

Biomarkers of inflammation are associated with elevated postoperative cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

Predictive value of the systemic immune-inflammation index on one-year mortality in geriatric hip fractures

BACKGROUND

Geriatric hip fractures are associated with a high incidence of mortality. This study examines the predictive value of the systemic immune-inflammation index (SII) on one-year mortality in elderly hip fracture patients.

METHODS

A single-center retrospective study was conducted between February 2017 and October 2020. Three hundred and eleven surgically treated consecutive hip fracture patients were included in the study. Admission, postoperative first day, and postoperative fifth-day SII values were calculated. The receiver operating characteristic (ROC) curve was used to calculate the cut-off values, and patients were divided into high and low groups according to these cut-off values. After univariate Cox regression analysis, significant factors were included in the multivariate Cox proportional hazards model to adjust the effect of covariates and explore independent predictive factors associated with mortality. Further subgroup analysis was performed to evaluate the accuracy of the results for different clinical and biological characteristics.

RESULTS

The mean age was 80.7 ± 8.0 years, and women made up the majority (67.8%) of the patients. The one-year mortality rate was 28.0%. After univariate and multivariate analyses, high postoperative fifth-day SII remained an independent predictor of one-year mortality (adjusted HR 2.16, 95% CI 1.38-3.38, p = 0.001). Older age, male gender, Charlson comorbidity index (CCI) ≥ 2, and hypoalbuminemia were found to be other independent predictors. The optimal cut-off value of the postoperative fifth-day SII was calculated at 1751.9 units (p < 0.001).

CONCLUSION

The postoperative fifth-day SII is a simple and useful inflammatory biomarker for predicting one-year mortality in patients with hip fracture.

The Role of Cytokines in Acute and Chronic Postsurgical Pain in Pediatric Patients after Major Musculoskeletal Surgeries

Study Objective

To determine if baseline cytokines and their changes over postoperative days 0-2 (POD0-2) predict acute and chronic postsurgical pain (CPSP) after major surgery.

Design

Prospective, observational, longitudinal nested study.

Setting

University-affiliated quaternary children's hospital.

Patients

Subjects (≥8 years old) with idiopathic scoliosis undergoing spine fusion or pectus excavatum undergoing Nuss procedure.

Measurements

Demographics, surgical, psychosocial measures, pain scores, and opioid use over POD0-2 were collected. Cytokine concentrations were analyzed in serial blood samples collected before and after (up to two weeks) surgery, using Luminex bead arrays. After data preparation, relationships between pre- and post-surgical cytokine concentrations with acute (% time in moderate-severe pain over POD0-2) and chronic (pain score>3/10 beyond 3 months post-surgery) pain were analyzed. After adjusting for covariates, univariate/multivariate regression analyses were conducted to associate baseline cytokine concentrations with postoperative pain, and mixed effects models were used to associate longitudinal cytokine concentrations with pain outcomes.

Main Results

Analyses included 3,164 measures of 16 cytokines from 112 subjects (median age 15.3, IQR 13.5-17.0, 54.5% female, 59.8% pectus). Acute postsurgical pain was associated with higher baseline concentrations of GM-CSF (β=0.95, SE 0.31; p=.003), IL-1β (β=0.84, SE 0.36; p=.02), IL-2 (β=0.78, SE 0.34; p=.03), and IL-12 p70 (β=0.88, SE 0.40; p=.03) and longitudinal postoperative elevations in GM-CSF (β=1.38, SE 0.57; p=.03), IFNγ (β=1.36, SE 0.6; p=.03), IL-1β (β=1.25, SE 0.59; p=.03), IL-7 (β=1.65, SE 0.7, p=.02), and IL-12 p70 (β=1.17, SE 0.58; p=.04). In contrast, CPSP was associated with lower baseline concentration of IL-8 (β= -0.39, SE 0.17; p=.02), and the risk of developing CPSP was elevated in patients with lower longitudinal postoperative concentrations of IL-6 (β= -0.57, SE 0.26; p=.03), IL-8 (β= -0.68, SE 0.24; p=.006), and IL-13 (β= -0.48, SE 0.22; p=.03). Furthermore, higher odds for CPSP were found for females (vs. males) for IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, and TNFα, and for pectus (vs. spine) surgery for IL-8 and IL-10.

Conclusion

We identified pro-inflammatory cytokines associated with increased acute postoperative pain and anti-inflammatory cytokines associated with lower CPSP risk, with potential to serve as predictive and prognostic biomarkers.

Perioperative Ketamine and Cancer Recurrence: A Comprehensive Review

Cancer is a significant global health threat and a leading cause of death worldwide. Effective early-stage interventions, particularly surgery, can potentially cure many solid tumors. However, the risk of postoperative cancer recurrence remains high. Recent research highlights the influence of perioperative anesthetic and analgesic choices on the fate of residual cancer cells, potentially affecting recurrence risks. Among these agents, ketamine-a well-known anesthetic and analgesic-has garnered interest due to its antitumor properties, mainly through inhibiting the N-methyl-D-aspartate (NMDA) receptor found in various cancer tissues. Additionally, ketamine's potential immunomodulatory effects, given the expression of NMDA receptors on immune cells, suggest that it plays a significant role during the perioperative period. This review synthesizes current evidence on ketamine's impact on cancer cell biology, inflammation, immune modulation, and the role of the gut microbiota, proposing ketamine as a promising agent for enhancing oncological outcomes.

Risk factors for surgical site infection after closed proximal humerus fractures

Proximal humerus fractures are common in clinical practice, and there are relatively a few studies on postoperative incision infections of such fractures. The purpose of this study was to explore the risk factors for surgical site infection (SSI) after internal fixation in patients with closed proximal humerus fractures. Patients with closed proximal humerus fractures who underwent surgery from January 2016 to January 2022 were retrospectively analysed. Cases with superficial or deep infections within 3 months after surgery were in the infection group and the remaining cases were in the non-infection group. The types of pathogenic bacteria in the infection group were analysed. The potential risk factors for SSI in all patients were recorded: (1) patient-related factors: gender, age, body mass index (BMI), smoking, comorbidities; (2) trauma-related factors: mechanism of injury, Injury Severity Score, visual analogue scale, fracture type, soft tissue condition and combined dislocation; (3) laboratory-related indexes: haemoglobin, albumin; (4) surgery-related factors: time from injury to surgery, American Society of Anesthesiologists anaesthesia classification, surgical time, fixation mode, intraoperative blood loss, suture method, bone graft and postoperative drainage. The risk factors for the occurrence of SSI were analysed using univariate analysis and multivariate logistic regression. The incidence of SSI was 15.7%. The most common bacterium in the infection group was Staphylococcus aureus. High BMI (p = 0.033), smoking (p = 0.030), an increase in mean time from injury to definitive surgery (p = 0.013), and prolonged surgical time (p = 0.044) were independent risk factors for the development of SSI after closed proximal humeral fractures. In patients with closed proximal humerus fractures, weight loss, perioperative smoking cessation, avoidance of delayed surgery, and shorter surgical time may be beneficial in reducing the incidence of SSI.

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Correlation between C-reactive protein and postoperative mortality in patients undergoing hip fracture surgery: a meta-analysis

BACKGROUND

Hip fracture is a common but devastating disease with a high mortality rate in the older adult population. C-reactive protein (CRP) is a predictor of the prognosis in many diseases, but its correlations with patient outcomes following hip fracture surgery remain unclear. In this meta-analysis, we investigated the correlation between perioperative CRP level and postoperative mortality in patients undergoing hip fracture surgery.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies published before September 2022. Observational studies investigating the correlation between perioperative CRP level and postoperative mortality in patients with hip fracture were included. The differences in CRP levels between the survivors and nonsurvivors following hip fracture surgery were measured with mean differences (MDs) and 95% confidence intervals (CIs).

RESULTS

Fourteen prospective and retrospective cohort studies comprising 3986 patients with hip fracture were included in the meta-analysis. Both the preoperative and postoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≥ 6 months (MD: 0.67, 95% CI: 0.37-0.98, P < 0.0001; MD: 1.26, 95% CI: 0.87-1.65, P < 0.00001, respectively). Preoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≤ 30 days (MD: 1.49, 95% CI: 0.29-2.68; P = 0.01).

CONCLUSIONS

Both higher preoperative and postoperative CRP levels were correlated with higher risk of mortality following hip fracture surgery, suggesting the prognostic role of CRP. Further studies are warranted to confirm the ability of CRP to predict postoperative mortality in patients with hip fracture.

Serum HMGB1 levels and its clinical significance in elderly patients with intertrochanteric fractures after intramedullary fixation surgery

BACKGROUND

Intramedullary fixation is a valuable alternative for the treatment of intertrochanteric fractures. However, further development of new biomarkers to predict the prognosis of the patient is still needed for timely and effective treatment and intervention. The present study aimed to explore the serum high-mobility group box 1 (HMGB1) levels in the prognosis of intertrochanteric fracture patients and its correlation with clinical results.

METHODS

The present prospective cohort study recruited 115 intertrochanteric fracture patients who were admitted from January 2015 to December 2019. All patients were evaluated preoperatively and treated (proximal femoral nail antirotation or intramedullary proximal femoral nail) by the same team. The serum HMGB1, interleukin-6, interleukin-1β, tumor necrosis factor α, and C-reactive protein levels were measured by enzyme-linked immunosorbent assay. Demographic and clinical data of all patients were collected. Harris score was used to assess the prognosis of intertrochanteric fracture patients after 6 months of treatment. Statistical analysis was conducted using SPSS software with P < .05 as statistically different.

RESULTS

The time of the operation and the amount of bleeding in intramedullary proximal femoral nail were remarkably elevated compared with the proximal femoral nail antirotation group (P < .05). The age, proportion of complications and visual analogue score VAS after 72 hours of surgery in the Harris score < 80 group were remarkably increased compared with Harris score ≥ 80 group (P < .05). In addition, we found that the serum HMGB1 levels in Harris score < 80 group were markedly elevated than the patients in Harris score ≥ 80 group at all time points (P < .05). The results showed that the serum HMGB1 levels at postoperative 48 hours had the highest predictive value for predicting poor prognosis in intertrochanteric fracture patients. It was found that HMGB1, age and VAS after 72 hours of surgery were the risk factors for poor prognosis of intertrochanteric fracture patients.

CONCLUSION

This study showed that the serum HMGB1 levels was significantly decreased in intertrochanteric fracture patients with bad prognoses. This study may provide a new approach to screening intertrochanteric fracture patients with worse prognoses in advance.

Cardiac alterations following experimental hip fracture - inflammaging as independent risk factor

Background

Cardiac injuries following trauma are associated with a worse clinical outcome. So-called trauma-induced secondary cardiac injuries have been recently described after experimental long bone fracture even in absence of direct heart damage. With the progressive aging of our society, the number of elderly trauma victims rises and therefore the incidence of hip fractures increases. Hip fractures were previously shown to be associated with adverse cardiac events in elderly individuals, which have mainly been attributed to pre-conditioned cardiac diseases. The aim of the present study was to investigate the effect of hip fractures on the heart in healthy young and middle-aged mice.

Materials and Methods

Young (12-week-old) and middle-aged (52-week-old) female C57BL/6 mice either received an intramedullary stabilized proximal femur fracture or sham treatment. The observation time points included 6 and 24 h. Systemic levels of pro-inflammatory mediators as well as local inflammation and alterations in myocardial structure, metabolism and calcium homeostasis in left ventricular tissue was analyzed following hip fracture by multiplex analysis, RT-qPCR and immunohistochemistry.

Results

After hip fracture young and middle-aged mice showed increased systemic IL-6 and KC levels, which were significantly elevated in the middle-aged animals. Furthermore, the middle-aged mice showed enhanced myocardial expression of HMGB1, TLR2/4, TNF, IL1β and NLRP3 as well as considerable alterations in the myocardial expression of glucose- and fatty acid transporters (HFABP, GLUT4), calcium homeostasis proteins (SERCA) and cardiac structure proteins (desmin, troponin I) compared to the young animals following hip fracture.

Conclusion

Young and middle-aged mice showed local myocardial alterations, which might predispose for the development of secondary cardiac injury following hip fracture. Age and the age-associated phenomenon of ‘inflammaging’ seemed to be an independent risk factor aggravating and accelerating cardiac alterations following hip fracture.

Clinical Data for Parametrization of In Silico Bone Models Incorporating Cell-Cytokine Dynamics: A Systematic Review of Literature

In silico simulations aim to provide fast, inexpensive, and ethical alternatives to years of costly experimentation on animals and humans for studying bone remodeling, its deregulation during osteoporosis and the effect of therapeutics. Within the varied spectrum of in silico modeling techniques, bone cell population dynamics and agent-based multiphysics simulations have recently emerged as useful tools to simulate the effect of specific signaling pathways. In these models, parameters for cell and cytokine behavior are set based on experimental values found in literature; however, their use is currently limited by the lack of clinical in vivo data on cell numbers and their behavior as well as cytokine concentrations, diffusion, decay and reaction rates. Further, the settings used for these parameters vary across research groups, prohibiting effective cross-comparisons. This review summarizes and evaluates the clinical trial literature that can serve as input or validation for in silico models of bone remodeling incorporating cells and cytokine dynamics in post-menopausal women in treatment, and control scenarios. The GRADE system was used to determine the level of confidence in the reported data, and areas lacking in reported measures such as binding site occupancy, reaction rates and cell proliferation, differentiation and apoptosis rates were highlighted as targets for further research. We propose a consensus for the range of values that can be used for the cell and cytokine settings related to the RANKL-RANK-OPG, TGF-β and sclerostin pathways and a Levels of Evidence-based method to estimate parameters missing from clinical trial literature.

Cytokine changes in cerebrospinal fluid and plasma after emergency orthopaedic surgery

Neuroinflammation after surgery and its contribution to peri-operative neurocognitive disorders (PND) is not well understood. Studying the association between central and peripheral cytokines and neuroinflammation is a prelude to the development of treatments for PND. Here, we investigate the hypotheses that there is a greater cytokine response in cerebrospinal fluid (CSF) than plasma after orthopaedic surgery, and that plasma cytokine levels are directly related to CSF cytokine levels, indicating that plasma cytokine levels may have potential as biomarkers of neuroinflammation. Patients admitted with a fractured neck of femur were invited to participate in this study. Participants had a spinal catheter inserted just prior to induction of anaesthesia. Samples of blood and CSF were taken before, immediately after, and on the first day following emergency surgery. The catheter was then removed. Samples were analysed for the presence of ten cytokines by immunoassay. A spinal catheter was successfully inserted in 11 participants during the 18-month study period. Five plasma cytokines (IL-4, IL-6, IL-10, IL-12p70 and IL-13) rose significantly following surgery, whereas all ten CSF cytokines rose significantly (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IFN-γ and TNF-α) (adjusted-p < 0.05). Central (CSF) cytokine levels were consistently higher than their peripheral (plasma) counterparts after surgery, with some patients having a particularly marked neuroinflammatory response. The greatest increases occurred in IL-8 in CSF and IL-6 in plasma. There were significant, strong positive correlations between several of the measured cytokines in the CSF after surgery, but far fewer in plasma. There was no significant correlation between cytokine levels in the plasma and CSF at each of the three time points. To our knowledge, this is the first study to analyse paired samples of plasma and CSF for cytokine levels before and after emergency orthopaedic surgery. This study demonstrates that following surgery for a fractured neck of femur, there is a far greater rise in cytokines in the CSF compared to plasma. The lack of correlation between peripheral and central cytokines suggests measurement of peripheral cytokines are not necessarily related to which patients may have a large neuroinflammatory response.

Incidence and risk factors associated with preoperative deep venous thrombosis in the young and middle-aged patients after hip fracture

Objective

This study aims to investigate the incidence, occurrence timing and locations of preoperative DVT and identify the associated factors in this group.

Methods

A retrospective analysis of collected data in young and middle-aged (18–59 years) patients who presented with hip fracture between October 2015 and December 2018 was conducted. Before operation, patients were routinely examined for DVT by Duplex ultrasonography (DUS). Electronic medical records were retrieved to collect the data, involving demographics, comorbidities, injury and laboratory biomarkers after admission. Multivariate logistic regression analysis was performed to identify factors that were independently associated with DVT.

Results

Eight hundred and fifty-seven patients were included, and 51 (6.0%) were diagnosed with preoperative DVT, with 2.5% for proximal DVT. The average age of patients with DVT is 48.7 ± 9.4 year, while that of patients without DVT is 45.0 ± 10.9 year. The mean time from injury to diagnosis of DVT was 6.8 ± 5.5 days, 43.1% cases occurring at day 2–4 after injury. Among 51 patients with DVT, 97 thrombi were found. Most patients had thrombi at injured extremity (72.5%), 19.6% at uninjured and 7.8% at bilateral extremities. There are significantly difference between patients with DVT and patients without DVT in term of prevalence of total protein (41.2% vs 24.4%, P = 0.008), albumin (54.9% vs 25.6%, P = 0.001), low lactate dehydrogenase (51.0% vs 30.3%, P = 0.002), lower serum sodium concentration (60.8% vs 29.9%, P = 0.001), lower RBC count (68.6% vs 37.0%, P = 0.001), lower HGB (51.0% vs 35.1%, P = 0.022), higher HCT (86.3% vs 35.1%, P = 0.022) and higher platelet count (37.3% vs 11.3%, P = 0.001). The multivariate analyses showed increasing age in year (OR 1.04, 95% CI; P = 0.020), delay to DUS (OR, 1.26; P = 0.001), abnormal LDH (OR, 1.45; P = 0.026), lower serum sodium concentration (OR, 2.56; P = 0.007), and higher HCT level (OR, 4.11; P = 0.003) were independently associated with DVT.

Conclusion

These findings could be beneficial in informed preventive of DVT and optimized management of hip fracture in specific group of young and mid-aged patients.

Effects of Omega-3 Polyunsaturated Fatty Acids on Cognitive Function after Splenectomy in Rats

Background

Postoperative cognitive dysfunction (POCD) is a common complication after abdominal surgery. Several studies have reported that POCD is related to neuroinflammation caused by surgery. Omega-3 polyunsaturated fatty acids (PUFAs) can effectively inhibit the systematic inflammatory response. So, we use fish oil to study the effect of fish oil on inflammation, immunity, and cognitive behavior after splenectomy in rats.

Methods

60 SD (Sprague-Dawley) rats were randomly divided into control group (group C, n = 20), surgery group (group S, n = 20), and omega-3 (fish oil) intervention group (group F, n = 20). Omega-3 PUFA was injected intraperitoneally from 3 days before operation to 7 days after operation in group F, and normal saline was injected simultaneously in group S. Rats in group S and group F received splenectomy under general anesthesia. Morris water maze behavioral evaluation was performed on the first, third, fifth, and seventh day after operation. The levels of IL-1β (interleukin-1β), IL-6 (interleukin-6), TNF-α (tumor necrosis factor-α), SOD (superoxide dismutase), and GSH-PX (glutathione peroxidase) were detected.

Results

Serums IL-1β, IL-6, and TNF-α concentrations in group S and group F were higher than those in group C (P < 0.01), while those inflammatory cytokines in group F were significantly lower than those in group S (P < 0.01); serum GSH-PX levels in group F were higher than group S (P < 0.01). The Morris water maze behavior test performance of group F was better than that of group S (P < 0.05).

Conclusion

Omega-3 PUFA can effectively improve postoperative inflammatory response, reduce the damage of antioxidant defense system, and improve postoperative cognitive function.

Correlation between neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture: a meta-analysis

Introduction

The neutrophil-to-lymphocyte ratio (NLR) is a crucial prognosis predictor following several major operations. However, the association between NLR and the outcome after hip fracture surgery is unclear. In this meta-analysis, we investigated the correlation between NLR and postoperative mortality in geriatric patients following hip surgery.

Method

PubMed, Embase, Cochrane library, and Google Scholar were searched for studies up to June 2021 reporting the correlation between NLR and postoperative mortality in elderly patients undergoing surgery for hip fracture. Data from studies reporting the mean of NLR and its 95% confidence interval (CI) were pooled. Both long-term (≥ 1 year) and short-term (≤ 30 days) mortality rates were included for analysis.

Result

Eight retrospective studies comprising a total of 1563 patients were included. Both preoperative and postoperative NLRs (mean difference [MD]: 2.75, 95% CI: 0.23–5.27; P = 0.03 and MD: 2.36, 95% CI: 0.51–4.21; P = 0.01, respectively) were significantly higher in the long-term mortality group than in the long-term survival group. However, no significant differences in NLR were noted between the short-term mortality and survival groups (MD: − 1.02, 95% CI: − 3.98 to 1.93; P = 0.5).

Conclusion

Higher preoperative and postoperative NLRs were correlated with a higher risk of long-term mortality following surgery for hip fracture in the geriatric population, suggesting the prognostic value of NLR for long-term survival. Further studies with well-controlled confounders are warranted to clarify the predictive value of NLR in clinical practice in geriatric patients with hip fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02831-6.

Prognostic factors of depression and depressive symptoms after hip fracture surgery: systematic review

Background

Patients with hip fracture and depression are less likely to recover functional ability. This review sought to identify prognostic factors of depression or depressive symptoms up to 1 year after hip fracture surgery in adults. This review also sought to describe proposed underlying mechanisms for their association with depression or depressive symptoms.

Methods

We searched for published (MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection) and unpublished (OpenGrey, Greynet, BASE, conference proceedings) studies. We did not impose any date, geographical, or language limitations. Screening (Covidence), extraction (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist), and quality appraisal (Quality in Prognosis Studies tool) were completed in duplicate. Results were summarised narratively.

Results

In total, 37 prognostic factors were identified from 12 studies included in this review. The quality of the underlying evidence was poor, with all studies at high risk of bias in at least one domain. Most factors did not have a proposed mechanism for the association. Where factors were investigated by more than one study, the evidence was often conflicting.

Conclusion

Due to conflicting and low quality of available evidence it is not possible to make clinical recommendations based on factors prognostic of depression or depressive symptoms after hip fracture. Further high-quality research investigating prognostic factors is warranted to inform future intervention and/or stratified approaches to care after hip fracture.

Trial registration

Prospero registration: CRD42019138690.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02514-1.

Point-of-care detection of cytokines in cytokine storm management and beyond: Significance and challenges

Cytokines are signaling molecules between cells in immune system. Cytokine storm, due to the sudden acute increase in levels of pro-inflammatory circulating cytokines, can result in disease severity and major-organ damage. Thus, there is urgent need to develop rapid, sensitive, and specific methods for monitoring of cytokines in biology and medicine. Undoubtedly, point-of-care testing (POCT) will provide clinical significance in disease early diagnosis, management, and prevention. This review aims to summarize and discuss the latest technologies for detection of cytokines with a focus on POCT. The overview of diseases resulting from imbalanced cytokine levels, such as COVID-19, sepsis and other cytokine release syndromes are presented. The clinical cut-off levels of cytokine as biomarkers for different diseases are summarized. The challenges and perspectives on the development of cytokine POCT devices are also proposed and discussed. Cytokine POCT devices are expected to be the ongoing spotlight of disease management and prevention during COVID-19 pandemic and also the post COVID-19 pandemic era.

Is Timing to Surgery an Independent Risk Factor for Complications Following Operative Treatment of Periprosthetic Lower Extremity Fractures?

OBJECTIVE

To identify whether timing to surgery was related to major 30-day morbidity and mortality rates in periprosthetic hip and knee fractures [OTA/AO 3 (IV.3, V.3), OTA/AO 4 (V4)].

DESIGN

Retrospective database review.

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS

Patients in the NSQIP database with periprosthetic hip or knee fractures between 2007 and 2015.

INTERVENTION

Surgical management of periprosthetic hip and knee fractures including revision or open reduction internal fixation.

MAIN OUTCOME MEASUREMENTS

Major 30-day morbidity and mortality after operative treatment of periprosthetic hip or knee fractures.

RESULTS

A total of 1265 patients, mean age 72, including 883 periprosthetic hip and 382 periprosthetic fractures about the knee were reviewed. Delay in surgery greater than 72 hours is a risk factor for increased 30-day morbidity in periprosthetic hip and knee fractures [relative risk = 2.90 (95% confidence interval: 1.74-4.71); P-value ≤ 0.001] and risk factor for increased 30-day mortality [relative risk = 8.98 (95% confidence interval: 2.14-37.74); P-value = 0.003].

CONCLUSIONS

Using NSQIP database to analyze periprosthetic hip and knee fractures, delay to surgery is an independent risk factor for increased 30-day major morbidity and mortality when controlling for patient functional status and comorbidities. Although patient optimization and surgical planning are paramount, minimizing extended delays to surgery is a potentially modifiable risk factor in the geriatric periprosthetic lower extremity fracture patient.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preadmission Statin Prescription and Inpatient Myocardial Infarction in Geriatric Hip Fracture

Statins have been shown to reduce myocardial infarction (MI) in cardiac and vascular surgery. MI is common in hip fracture. This study aims to investigate whether statins decrease MI in hip fracture surgery and reduce mortality resulting from MI. Patients aged 65 years and above with a low-energy hip fracture were identified between January 2015 and December 2017. Demographics, comorbidities, predictive scores, medications and outcomes were assessed retrospectively. The primary outcome was inpatient MI. The secondary outcome was inpatient mortality resulting from MI, for which fatal and non-fatal MI were modelled. Regression analysis was conducted with propensity score weighting. Hip fracture occurred in 1166 patients, of which 391 (34%) were actively taking statins. Thirty-one (2.7%) patients were clinically diagnosed with MI. They had a higher inpatient mortality than those who did not sustain an MI (35% vs. 5.3%, p < 0.0001). No reduction was seen between statin use and the occurrence of MI (OR = 0.97, 95% CI: 0.45-2.11; p = 0.942) including Fluvastatin-equivalent dosage (OR = 1.00, 95% CI: 0.96-1.03, p = 0.207). Statins were not associated with having a non-fatal MI (OR 1.47, 95% CI: 0.58-3.71; p = 0.416) or preventing fatal MI (OR = 0.40, 95% CI: 0.08-1.93; p = 0.255). Preadmission statin use and associations with clinically diagnosed inpatient MI or survival after inpatient MI were not able to be established.

Peripheral IL-6 Levels but not Sarcopenia Are Predictive of 1-Year Mortality After Hip Fracture in Older Patients

BACKGROUND

Sarcopenic patients may have an increased risk of poor outcomes after a hip fracture. The objective of this study was to determine whether sarcopenia and a set of biomarkers were potential predictors of 1-year-mortality in older patients after a hip fracture.

METHODS

About 150 patients at least 80 years old were hospitalized for the surgical treatment of a hip fracture. The primary outcome measure was the death in the first year after the hip fracture. Sarcopenia was defined at baseline by having both low muscle mass (bioimpedance analysis) and handgrip and using the updated European Working Group on Sarcopenia in Older People (EWGSOP2) definition of probable sarcopenia. Janssen's (J) and Masanés (M) cutoff points were used to define low muscle mass.

RESULTS

Mortality 1 year after the hip fracture was 11.5%. In univariate analyses, baseline sarcopenia was not associated with mortality, using neither of the muscle mass cutoff points: 5.9% in sarcopenic (J) versus 12.4% in non-sarcopenic participants (p = .694) and 16% in sarcopenic (M) versus 9.6% in non-sarcopenic participants (p = .285). Probable sarcopenia (EWGSOP2) was not associated with mortality. Peripheral levels of IL-6 at baseline were significantly higher in the group of participants who died in the year after the hip fracture (17.14 ± 16.74 vs 11.42 ± 7.99 pg/mL, p = .026). TNF-α peripheral levels had a nonsignificant trend to be higher in participants who died. No other biomarker was associated with mortality.

CONCLUSIONS

Sarcopenia at baseline was not a predictor of 1-year mortality in older patients after a hip fracture. IL-6 was associated with a higher risk of mortality in these patients, regardless of sarcopenia status.

Usefulness of an accelerometer-based navigation system in bilateral one-stage total knee arthroplasty

Background

Bilateral one-stage total knee arthroplasty (BTKA) have increased because it provides a number of advantages. Recently, Accelerometer-based navigation (ABN) system which guide the cutting plane without intramedullary disturbance might result in less endothelial and microvascular damage. Therefore, we hypothesized that the ABN may reduce blood loss, reduce postoperative pain, and better restore BTKA alignment compared to conventional instruments.

Methods

We retrospectively compared 44 consecutive patients receiving ABN assisted BTKA (iBTKA) to 57 patients with conventional instruments (cBTKA). Identical pre- and post-operative care was utilized to all patients. The outcome measures assessed were hemoglobin (Hb), calculated blood loss (CBL), blood transfusion, VAS score for pain, morphine consumption, knee flexion angle, and length of stay (LOS). Radiographic assessment included mechanical axis (MA) and component positioning at 3–6 months of follow up.

Results

Both iBTKA and cTKA groups had equivalent demographic data. Postoperative Hb of the cBTKA group was significantly lower than those in the iBTKA group at 24 h (p = 0.02), but there was no significant difference in drain volume, CBL, and blood transfusion rate. For radiographic measures, the iBTKA group had more accurate MA and component orientation, and had a lower number of outliers than those in the cBTKA group (p ≤ 0.01), except for the sagittal femoral component angle.

Conclusion

The ABN assisted BTKA could not reduce blood loss or postoperative pain more than cBTKA, nor improve functional recovery. However, the ABN significantly improved the accuracy of MA and prostheses positioning.

Trial registration

The protocol of this study was registered in the Thai Clinical Trials Registry database No. TCTR20180731001# on 25 July 2018.

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the "first hit"). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the "second hit" and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality. The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the "Safe Definitive Surgery" (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.

Hip Fracture Leads to Transitory Immune Imprint in Older Patients

Background: Hip fracture (HF) is common in the geriatric population and is associated with a poor vital and functional prognosis which could be impacted by immunological changes. The objective here is to decipher immune changes occurring in the 1st days following HF and determine how phenotype, function, and regulation of innate and adaptive compartments adapt during acute stress event.

Methods: We included HF patients, aged over 75 years. For each patient, blood samples were taken at five different timepoints: four in the perioperative period (day 0 to hospital discharge) and one at long term (6–12 months). Phenotypical and functional analysis were performed longitudinally on fresh blood or cryopreserved PBMCs. Clinical data were prospectively collected.

Results: One-hundred HF patients and 60 age-matched controls were included. Innate compartment exhibits pro-inflammatory phenotypes (hyperleukocytosis, increase of CD14+ CD16+ proportion and CCR2 expression), maintaining its ability to produce pro-inflammatory cytokines. Adaptive compartment extends toward a transitory immunosuppressive profile (leucopenia) associated with an active T-cell proliferation. Furthermore, increases of LAG-3 and PD-1 and a decrease of 2-B4 expression are observed on T-cells, reinforcing their transitory suppressive status. Of note, these immune changes are transitory and sequential but may participate to a regulation loop necessary for homeostatic immune control at long term.

Conclusion: HF is associated with several transitory immunological changes including pro-inflammatory phenotype in innate compartment and immunosuppressive profile in adaptive compartment. A comprehensive assessment of immune mechanisms implicated in the patient's prognosis after HF could pave the way to develop new immune therapeutics strategies.

17-β-Estradiol and Progesterone as Efficient Predictors of Survival in Older Women Undergoing Hip Fracture Surgery

Objective: Sex hormones have been linked to fractures in older women. The purpose of this present study was to investigate the prognostic impact of preoperative sex hormone levels on 30-day mortality in older women undergoing hip fracture surgery.

Patients and Methods: A total of 157 female subjects with hip fractures were eligible for the study conducted from January 2010 to December 2019. The serum levels of sex hormones [follicle-stimulating hormone, prolactin, progesterone, testosterone, luteinizing hormone, and 17-β-estradiol (E2)] were measured at admission. To evaluate the prognostic significance of sex hormone levels, Cox proportional hazard models and Kaplan–Meier analyses were applied.

Results: Of the 157 subjects, 13 (8.28%) deceased within 30 days. The deceased subjects had lower progesterone (P = 0.021) and E2 (P < 0.001) levels than the surviving group. Higher progesterone (HR = 0.168, 95% CI = 0.037–0.673) and E2 (HR = 0.857, 95% CI = 0.690–0.968) levels were the key protective factors for 30-day mortality in older women undergoing hip fracture surgery. Survival analysis showed that subjects with lower E2 or/and progesterone levels had a significantly higher percentage of 30-day mortality (log-rank test, P < 0.05).

Conclusion: E2 and progesterone might be effective predictors of 30-day mortality in older women undergoing hip fracture surgery.

Effects of Anesthesia Techniques on Outcomes after Hip Fracture Surgery in Elderly Patients: A Prospective, Randomized, Controlled Trial

The superiority of distinct anesthesia methods for geriatric hip fracture surgery remains unclear. We evaluated high mobility group box-1 (HMGB1) and interleukin-6 (IL-6) with three different anesthesia methods in elderly patients undergoing hip fracture surgery. Routine blood test findings, postoperative morbidity, and mortality were assessed as secondary outcome. In total, 176 patients were randomized into desflurane (n = 60), propofol (n = 58), or spinal groups (n = 58) that received desflurane-based balanced anesthesia, propofol-based total intravenous anesthesia (TIVA), or spinal anesthesia, respectively. The spinal group required less intraoperative vasopressors (p < 0.001) and fluids (p = 0.006). No significant differences in HMGB1 (p_group×time = 0.863) or IL-6 (p_group×time = 0.575) levels were noted at baseline, postoperative day (POD) 1, or POD2. Hemoglobin, albumin, creatinine, total lymphocyte count, potassium, troponin T, and C-reactive protein were comparable among groups at all time-points. No significant differences in postoperative hospital stay, intensive care unit (ICU) stay, and ventilator use among groups were observed. Postoperative pulmonary, cardiac, and neurologic complications; and in-hospital, 30-day, and 90-day mortality were not significantly different among groups (p = 0.974). In conclusion, HMGB1 and IL-6, and all secondary outcomes, were not significantly different between desflurane anesthesia, propofol TIVA, and spinal anesthesia.

Tranexamic Acid Reduces Total Blood Loss and Inflammatory Response in Computer-Assisted Navigation Total Knee Arthroplasty

Introduction

Tranexamic acid (TXA) is an effective blood salvage agent that reduces perioperative blood loss in conventional total knee arthroplasty (TKA). As computer-assisted surgery for TKA (CAS-TKA) results in a lower perioperative blood loss than conventional TKA, the additional effect of blood conservation by TXA might be mitigated. This study aimed to evaluate the efficacy of TXA in CAS-TKA.

Methods

We retrospectively reviewed 222 consecutive patients who underwent CAS-TKA. Intravenous TXA was administered in 103 patients (TXA group) at a dosage of 20 mg/kg 15 min before deflation of the tourniquet. The other 119 patients did not receive TXA (control group). Patient demographic data including age, gender, BMI, DM, and hypertension were collected. The primary outcomes were the estimated total blood loss (ETBL) and perioperative data, including tourniquet duration, preoperative and postoperative day 1 (POD1) and day 3 (POD3) serum D-dimer, CRP, hemoglobin (Hb), and hematocrit (Hct) levels. Secondary outcomes including transfusion rate and 90-day complications were recorded.

Results

The ETBL was lower in the TXA group on both POD1 (404.34 ± 234.77 vs. 595.47 ± 279.04, p < 0.001) and POD3 (761.39 ± 260.88 vs. 987.79 ± 326.58, p < 0.001). The TXA group also demonstrated a lower level of CRP on POD1 (p=0.02) and lower levels of CRP and serum D-dimer on POD3 (p=0.008 and p < 0.001). Consumption of fibrinogen was higher in the control group on both POD1 (p=0.013) and POD3 (p < 0.001). Length of hospital stay was lower in the TXA group (5.42 ± 1.21 vs. 6.25 ± 1.49, p < 0.001). The transfusion rate and perioperative complications were not significantly different between the two groups.

Conclusion

Administration of TXA is not only effective in reducing perioperative blood loss and length of hospital stay but also exerts an anti-inflammatory effect following CAS-TKA without causing major complications.

Biochemical markers of inflammation are associated with increased mortality in hip fracture patients: the Bispebjerg Hip Fracture Biobank

PURPOSE

The purpose of this study was to examine the possible association between mortality following a hip fracture and known biochemical markers of inflammation.

METHODS

The study population was identified using two local databases from Bispebjerg Hospital (Copenhagen, Denmark): the Hip Fracture Database containing all patients admitted to the hospital with a fractured hip from 1996 to 2012 and the Hip Fracture Biobank, containing whole blood, serum and plasma taken in relation to admission on a subgroup of patients from the Hip Fracture Database, consecutively collected over a period of 2.5 years from 2008 to 2011. The following biochemical markers of inflammation were included: C-reactive protein (CRP), the soluble urokinase plasminogen activating receptor (suPAR), ferritin and transferrin. The association between the blood markers and mortality was examined using Cox proportional hazards models. Hazard ratios (HR) were expressed per quartile increase in the biochemical markers.

RESULTS

A total of 698 patients were included, 69 (9.9%) died within 30 days after sustaining a hip fracture. The HR for 30-day mortality was significantly increased with increasing quartiles of suPAR, CRP and ferritin and with decreasing quartiles of transferrin.

CONCLUSION

This study shows that 30-day mortality after a hip fracture is associated with elevated levels of suPAR, CRP and ferritin as well as with lower levels of transferrin. This excess inflammatory response is likely caused by muscle damage associated with the hip fracture. However, this needs to be further clarified.

Inflammatory cytokines IL-6 and TNF-α in patients with hip fracture

Mortality and remaining bedridden following the hip fracture surgery are not rare. We tried to measure the levels of inflammatory markers tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) following the hip fracture surgery and compare their levels with controls. We aimed to show a relationship between the levels of these markers and post-operative mortality and walking capability.

INTRODUCTION

Osteoporosis is a condition, causing the hip fractures in the elderly. Hip fractures have a high rate of overall mortality up to 30% following the incident. Cytokines such as IL-6 and TNF-α are suggested to play a role in bone resorption and, thus, in the etiology of osteoporosis.

METHODS

Plasma levels of IL-6 and TNF-α were measured pre-operatively and on the first and second days after the surgery in 40 Turkish hip fracture patients. The levels of these cytokines were compared with 40 Turkish age-matched healthy controls. The levels of these cytokines were compared between the deceased and surviving patients, as well as the existence of walking capability following the surgery.

RESULTS

Significantly higher IL-6 levels were shown on the first and second days after the surgery (p = 0.005; p = 0.01, respectively). The overall death rate of our study group within the 2-year follow-up time was found to be 35%. No statistical significance was found in the means of 2-year follow-up mortality between the patients. Presence of walking capability did not differ between the patients, as well.

CONCLUSION

We demonstrated an association between IL-6 levels and hip fracture in our study group following the surgery. We also suggest that TNF-α and IL-6 levels are not related to the occurrence of death and walking capability after the surgery. However, these findings need further functional and clinical confirmation.

Chemokine analysis as a novel diagnostic modality in the early prediction of the outcome of non-union therapy: a matched pair analysis

BACKGROUND

Despite the regenerative capability of skeletal tissue fracture, non-union is common. Treatment of non-unions remains challenging, and early determination of the outcome is impossible. Chemokines play an important role in promoting the formation of new bone and remodeling existing bone. Despite their importance regarding the regulation of bone biology, the potential of chemokines as biological markers reflecting osseous regeneration is unknown. The purpose of this study was to determine (1) if serum chemokine expression levels correlate with the outcome of non-union surgery and (2) if chemokine expression analysis can be used to identify patients at risk for treatment failure.

METHODS

Non-union patients receiving surgical therapy in our institution between March 2012 and March 2014 were prospectively enrolled in a clinical observer study. Regular clinical and radiological follow-up was conducted for 12 months including collection of blood during the first 12 weeks. Based on the outcome, patients were declared as responders or non-responders to the therapy. To minimize biases, patients were matched (age, sex, body mass index (BMI)) and two groups of patients could be formed: responders (R, n = 10) and non-responders (NR, n = 10). Serum chemokine expression (CCL-2, CCL-3, CCL-4, CXCL-10, CCL-11, and interferon gamma (IFN-γ)) was analyzed using Luminex assays. Data was compared and correlated to the outcome.

RESULTS

CCL-3 expression in NR was significantly higher during the course of the study compared to R (p = 0.002), and the expression pattern of CCL-4 correlated with CCL-3 in both groups (NR: p < 0.001 and r = 0.63). IFN-γ expression in NR was continuously higher than in R (p < 0.001), and utilization of CCL-3 and IFN-γ serum expression levels 2 weeks after the treatment resulted in a predictive model that had an AUC of 0.92 (CI 0.74-1.00).

CONCLUSION

Serum chemokine expression analysis over time is a valid and promising diagnostic tool. The chemokine expression pattern correlates with the outcome of the Masquelet therapy of lower limb non-unions. Utilization of the serum analysis of CCL-3 and IFN-γ 2 weeks after the treatment resulted in an early predictive value regarding the differentiation between patients that are likely to heal and those that are prone to high risk of treatment failure.

Effects of computer-assisted navigation versus conventional total knee arthroplasty on the levels of inflammation markers: A prospective study

Total knee arthroplasty (TKA) is a well-established modality for the treatment of advanced knee osteoarthritis (OA). However, the detrimental effects of intramedullary reaming used in conventional TKA for distal femur cutting are of concern. Avoiding intramedullary reaming with the use of computer-assisted navigation TKA can not only provide superior prosthetic alignment, but also mitigate perioperative blood loss and the dissipation of marrow emboli. We quantified local and systemic concentrations of inflammation markers for both techniques. Forty-four participants undergoing computer-assisted navigation and 53 receiving conventional TKA for advanced knee OA were recruited between 2013/02/08 and 2015/12/09. Blood samples were collected from all participants at baseline then again at 24 and 72 hours postoperatively and analyzed by ELISA for interleukin 6 (IL-6), IL-10, tumor necrosis factor alpha (TNF-α) and transforming growth factor beta 1 (TGF-β1); these markers were also measured in Hemovac drain fluid collected at 24 and 72 hours. Serum levels of IL-6, IL-10, TNF-α and TGF-β1(unit for all markers: pg/mL) were increased from baseline by smaller increments in the navigation TKA cohort compared with the conventional TKA group at 24 hours (17.06 vs 29.39, p = 0.02; 0.51 vs 0.83, p = 0.16; -0.04 vs 0.36, p < 0.01 and -48.18 vs 63.24, p< 0.01, respectively) and at 72 hours (12.27 vs 16.87, p = 0.01; -0.40 vs 0.48, p < 0.01; 0.58 vs 0.98, p = 0.07 and -55.16 vs 63.71, p < 0.01, respectively). IL-10 levels in drainage fluids collected 24 hours after TKA were also significantly lower in the navigation group versus the conventional TKA group (8.55 vs 12.32, p < 0.01). According to our evidence, the merits of computer-assisted navigation TKA are augmented by low levels of inflammation markers.

Risk factors for mortality in elderly patients with hip fractures: a meta-analysis of 18 studies

BACKGROUND

Hip fracture is common and associated with poor outcomes in elderly patients. This meta-analysis aims to investigate the risk factors that might increase the mortality rate in elderly patients with hip fracture.

METHODS

PubMed, Embase, and Web of Science were systematically searched for observational studies regarding the prognostic factors of mortality in elderly patients with hip fracture. A fixed-effects or random-effects model was used to calculate pooled hazard ratio (HR) and 95% confidence intervals (95% CIs).

RESULTS

Eighteen cohort studies, involving 223,875 patients, were included in this meta-analysis. The most prominent factors associated with mortality were higher age (HR 1.51, 95% CI 1.37, 1.67; P < 0.001), male gender (HR 1.91, 95% CI 1.67, 2.19; P < 0.001), cognitive impairment (HR 2.06, 95% CI 1.25, 3.40; P = 0.005), delirium (HR 2.14, 95% CI 1.50, 3.05; P < 0.001), dementia (HR 2.72, 95% CI 1.41, 5.26; P = 0.003), depression (HR 1.71, 95% CI 1.43, 2.05; P < 0.001), living with caregiver (HR 1.61, 95% CI 1.43, 1.82; P < 0.001), cardiovascular disease (HR 2.10, 95% CI 1.14, 3.86; P = 0.018), renal disease (HR 1.66, 95% CI 1.52, 1.82; P < 0.001), and malignancy (HR 1.75, 95% CI 1.30, 2.37; P = 0.031), whereas respiratory disease (HR 1.49, 95% CI 0.99, 2.24; P = 0.056), diabetes (HR 1.15, 95% CI 0.96, 1.37; P = 0.121), and smoking (HR 1.54, 95% CI 0.64, 3.71; P = 0.337) did not increase the risk of mortality.

CONCLUSION

The current study investigated several factors that might increase the risk of mortality in elderly patients with hip fracture. Further studies are needed to evaluate the effectiveness of specific interventions to reduce the risk of mortality.

Postoperative Myocardial Injury and Inflammation Is Not Blunted by a Trial of Atorvastatin in Orthopedic Surgery Patients

BACKGROUND

Orthopedic patients are at risk for adverse postoperative cardiovascular outcomes.

QUESTIONS/PURPOSES

This pilot randomized controlled trial (RCT) of atorvastatin vs. placebo in orthopedic surgery patients was performed in order to assess: (1) the prevalence of perioperative myocardial injury; (2) the effect of atorvastatin on perioperative inflammation; and (3) the feasibility of performing a large RCT of statin therapy in orthopedic patients.

METHODS

Hip fracture (hip Fx) and total hip and knee replacement (THR and TKR) patients were randomized 1:1 to atorvastatin 40 mg daily vs. placebo, starting preoperatively and continuing until postoperative day (POD) 45. High-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) were measured preoperatively and on POD 2. Patients were monitored for adverse events until POD 90.

RESULTS

Five hundred fifty-six patients were screened, 22 were recruited (4 hip Fx, 11 THR, 7 TKR), and 2 withdrew. Most (80%) had detectable hs-cTnI (> 1.1 pg/mL) preoperatively. Twenty percent had a perioperative rise in hs-cTnI (≥ 10 pg/mL), which was not blunted by atorvastatin. Hs-CRP rose in 19/20 patients, and IL-6 rose in all patients. However, atorvastatin did not blunt the rise in these inflammatory biomarkers. On POD 2, IL-6 and hs-cTnI levels correlated (ρ = 0.59, p = 0.02). Recruitment was limited by the high prevalence of statin use in the screened population and a high prevalence of exclusions among hip fracture patients.

CONCLUSION

Perioperative myocardial injury and inflammation are common in orthopedic patients and do not appear to be reduced in those randomized to atorvastatin.

TRIAL REGISTRATION

NCT02197065.

Specific microRNA signatures responsible for immune disturbance related to hip fracture in aged rats

Background

Hip fracture is commonly associated with an overwhelming inflammatory response, which may lead to high rates of morbidity and mortality in the elderly. MicroRNAs (miRNAs) play important roles in the functions of immune system. However, the association between miRNA dysregulation and immune disturbance (IMD) related to elderly hip fracture is largely unknown.

Methods

In this study, microarray profiling was carried out to evaluate the differential expression patterns of miRNAs in plasma of the aged hip fracture rats with IMD, those without IMD, and normal aged rats, followed by validation using quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). Genes and signaling pathways of the dysregulated miRNAs related to elderly hip fracture-induced IMD were investigated in silico using Gene Ontology and analysis of Kyoto Encyclopedia of Genes or Genomes.

Results

Dead or moribund rats with hip fracture exhibited significantly reduced TNF-α/IL-10 ratio compared with healthy controls and other hip fracture rats, which were therefore named as hip fracture rats with IMD. Seven serum miRNAs in hip fracture rats with IMD were significantly downregulated. qRT-PCR and in silico analysis revealed that miR-130a-3p likely participated in regulating the hip fracture-induced IMD. Furthermore, Western blot experiment demonstrated that in lung tissue, the reduction of miR-130a-3p was accompanied with the increase of the protein expression of interferon regulatory factor-1 (IRF1) and sphingosine-1-phosphate receptor 1 (SIPR1).

Conclusions

miR-130a-3p desregulation may be associated with elderly hip fracture-induced IMD, which might act as a new potential biomarker for the diagnosis and prognosis of elderly hip fracture-induced IMD and a potential therapeutic target as well.

Blood prefabricated hydroxyapatite/tricalcium phosphate induces ectopic vascularized bone formation via modulating the osteoimmune environment

Blood prefabricated hydroxyapatite/tricalcium phosphate induces ectopic vascularized bone formation via modulating the osteoimmune environment.

Nanotopography-based strategy for the precise manipulation of osteoimmunomodulation in bone regeneration

Immune cells play vital roles in regulating bone dynamics. Successful bone regeneration requires a favourable osteo-immune environment. The high plasticity and diversity of immune cells make it possible to manipulate the osteo-immune response of immune cells, thus modulating the osteoimmune environment and regulating bone regeneration. With the advancement in nanotechnology, nanotopographies with different controlled surface properties can be fabricated. On tuning the surface properties, the osteo-immune response can be precisely modulated. This highly tunable characteristic and immunomodulatory effects make nanotopography a promising strategy to precisely manipulate osteoimmunomdulation for bone tissue engineering applications. This review first summarises the effects of the immune response during bone healing to show the importance of regulating the immune response for the bone response. The plasticity of immune cells is then reviewed to provide rationales for manipulation of the osteoimmune response. Subsequently, we highlight the current types of nanotopographies applied in bone biomaterials and their fabrication techniques, and explain how these nanotopographies modulate the immune response and the possible underlying mechanisms. The effects of immune cells on nanotopography-mediated osteogenesis are emphasized, and we propose the concept of "nano-osteoimmunomodulation" to provide a valuable strategy for the development of nanotopographies with osteoimmunomodulatory properties that can precisely regulate bone dynamics.

Elevated Neopterin Levels Predict Early Death in Older Hip-fracture Patients

Our society faces a major challenge concerning management of the health and socio-economic burden caused by acute physical stress in the older population (+ 75 years). In particular, hip-fracture surgery (HFS) represents a major health care preoccupation, affecting 1.6 million patients worldwide, resulting in a significant drop in life quality and autonomy. The trauma is associated with 20–30% one-year mortality in the elderly. In the present study, we aim to identify factors, which influence and/or predict the outcome of elderly hip- fracture patients (HFP) post-surgery.

Our objective was to identify biomarkers with a prognostic capacity of one-year mortality. We employed an observational cohort of HFP (n = 60) followed-up longitudinally during the first year post fracture. Clinical and biological data (n = 136), collected at arrival to hospital, were then compared to healthy controls (n = 42) and analyzed using a regularized logistic regression model with lasso penalty followed by 10-fold cross-validation of variables.

We show that plasmatic neopterin levels, a molecule released by IFN-γ-activated macrophages, is predictive of mortality in HFP (ROC-AUC = 0.859). Moreover, neopterin measured at arrival to the hospital correlated negatively with the time of survival after HFS.

Neopterin therefore represents a biomarker, which enables better follow-up of patients at risk of early death.

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Neopterin level, measured at arrival to hospital, is a robust predictive marker of one-year mortality in HFPs.

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Neopterin concentration correlated negatively with the time of survival after hip fracture surgery.

The growing incidence of hip fractures, due to demographically aging populations, represent an important burden for health care systems and for injured patients in terms of hospitalization, rehabilitation, needs for long-term care, change in autonomy and mortality. Hip fractures are associated with high rates of adverse outcome, but previous studies have not discovered methods to identify patients at high risk of pernicious clinical outcome or death. Here, we show that innate immune activation post hip fracture in older adults is associated with pernicious clinical outcome.

Prognostic Value of Serum Procalcitonin After Orthopedic Surgery in the Elderly Population

Background

Orthopedic surgery is more and more frequent in the older patients and is associated with a high mortality rate. Although serum procalcitonin levels are associated with prognosis in young adults, data are still lacking in the elderly population, and especially after surgery. The main objective of this study was to determine the prognostic value of procalcitonin levels in a large geriatric orthopedic population, and we compared it with clinical variables and biomarkers.

Methods

This is a prospective study including patients admitted in our dedicated geriatric postoperative unit, after orthopedic surgery with immediate postoperative measured procalcitonin levels. Collected data included age, sex, medical history, functional status (activities of daily living [ADL]), fracture type, Cumulative Illness Rating scale (CIRS), postoperative complications, and biological data. The primary endpoint was the 30-day mortality.

Results

436 patients (age 85±6 years) were included. Hip fracture surgery was the most frequent (n = 310; 71%), and the 30-day mortality rate was 6.9%. Compared with C-reactive protein (CRP), albumin, CIRS, and ADL, procalcitonin had the highest area under the receiver operating characteristic curve for predicting 30-day mortality (0.74; 95% CI: 0.70-0.78). Using a cutoff at 1 µg/L, procalcitonin was more specific than CIRS to predict 30-day mortality (92 vs 77%; p < .001). In a multivariable analysis, procalcitonin level higher than 0.39 µg/L is a significant predictor of mortality within 30 days (odds ratio 3.84; 95% CI: 1.61-9.14, p = .002).

Conclusion

Elevated procalcitonin values were strongly and significantly associated with mortality within 30 days in older patients after orthopedic surgery.

Inflammation and post-operative recovery in patients undergoing total knee arthroplasty-secondary analysis of a randomized controlled trial

OBJECTIVE

Reduced function persists for many patients after total knee arthroplasty (TKA). Inflammation is part of osteoarthritis' pathophysiology, and surgery induces a marked inflammatory response. We therefore wanted to explore the role of inflammation in long-term recovery after TKA, and thus conducted this secondary analysis of our randomized controlled trial (RCT) of physical rehabilitation ± progressive strength training (PST). We aimed to investigate whether (1) inflammation is associated with functional performance, knee-extension strength, and knee pain before TKA; (2) PST affects inflammation, and the inflammatory state over time; (3) baseline or surgery-induced inflammation modifies the effect of rehabilitation ± PST on change in 6-min walk test (Δ6MWT); and (4) baseline or surgery-induced inflammation is associated with Δ6MWT following TKA.

DESIGN

In the primary trial report's per-protocol analysis, 72/82 patients were included. Sixty had ≥1 blood sample before and after TKA, and were included in this secondary analysis. Inflammation was measured by interferon γ-inducible protein (IP)-10, soluble urokinase plasminogen activator receptor (suPAR), interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α at baseline; day 1, week 4, 8, and 26 after TKA.

RESULTS

At baseline, suPAR (P = 006) was negatively associated with 6MWT. Neither baseline nor surgery-induced inflammation modified the response to rehabilitation ± PST. Only surgery-induced IL-10 was associated with Δ6MWT_{26 weeks-baseline} (P = 0.001), also adjusted for 6MWT_baseline, age, sex and body mass index (BMI).

CONCLUSION

In this secondary analysis, only increased surgery-induced IL-10 response was associated with decreased long-term functional performance after TKA. The importance of controlling the surgery-induced immune response remains to be investigated further.

TRIAL IDENTIFICATION

NCT01351831.

Epigallocatechin Gallate Attenuates Hip Fracture-Induced Acute Lung Injury by Limiting Mitochondrial DNA (mtDNA) Release

BACKGROUND To study the protective effects and explore the mechanism of epigallocatechingallate (EGCG) on the hip fracture-induced acute lung injury. MATERIAL AND METHODS Thirty male Sprague-Dawley (SD) rats were randomly divided into the control group, hip fracture group, and hip fracture + EGCG (10 mg/Kg) group. After 24 h, blood samples, bronchoalveolar lavage fluid (BALF), and lung tissue were collected. Serum mitochondrial DNA (mtDNA) was measured by RT-PCR and BALF was used to perform cytological analysis and enzyme-linked immunosorbent assay (ELISA) assay. Lung tissue was used to evaluate the injury level. RESULTS EGCG significantly reduced the hip fracture-induced high level of serum mtDNA (p<0.05). HE staining showed protective effects of EGCG. Lower lung injury score and wet/dry ratio were identified in the hip fracture + EGCG group than in the hip fracture group (p<0.05). We found significantly lower levels of infiltration of inflammatory cells and production of inflammatory cytokines in the BALF of the hip fracture + EGCG group than in the hip fracture group (p<0.05). CONCLUSIONS Our study found that EGCG had protective effects on hip fracture-induced acute lung injury and suggests that EGCG exerts its protective effects through limiting the release of mtDNA. Our results provide a novel pharmacological agent to attenuate hip fracture-induced acute lung injury, as well as a potential theory to better explain the anti-inflammatory property of EGCG.

Plasma mitochondrial DNA levels were independently associated with lung injury in elderly hip fracture patients

INTRODUCTION

Hip fracture in the elderly can induce systemic inflammatory response (SIRS) and lung injury which increases the risk of lung infection and death. Mitochondrial DNA (mtDNA) plays a role in SIRS and lung injury in patients with multi-trauma, and also in patients with hip fractures. This study evaluated the potential value of plasma mtDNA in the early prognosis of lung injury in elderly fracture patients.

METHODS

This study enrolled 156 elderly patients with intertrochanteric fracture. Plasma mtDNA, IL-6, IL-10, prostaglandin E2 (PGE2) levels were measured at admission. Sixty-one and 31 patients were diagnosed with systemic inflammatory response syndrome (SIRS) and lung injury, respectively.

RESULTS

Plasma mtDNA levels were higher in hip fracture patients compared to healthy controls (P<0.001) and significantly higher in the lung injury subgroup compared to the lung injury absent subgroup (P<0.001). MtDNA levels were correlated with the SIRS score (r=0.446, P<0.001), IL-6 (r=0.506, P<0.001), IL-10 (r=0.523, P<0.001), and PGE2 (r=0.360, P<0.001). Logistic regression analysis revealed that plasma mtDNA, IL-6, PGE2 and SIRS score were independent predictors of the risk of lung injury.

CONCLUSION

Plasma mtDNA release induced by hip fracture in elderly patients, might be an early predictor of lung injury in these patients.

Comparison of the acute-phase response after laparoscopic versus open aortobifemoral bypass surgery: a substudy of a randomized controlled trial

PURPOSE

Minimally invasive surgical techniques have been shown to reduce the inflammatory response related to a surgical procedure. The main objective of our study was to measure the inflammatory response in patients undergoing a totally laparoscopic versus open aortobifemoral bypass surgery. This is the first randomized trial on subjects in this population.

PATIENTS AND METHODS

This is a substudy of a larger randomized controlled multicenter trial (Norwegian Laparoscopic Aortic Surgery Trial). Thirty consecutive patients with severe aortoiliac occlusive disease eligible for aortobifemoral bypass surgery were randomized to either a totally laparoscopic (n=14) or an open surgical procedure (n=16). The inflammatory response was measured by perioperative monitoring of serum interleukin-6 (IL-6), IL-8, and C-reactive protein (CRP) at six different time points.

RESULTS

The inflammatory reaction caused by the laparoscopic procedure was reduced compared with open surgery. IL-6 was significantly lower after the laparoscopic procedure, measured by comparing area under the curve (AUC), and after adjusting for the confounding effect of coronary heart disease (P=0.010). The differences in serum levels of IL-8 and CRP did not reach statistical significance.

CONCLUSION

In this substudy of a randomized controlled trial comparing laparoscopic and open aortobifemoral bypass surgeries, we found a decreased perioperative inflammatory response after the laparoscopic procedure measured by comparing AUC for serum IL-6.

Significance of Serum mtDNA Concentration in Lung Injury Induced by Hip Fracture

Acute lung injury is the most serious and fatal complication of the elderly patients with hip fracture, but the mechanisms are unknown. Recent studies demonstrated the mitochondrial DNA (mtDNA) release was associated with lung injury after trauma. This study aimed to examine the differential release of mtDNA between younger and elderly rats suffering from hip fracture and to investigate the possible mechanism of mtDNA in the lung injury induced by hip fracture. In the first part of the study, we investigated the effects of hip fracture on the rats. The elderly and younger rats, respectively, received hip fracture operations. The degree of lung injury was evaluated, toll-like receptor 9 (TLR9) and nuclear factor kappa B (NF-κB) were determined using Western blot, and mtDNA were analyzed by fluorescent quantitative polymerase chain reaction. In the second part of the study, we investigated the effects of mtDNA on the rats. The elderly and younger rats directly received intravenous injections with mtDNA. After 24 h, the specimens were collected and detected as the first part. Hip fracture resulted in significant mtDNA release, TLR9 and NF-κB p65 expression, and lung injury in the rats. Meanwhile, the mtDNA injection could indirectly induce lung injury. Compared to the younger ones, the elderly rats suffered more serious lung injury after hip fracture and mtDNA injection. These results suggest that the lung injury induced by hip fracture may be involved with the mtDNA release and its TLR9/NF-κB pathway.