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Kristiansen S, Storm BS, Emblem ÅE, Grønli RH, Pettersen K, Hilmo J, Jarmund AH, Leth-Olsen M, Nyrnes SA, Nilsen BA, Nielsen EW, Mollnes TE. Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs. Front Immunol 2024; 15:1396800. [PMID: 39100680 PMCID: PMC11294081 DOI: 10.3389/fimmu.2024.1396800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Bone marrow embolization may complicate orthopedic surgery, potentially causing fat embolism syndrome. The inflammatory potential of bone marrow emboli is unclear. We aimed to investigate the inflammatory response to femoral intramedullary nailing, specifically the systemic inflammatory effects in plasma, and local tissue responses. Additionally, the plasma response was compared to that following intravenous injection of autologous bone marrow. Methods Twelve pigs underwent femoral nailing (previously shown to have fat emboli in lung and heart), four received intravenous bone marrow, and four served as sham controls. Blood samples were collected hourly and tissue samples postmortem. Additionally, we incubated bone marrow and blood, separately and in combination, from six pigs in vitro. Complement activation was detected by C3a and the terminal C5b-9 complement complex (TCC), and the cytokines TNF, IL-1β, IL-6 and IL-10 as well as the thrombin-antithrombin complexes (TAT) were all measured using enzyme-immunoassays. Results After nailing, plasma IL-6 rose 21-fold, compared to a 4-fold rise in sham (p=0.0004). No plasma differences in the rest of the inflammatory markers were noted across groups. However, nailing yielded 2-3-times higher C3a, TCC, TNF, IL-1β and IL-10 in lung tissue compared to sham (p<0.0001-0.03). Similarly, heart tissue exhibited 2-times higher TCC and IL-1β compared to sham (p<0.0001-0.03). Intravenous bone marrow yielded 8-times higher TAT than sham at 30 minutes (p<0.0001). In vitro, incubation of bone marrow for four hours resulted in 95-times higher IL-6 compared to whole blood (p=0.03). Discussion A selective increase in plasma IL-6 was observed following femoral nailing, whereas lung and heart tissues revealed a broad local inflammatory response not reflected systemically. In vitro experiments may imply bone marrow to be the primary IL-6 source.
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Affiliation(s)
- Steinar Kristiansen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Benjamin Stage Storm
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Research Laboratory, Nordland Hospital, Bodø, Norway
| | | | | | | | - Jonas Hilmo
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hagen Jarmund
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martin Leth-Olsen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bent Aksel Nilsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Erik Waage Nielsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Pain Medicine and Research, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
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Werner BC, Burrus MT, Denard PJ, Romeo AA, Lederman E, Griffin JW, Sears B. Stemless anatomic total shoulder arthroplasty is associated with less early postoperative pain. JSES Int 2024; 8:197-203. [PMID: 38312271 PMCID: PMC10837735 DOI: 10.1016/j.jseint.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Improvements in pain control after shoulder arthroplasty with a reduction in narcotic use continues to be an important postoperative goal. With the increased utilization of stemless anatomic total shoulder arthroplasty (aTSA), it is relevant to compare between stemmed and stemless arthroplasty to assess if there is any association between this implant design change and early postoperative pain. Methods Patients from a multicenter, prospectively-maintained database who had undergone a stemless aTSA with a minimum of two year clinical follow-up were retrospectively identified. Patients who underwent aTSA with a short stem were identified in the same registry, and matched to the stemless aTSA patients by age, sex and preoperative pain score. The primary study outcome was the Visual Analog Scale pain score. Secondary pain outcomes were the American Shoulder and Elbow Surgeons shoulder pain subscore, Western Ontario Osteoarthritis of the Shoulder physical symptoms subscore, and the Single Assessment Numeric Evaluation score. Finally, the percentage of patients who could sleep on the affected shoulder was assessed for each group. These pain-related clinical outcomes were assessed and compared preoperatively, and postoperatively at 9 weeks, 26 weeks, one year and two years. For all statistical comparisons, P > .05 was considered significant. Results 124 patients were included in the study; 62 in each group. At 9 weeks after surgery, statistically significantly improved pain control was reported by patients undergoing stemless aTSA, as assessed by the Visual Analog Scale (stemless: 1.5, stemmed: 2.5, P = .001), American Shoulder and Elbow Surgeons pain subscore (stemless: 42.4, stemmed: 37.3, P < .001), Western Ontario Osteoarthritis of the Shoulder Physical Symptoms (stemless: 80.3, stemmed: 73.1, P = .006) and Single Assessment Numeric Evaluation (stemless: 58.1, stemmed: 47.4, P = .011). Patients who underwent a stemless aTSA were significantly more likely to be able to sleep on the affected shoulder at 9 weeks (29% vs. 11%, odds ratio 3.2, 95% confidence interval 1.2-8.4, P = .014). By 26 weeks postoperatively, there were no differences in all pain-specific outcomes. At two years postoperatively, patient-reported outcomes, range of motion, and strength measures were all similar between the two cohorts. Conclusion Stemless aTSA provides earlier improvement in postoperative shoulder pain compared to matched patients undergoing short-stem aTSA. Additionally, earlier return to sleeping on the affected shoulder was reported in the stemless aTSA group. The majority of these differences dissipate by 26 weeks postoperatively and there were no differences in pain, patient-reported outcomes, range of motion or strength measures between stemless and short-stem aTSA at 2 years postoperatively.
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Affiliation(s)
- Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Evan Lederman
- Department of Orthopaedic Surgery, Banner Health, Phoenix, AZ, USA
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Kreinces J, Lapow J, Feingold J, Akinleye O, Spirollari E, Asprinio DE, Wellman DS. Independent predictors of systemic inflammatory response syndrome for intramedullary nailing of femoral shaft fractures: Analysis of national inpatient sample database. J Orthop 2023; 46:107-111. [PMID: 37994366 PMCID: PMC10659992 DOI: 10.1016/j.jor.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/04/2023] [Accepted: 10/28/2023] [Indexed: 11/24/2023] Open
Abstract
Background The systemic inflammatory response syndrome (SIRS) is a clinical reaction that can occur due to a variety of stimuli. Reamed intramedullary femoral nailing is a common orthopedic surgery that has been shown to induce SIRS. To date, no nationwide analyses have been performed to evaluate the incidence, risk factors, and economic burdens of SIRS following intramedullary femoral nailing for femoral shaft fractures. The objective of this study is to investigate the independent predictors, incidence, post-operative, and economic burden of SIRS among patients treated with intramedullary nailing for femoral shaft fractures. Methods We utilized the 2016-2019 National Inpatient Sample (NIS) to identify patients who underwent intramedullary femoral nailing and were diagnosed with non-infectious SIRS (NI-SIRS) based on ICD-10-CM coding. Identified patients who underwent intramedullary femoral nailing were dichotomized into SIRS and Non-SIRS groups to assess independent predictors of SIRS development, and to compare post-operative complications and costs. Results A total of 65,240 patients with femur shaft fractures underwent IMFN, of which 665 (1.0 %) developed NI-SIRS. Patients with NI-SIRS had a higher incidence of laparotomy (OR = 13.97, p < 0.001), initial treatment with external fixation (OR = 1.845, p < 0.001), and late application of external fixation (OR = 4.884, p = 0.005). Routine discharge (OR = 0.491, p < 0.001) was less likely in patients with NI-SIRS. Length of stay (12.38 days vs 7.16 days, p < 0.001) and total charges ($278, 590 vs $145,118, p < 0.001) were both increased in patients with NI-SIRS. Conclusion NI-SIRS is associated with increasing injury severity and post-operative complications. Those that developed NI-SIRS experienced higher healthcare resource utilization. Risk factors associated with development of NI-SIRS warrant further investigation.
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Affiliation(s)
- Jason Kreinces
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | - Justin Lapow
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | - Jacob Feingold
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | | | - Eris Spirollari
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | - David E. Asprinio
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - David S. Wellman
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
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Vittrup S, Stilling M, Hanberg P, Tøstesen SK, Knudsen MB, Kipp JO, Bue M. Concentrations of co-administered vancomycin and meropenem in the internal dead space of a cannulated screw and in cancellous bone adjacent to the screw - Evaluated by microdialysis in a porcine model. Injury 2022; 53:2734-2740. [PMID: 35710595 DOI: 10.1016/j.injury.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/22/2022] [Accepted: 06/09/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cannulated screws are often used in the management of open lower extremity fractures. These fractures exhibit broad contamination profiles, necessitating empirical Gram-positive and Gram-negative antibiotic coverage. To ensure full antibiotic protection of the cannulated screw and the bone tissue, it is generally accepted that target tissue antibiotic concentrations, as a minimum, reach and remain above relevant epidemiological cut-off minimal inhibitory concentrations (T>MIC) for a sufficient amount of time. METHODS 8 female pigs were included. Microdialysis catheters were placed in the internal dead space of a cannulated screw placed in tibial cancellous bone, in tibial cancellous bone adjacent to the screw (mean distance to the screw: 3 mm), and in cancellous bone on the contralateral tibia. Following single-dose simultaneous intravenous administrations of vancomycin (1000 mg) and meropenem (1000 mg), microdialysates and plasma were dynamically sampled over 8 h. The applied MIC targets ranged from 1 to 4 µg/mL for vancomycin and 0.125-2 µg/mL for meropenem RESULTS: For both drugs, and for all MIC targets investigated (except for the high vancomycin target: 4 µg/mL), the internal dead space of the cannulated screw had the shortest T>MIC. At the low MIC targets T>MIC ranged between 88 and 449 min across sampling sites for vancomycin (1 µg/mL), and 148-406 min for meropenem (0.125 µg/mL). For the high MIC targets, T>MIC ranged between 3 and 446 min for vancomycin (4 μg/mL) and 17-181 min for meropenem (2 μg/mL). Vancomycin displayed longer T>MIC (2 and 4 μg/mL), higher area under the concentration time curve (AUC0-last) and peak drug concentration in the proximal tibial cancellous bone without a screw nearby. For meropenem, only the cancellous bone AUC0-last was significantly higher on the side with no screw. CONCLUSION We found short T>MIC, particularly for the high MIC targets for vancomycin and meropenem, both inside the cannulated screw and in cancellous bone adjacent to the screw. The presence of a cannulated screw impaired the penetration of especially vancomycin into cancellous bone adjacent to the screw. More aggressive or different vancomycin and meropenem approaches may be considered to encompass contaminating differences and to ensure a theoretically more sufficient antibiotic protection of cannulated screws when used in the management of open lower extremity fractures.
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Affiliation(s)
- Sofus Vittrup
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark.
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark
| | - Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark
| | - Martin Bruun Knudsen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark
| | - Josephine Olsen Kipp
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
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Teuben MPJ, Pfeifer R, Horst K, Simon TP, Heeres M, Kalbas Y, Blokhuis T, Hildebrand F, Koenderman L, Pape HC, Leenen L. Standardized porcine unilateral femoral nailing is associated with changes in PMN activation status, rather than aberrant systemic PMN prevalence. Eur J Trauma Emerg Surg 2022; 48:1601-1611. [PMID: 34114052 PMCID: PMC9192391 DOI: 10.1007/s00068-021-01703-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/13/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE Intramedullary nailing (IMN) of fractures is associated with increased rates of inflammatory complications. The pathological mechanism underlying this phenomenon is unclear. However, polymorphonuclear granulocytes (PMNs) seem to play an important role. We hypothesized that a femur fracture and standardized IMN in pigs is associated with altered appearance of PMNs in circulation and enhanced activation status of these cells. METHODS A porcine model including a femur fracture and IMN was utilized. Animals were randomized for control [anesthesia + mechanical ventilation only (A/MV)] and intervention [A/MV and unilateral femur fracture (FF) + IMN] conditions. PMN numbers and responsiveness, integrin (CD11b), L-selectin (CD62L) and Fcγ-receptor (CD16 and CD32)-expression levels were measured by flowcytometry of blood samples. Animals were observed for 72 h. RESULTS Circulatory PMN numbers did not differ between groups. Early PMN-responsiveness was retained after insult. PMN-CD11b expression increased significantly upon insult and peaked after 24 h, whereas CD11b in control animals remained unaltered (P = 0.016). PMN-CD16 expression levels in the FF + IMN-group rose gradually over time and were significantly higher compared with control animals, after 48 h (P = 0.016) and 72 h (P = 0.032). PMN-CD62L and CD32 expression did not differ significantly between conditions. CONCLUSION This study reveals that a femur fracture and subsequent IMN in a controlled setting in pigs is associated with enhanced activation status of circulatory PMNs, preserved PMN-responsiveness and unaltered circulatory PMN-presence. Indicating that monotrauma plus IMN is a specific and substantial stimulus for the cellular immune system. Early alterations of circulatory PMN receptor expression dynamics may be predictive for the intensity of the post traumatic response.
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Affiliation(s)
- Michel Paul Johan Teuben
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Klemens Horst
- Department of Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Marjolein Heeres
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Hospital Maastricht, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Frank Hildebrand
- Department of Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Leo Koenderman
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Pulmonology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Luke Leenen
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Vittrup SØ, Hanberg P, Knudsen MB, Tøstesen SK, Kipp JO, Hansen J, Jørgensen NP, Stilling M, Bue M. Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem - evaluated by microdialysis in a porcine model : should patients with open fractures have higher doses of antibiotics? Bone Joint Res 2022; 11:112-120. [PMID: 35176868 PMCID: PMC8882321 DOI: 10.1302/2046-3758.112.bjr-2021-0321.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem. Methods Eight pigs received a single dose of 1,000 mg vancomycin and 1,000 mg meropenem simultaneously over 100 minutes and 10 minutes, respectively. Microdialysis catheters were placed for sampling over eight hours in tibial cancellous bone, cortical bone, and adjacent subcutaneous adipose tissue. Venous blood samples were collected as references. Results Across the targeted ECOFF values, vancomycin displayed longer T > MIC in all the investigated compartments in comparison to meropenem. For both drugs, cortical bone exhibited the shortest T > MIC. For the low MIC targets and across compartments, mean T > MIC ranged between 208 and 449 minutes (46% to 100%) for vancomycin and between 189 and 406 minutes (42% to 90%) for meropenem. For the high MIC targets, mean T > MIC ranged between 30 and 446 minutes (7% to 99%) for vancomycin and between 45 and 181 minutes (10% to 40%) for meropenem. Conclusion The differences in the T > MIC between the low and high targets illustrate how the interpretation of these results is highly susceptible to the defined MIC target. To encompass any trauma, contamination, or individual tissue differences, a more aggressive dosing approach may be considered to achieve longer T > MIC in all the exposed tissues, and thereby lower the risk of acquiring an infection after open tibial fractures. Cite this article: Bone Joint Res 2022;11(2):112–120.
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Affiliation(s)
- Sofus Ørbæk Vittrup
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martin Bruun Knudsen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Josephine Olsen Kipp
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jakob Hansen
- Department of Forensic Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review. J Clin Med 2021; 10:jcm10122733. [PMID: 34205701 PMCID: PMC8234368 DOI: 10.3390/jcm10122733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. MATERIALS AND METHODS Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. STUDY SELECTION Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. DATA EXTRACTION Two authors independently extracted data using a predesigned form. STATISTICS Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. RESULTS Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). CONCLUSIONS There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.
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Early myocardial damage (EMD) and valvular dysfunction after femur fracture in pigs. Sci Rep 2021; 11:8503. [PMID: 33875675 PMCID: PMC8055677 DOI: 10.1038/s41598-021-86151-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 10/01/2020] [Indexed: 12/27/2022] Open
Abstract
Musculoskeletal injuries are the most common reason for surgery in severely injured patients. In addition to direct cardiac damage after physical trauma, there is rising evidence that trauma induces secondary cardiac structural and functional damage. Previous research associates hip fractures with the appearance of coronary heart disease: As 25% of elderly patients developed a major adverse cardiac event after hip fracture. 20 male pigs underwent femur fracture with operative stabilization via nailing (unreamed, reamed, RIA I and a new RIA II; each group n = 5). Blood samples were collected 6 h after trauma and the concentration of troponin I and heart-type fatty acid binding protein (HFABP) as biomarkers for EMD were measured. At baseline and 6 h after trauma, transesophageal ECHO (TOE) was performed; and invasive arterial and left ventricular blood pressure were measured to evaluate the cardiac function after femur fracture. A systemic elevation of troponin I and HFABP indicate an early myocardial damage after femur fracture in pigs. Furthermore, various changes in systolic (ejection fraction and cardiac output) and diastolic (left ventricular end-diastolic pressure, mitral valve deceleration time and E/A ratio) parameters illustrate the functional impairment of the heart. These findings were accompanied by the development of valvular dysfunction (pulmonary and tricuspid valve). To the best of our knowledge, we described for the first time the development of functional impairment of the heart in the context of EMD after long bone fracture in pigs. Next to troponin and HFABP elevation, alterations in the systolic and diastolic function occurred and were accompanied by pulmonary and tricuspid valvular insufficiency. Regarding EMD, none of the fracture stabilization techniques (unreamed nailing, reaming, RIA I and RIA II) was superior.
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Structural alterations and inflammation in the heart after multiple trauma followed by reamed versus non-reamed femoral nailing. PLoS One 2020; 15:e0235220. [PMID: 32584885 PMCID: PMC7316303 DOI: 10.1371/journal.pone.0235220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Approximately 30,000 patients with blunt cardiac trauma are recorded each year in the United States. Blunt cardiac injuries after trauma are associated with a longer hospital stay and a poor overall outcome. Organ damage after trauma is linked to increased systemic release of pro-inflammatory cytokines and damage-associated molecular patterns. However, the interplay between polytrauma and local cardiac injury is unclear. Additionally, the impact of surgical intervention on this process is currently unknown. This study aimed to determine local cardiac immunological and structural alterations after multiple trauma. Furthermore, the impact of the chosen fracture stabilization strategy (reamed versus non-reamed femoral nailing) on cardiac alterations was studied. EXPERIMENTAL APPROACH 15 male pigs were either exposed to multiple trauma (blunt chest trauma, laparotomy, liver laceration, femur fracture and haemorrhagic shock) or sham conditions. Blood samples as well as cardiac tissue were analysed 4 h and 6 h after trauma. Additionally, murine HL-1 cells were exposed to a defined polytrauma-cocktail, mimicking the pro-inflammatory conditions after multiple trauma in vitro. RESULTS After multiple trauma, cardiac structural changes were observed in the left ventricle. More specifically, alterations in the alpha-actinin and desmin protein expression were found. Cardiac structural alterations were accompanied by enhanced local nitrosative stress, increased local inflammation and elevated systemic levels of the high-mobility group box 1 protein. Furthermore, cardiac alterations were observed predominantly in pigs that were treated by non-reamed intramedullary reaming. The polytrauma-cocktail impaired the viability of HL-1 cells in vitro, which was accompanied by a release of troponin I and HFABP. DISCUSSION Multiple trauma induced cardiac structural alterations in vivo, which might contribute to the development of early myocardial damage (EMD). This study also revealed that reamed femoral nailing (reamed) is associated with more prominent immunological cardiac alterations compared to nailing without reaming (non-reamed). This suggests that the choice of the initial fracture treatment strategy might be crucial for the overall outcome as well as for any post-traumatic cardiac consequences.
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Abstract
INTRODUCTION Organ dysfunction remains a major cause of morbidity after trauma. The development of organ dysfunction is determined by the inflammatory response, in which neutrophils are important effector cells. A femoral fracture particularly predisposes for the development of organ dysfunction. This study investigated the chronologic relation between neutrophil characteristics and organ dysfunction in trauma patients with a femoral fracture. METHODS Patients with a femoral fracture presenting at the University Medical Center Utrecht between 2007 and 2013 were included. Data of neutrophil characteristics from standard hematological analyzers were recorded on a daily basis until the 28th day of hospital stay or until discharge. Generalized Estimating Equations were used to compare outcome groups. RESULTS In total 157 patients were analyzed, of whom 81 had polytrauma and 76 monotrauma. Overall mortality within 90 days was 6.4% (n = 10). Eleven patients (7.0%) developed organ dysfunction. In patients who developed organ dysfunction a significant increase in neutrophil count (P = 0.024), a significant increase in neutrophil cell size (P = 0.026), a significant increase in neutrophil complexity (P < 0.004), and a significant decrease in neutrophil lobularity (P < 0.001) were seen after trauma. The rise in neutrophil cell size preceded the clinical manifestation of organ dysfunction in every patient. CONCLUSION Patients who develop organ dysfunction postinjury show changes in neutrophil characteristics before organ dysfunction becomes clinically evident. These findings regarding post-traumatic organ dysfunction may contribute to the development of new prognostic tools for immune-mediated complications in trauma patients. LEVEL OF EVIDENCE Level II, etiologic study.
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11
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Moore TA, Simske NM, Vallier HA. Fracture fixation in the polytrauma patient: Markers that matter. Injury 2020; 51 Suppl 2:S10-S14. [PMID: 31879174 DOI: 10.1016/j.injury.2019.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 02/02/2023]
Abstract
Timing and type of fracture fixation in the multiply-injured trauma patient have been important and controversial topics. Ideal care for these patients come from providers who communicate well with one another in a team fashion and view the whole person, rather than focusing on injury to individual systems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which may have profound impact upon outcomes. The concept of Early Total Care arose from the realization that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most patients. However, insufficient assessment and understanding of the physiological status of polytraumatized patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other procedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improvement of acidosis.
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12
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Lamm BM, Moore KR, Knight JM, Pugh E, Baker JR, Gesheff MG. Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia. J Foot Ankle Surg 2019; 57:987-994. [PMID: 30030039 DOI: 10.1053/j.jfas.2017.10.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Indexed: 02/03/2023]
Abstract
Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.
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Affiliation(s)
- Bradley M Lamm
- Chief, Foot and Ankle Surgery, The Paley Institute, St. Mary's Hospital, West Palm Beach, FL; Director, Foot and Ankle Deformity Center, The Paley Institute, St. Mary's Hospital, West Palm Beach, FL; Director, Foot and Ankle Deformity Correction Fellowship, The Paley Institute, St. Mary's Hospital, West Palm Beach, FL.
| | - Kyle R Moore
- Clinical Fellow, Foot and Ankle Deformity Correction Fellowship, The Paley Institute, St. Mary's Hospital, West Palm Beach, FL
| | - Jessica M Knight
- Associate, Weil Foot and Ankle Institute, Northwest Community Hospital Medical Group, Arlington Heights, IL
| | - Emily Pugh
- Podiatrist and Foot and Ankle Surgeon, Harvard Vanguard Medical Associates, Wellesley, MA
| | - Jeffrey R Baker
- Podiatrist, Foot and Ankle Surgeon, Associate Fellowship Director, Weil Foot and Ankle Institute, Des Plaines, IL
| | - Martin G Gesheff
- Clinical Research Manager, International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics at Sinai Hospital, Baltimore, MD
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Albert V, Subramanian A, Trikha V, Veerappan SK, Jothi A. Acute coagulofibrinolytic and inflammatory changes in response to intramedullary nailing and its impact on outcome. J Clin Orthop Trauma 2018; 9:S67-S73. [PMID: 29628702 PMCID: PMC5883903 DOI: 10.1016/j.jcot.2018.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022] Open
Affiliation(s)
- Venencia Albert
- Departments of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Arulselvi Subramanian
- Departments of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India,Corresponding author at: Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Vivek Trikha
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Senthil Kumar Veerappan
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Arul Jothi
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Ebrahimpour A, Okhovatpour MA, Sadighi M, Sarejloo AH, Sajjadi MRM. Comparative investigation of percutaneous plating and intramedullary nailing effects on IL-6 production in patients with tibia shaft fracture. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:478-481. [PMID: 29122411 PMCID: PMC6197449 DOI: 10.1016/j.aott.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/13/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the effect of intramedullary nailing (IMN), open plating and percutaneous plating on the induction of IL-6 in patients with tibia fractures. METHODS A total of 30 patients with tibia shaft fracture underwent either intramedullary nailing (IMN, n = 15; 14 males and 1 female; mean age: 32.1 ± 15.6), ORIF plating (n = 8; 5 males and 3 females; mean age: 60.0 ± 17.8), or percutaneous plating (n = 7; 6 males and 1 female; mean age: 43.1 ± 21.4). Serum IL-6 cytokine levels were measured prior to, and 6 and 24 h after the surgery, using a special ELISA kit. RESULTS The IL-6 concentration increased to peak levels at 6 h in both IMN and percutaneous plating groups, and at 24 h in ORIF plating group (p < 0.001). The mean IL-6 concentration of percutaneous plating group was significantly lower than that of the IMN group at 6 h following the surgery (p = 0.022). In addition, the mean IL-6 concentration of ORIF plating group was significantly higher than that of the percutaneous plating group at 24 h post operation (p = 0.009). CONCLUSION Our results suggest that percutaneous plating compared to the IMN has lower effects on IL-6 production in patients with tibia fracture. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Adel Ebrahimpour
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Ali Okhovatpour
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sadighi
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir-Hossein Sarejloo
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Minator Sajjadi
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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McSweeney AL, Zani BG, Baird R, Stanley JR, Hayward A, Markham PM, Kopia GA, Edelman ER, Rabiner R. Biocompatibility, bone healing, and safety evaluation in rabbits with an IlluminOss bone stabilization system. J Orthop Res 2017; 35:2181-2190. [PMID: 28135014 PMCID: PMC5534392 DOI: 10.1002/jor.23532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/23/2017] [Indexed: 02/04/2023]
Abstract
Bone healing, biocompatibility, and safety employing the IlluminOss System (IS), comprised of an inflatable balloon filled with photopolymerizable liquid monomer, was evaluated in New Zealand white rabbits. Successful bone healing and callus remodeling over 6 months was demonstrated radiologically and histologically with IS implants in fenestrated femoral cortices. Biocompatibility was demonstrated with IS implants in brushed, flushed femoral intramedullary spaces, eliciting no adverse, local, or systemic responses and with similar biocompatibility to K-wires in contralateral femurs up to 1 year post-implant. Lastly simulated clinical failures demonstrated the safety of IS implants up to 1 year in the presence of liquid or polymerized polymer within the intramedullary space. Polymerized material displayed cortical bone and vasculature effects comparable to mechanical disruption of the endosteum. In the clinically unlikely scenario with no remediation or polymerization, a high dose monomer injection resulted in marked necrosis of cortical bone, as well as associated vasculature, endosteum, and bone marrow. Overall, when polymerized and hardened within bone intramedullary spaces, this light curable monomer system may provide a safe and effective method for fracture stabilization. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2181-2190, 2017.
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Affiliation(s)
- Amanda L. McSweeney
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421,Author to whom all correspondence should be addressed: Amanda L. McSweeney, BS, RLATG, SRS, CBSET, Inc., 500 Shire Way, Lexington, MA 02421, Phone: 781-541-5567,
| | - Brett G. Zani
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421
| | - Rose Baird
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421
| | - James R.L. Stanley
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421
| | - Alison Hayward
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421
| | - Peter M. Markham
- Concord Biomedical Sciences and Emerging Technologies, 500 Shire Way, Lexington, MA 02421
| | | | - Elazer R. Edelman
- Institute for Medical and Engineering Science, Massachusetts Institute of Technology, E25, 45 Carleton St., Cambridge, MA, 02139
| | - Robert Rabiner
- IlluminOss Medical Inc., 993 Waterman Ave., East Providence, RI 02914
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Abstract
Intramedullary nailing, as the gold standard stabilisation method of most long bones, has been tailed by its extensive use as the basic tool of investigating the immune response to trauma in many large and small animal models, as well as at the clinical setting. Over the last few decades a complex map of interactions between pro and anti-inflammatory pathways has been the result of these significant global research efforts. Parallel to the evolution of modern nailing and reaming techniques, significant developments at the fields of other disciplines relevant to trauma care, has improved the contemporary management of injured patients, challenging previous concepts and altering clinical barriers. The current article aims to summarise the current understanding of the effect of instrumenting the medullary canal after trauma, and hint on potential future directions.
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Affiliation(s)
- Nikolaos K Kanakaris
- Clinical Lead of Major Trauma Services, Leeds General Infirmary, Clarendon Wing, Level D, LS13EX, Leeds, West Yorkshire, UK.
| | - Christopher Anthony
- Trauma and Orthopaedics Yorkshire and Humber Deanery, Leeds Teaching Hospitals NHS Trust, UK.
| | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, UK.
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Reich MS, Dolenc AJ, Moore TA, Vallier HA. Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients? J Orthop Surg Res 2016; 11:106. [PMID: 27671737 PMCID: PMC5037639 DOI: 10.1186/s13018-016-0441-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/15/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications. METHODS Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death. RESULTS Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046). CONCLUSIONS EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients. LEVEL OF EVIDENCE level II prospective, comparative study.
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Affiliation(s)
- M S Reich
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - A J Dolenc
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - T A Moore
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - H A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
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In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006. J Trauma Acute Care Surg 2014; 76:1433-40. [PMID: 24854312 DOI: 10.1097/ta.0000000000000230] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Optimal surgical timing for definitive treatment of femur fractures in severely injured patients remains controversial. This study was performed to examine in-hospital mortality for patients with femur fractures with regard to surgical timing, Injury Severity Score (ISS), and age. METHODS The National Trauma Data Bank version 7.0 was used to evaluate in-hospital mortality for patients presenting with unilateral femur fractures. Patients were stratified into four groups by surgical timing (ST) and four groups by ISS. χ tests were used to evaluate baseline interrelationships. Binary regression was used to examine the association between time to surgery, ISS score, age, and mortality after adjusting for patient medical comorbidities, and personal demographics. RESULTS A total of 7,540 patients met inclusion criteria, with a 1.4% overall in-hospital mortality rate. For patients with an isolated femur fracture, surgical delay beyond 48 hours was associated with nearly five times greater mortality risk compared with surgery within 12 hours (adjusted relative risk, 4.8; 95% confidence interval, 1.6-14.1). Only severely injured patients (ISS, 26+) had higher associated mortality with no delay in surgical fixation (ST1 < 12 hours) relative to ST2 of 13 hours to 24 hours with an adjusted relative risk of 4.2 (95% confidence interval, 1.0-16.7). The association between higher mortality rates and surgical delay beyond 48 hours was even stronger in the elderly patients. CONCLUSION This study supports the work of previous authors who reported that early definitive fixation of femur fractures is not only beneficial, particularly in the elderly, but also consistent with more recent studies recommending at least 12-hour to 24-hour delay in fixation in severely injured patients to promote better resuscitation. LEVEL OF EVIDENCE Therapeutic study, level III.
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Xiang L, Lu S, Mittwede PN, Clemmer JS, Husband GW, Hester RL. β(2)-Adrenoreceptor blockade improves early posttrauma hyperglycemia and pulmonary injury in obese rats. Am J Physiol Heart Circ Physiol 2014; 307:H621-7. [PMID: 24929860 DOI: 10.1152/ajpheart.00208.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Early hyperglycemia after trauma increases morbidity and mortality. Insulin is widely used to control posttrauma glucose, but this treatment increases the risk of hypoglycemia. We tested a novel method for early posttrauma hyperglycemia control by suppressing hepatic glycogenolysis via β2-adrenoreceptor blockade [ICI-118551 (ICI)]. We have shown that, after severe trauma, obese Zucker (OZ) rats, similar to obese patients, exhibit increased acute lung injury compared with lean Zucker (LZ) rats. We hypothesized that OZ rats exhibit a greater increase in early posttrauma glucose compared with LZ rats, with the increased posttrauma hyperglycemia suppressed by ICI treatment. Orthopedic trauma was applied to both hindlimbs in LZ and OZ rats. Fasting plasma glucose was then monitored for 6 h with or without ICI (0.2 mg·kg(-1)·h(-1) iv.) treatment. One day after trauma, plasma IL-6 levels, lung neutrophil numbers, myeloperoxidase (MPO) activity, and wet-to-dry weight ratios were measured. Trauma induced rapid hepatic glycogenolysis, as evidenced by decreased liver glycogen levels, and this was inhibited by ICI treatment. Compared with LZ rats, OZ rats exhibited higher posttrauma glucose, IL-6, lung neutrophil infiltration, and MPO activity. Lung wet-to-dry weight ratios were increased in OZ rats but not in LZ rats. ICI treatment reduced the early hyperglycemia, lung neutrophil retention, MPO activity, and wet-to-dry weight ratio in OZ rats to levels comparable with those seen in LZ rats, with no effect on blood pressure or heart rate. These results demonstrate that β2-adrenoreceptor blockade effectively reduces the early posttrauma hyperglycemia, which is associated with decreased lung injury in OZ rats.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Silu Lu
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Peter N Mittwede
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Graham W Husband
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert L Hester
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
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Easton R, Balogh ZJ. Peri-operative changes in serum immune markers after trauma: a systematic review. Injury 2014; 45:934-41. [PMID: 24388280 DOI: 10.1016/j.injury.2013.12.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 11/27/2013] [Accepted: 12/02/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgery is a posttraumatic immune stimulus which contributes to the systemic inflammatory response syndrome and multiple organ failure (MOF). Serum markers may facilitate post-injury immune monitoring, predict complications and guide the timing of surgery. AIM To evaluate whether immune markers increase after surgery in trauma patients, if this is affected by the timing of surgery, and whether immune markers correlate with clinical outcomes. PATIENTS AND METHODS Systematic review of MEDLINE, Cochrane and EMBASE using a combination of keywords including trauma, biological markers, immune monitoring, and surgical procedures. The last search was performed on 26/11/13. The search considered English language studies enrolling adult trauma patients. Outcomes were perioperative immune markers plus clinical outcomes including mortality, MOF, sepsis. RESULTS 1612 Articles were identified using the search strategy. 1548 Articles were excluded by title and 40 excluded by abstract, leaving 24 articles for full text review. Of these articles, fifteen studies were eligible for study inclusion. The disparity in interventions and outcome measures precluded combined statistical analysis. The surgical intervention studied was mostly intramedullary nailing of long bone fractures. All articles described a postoperative increase in at least one marker. Interleukin (IL)-6 and IL-10 were consistently elevated and tested in the greatest number of patients. Many studies did not correlate markers with clinical outcomes and few significant associations were demonstrated. Two studies considered the timing of surgery and showed greater increase in IL-6 after "early" surgery, though definitions of timing were dissimilar. DISCUSSION An increase in posttraumatic serum cytokines has been demonstrated after surgery, but without consistent clinical associations. The timing of surgery may modulate this increase. Future research directions include confirmation of findings in larger populations, clarifying clinical associations, and evaluation of other surgical interventions.
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Affiliation(s)
- Ruth Easton
- Trauma Service, Division of Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Trauma Service, Division of Surgery, John Hunter Hospital, Newcastle, NSW, Australia.
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Xiang L, Lu S, Mittwede PN, Clemmer JS, Hester RL. Inhibition of NADPH oxidase prevents acute lung injury in obese rats following severe trauma. Am J Physiol Heart Circ Physiol 2014; 306:H684-9. [PMID: 24414071 DOI: 10.1152/ajpheart.00868.2013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Lung capillary filtration coefficient (Kf) and impacts of oxidative stress have not been determined in the setting of severe trauma, especially in obese patients who exhibit increased lung injury. We hypothesized that severe trauma leads to a greater increase in lung Kf in obesity due to exacerbated production of and/or vulnerability to oxidative stress. Severe trauma was induced in lean and obese Zucker rats by muscle injury, fibula fracture, and bone component injection to both hindlimbs, with or without 24-h treatments of apocynin, a NADPH oxidase (NOX) inhibitor. Lung wet/dry weight ratios, lung vascular Kf, lung neutrophil counts, lung NOX and myeloperoxidase (MPO) activity, and plasma IL-6 levels were measured 24 h after trauma. In an additional study, lungs were isolated from nontrauma lean and obese rats to determine the acute effect of phenazime methosulfate, a superoxide donor, on pulmonary vascular Kf. After trauma, compared with lean rats, obese rats exhibited greater increases in lung capillary Kf, neutrophil accumulation, NOX and MPO activity, and plasma IL-6. The lung wet/dry weight ratio was increased in obese rats but not in lean rats. Apocynin treatment decreased lung Kf, neutrophil counts, NOX and MPO activities, wet/dry weight ratio, and plasma IL-6 in obese rats. Phenazime methosulfate treatment resulted in a greater increase in lung Kf in nontrauma obese rats compared with nontrauma lean rats. These results suggest that obese rats are susceptible to lung injury following severe trauma due to increased production of and responsiveness to pulmonary oxidative stress.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
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Gradl G. Intramedullary nailing of long bone fractures: sixty years of evolution but what the future holds? Injury 2014; 45 Suppl 1:S1-2. [PMID: 24239312 DOI: 10.1016/j.injury.2013.10.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Georg Gradl
- Department of Trauma- and Reconstructive Surgery, Surgical Clinic University of Rostock, Schillingallee 35, 18055 Rostock, Germany.
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Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma 2013; 27:543-51. [PMID: 23760182 DOI: 10.1097/bot.0b013e31829efda1] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications. DESIGN Statistical modeling based on retrospective database. SETTING Level 1 trauma center. PATIENTS A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures. INTERVENTION All fractures were treated surgically. MAIN OUTCOME MEASUREMENTS Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated. RESULTS Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis. CONCLUSIONS Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.
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Balogh ZJ, Reumann MK, Gruen RL, Mayer-Kuckuk P, Schuetz MA, Harris IA, Gabbe BJ, Bhandari M. Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet 2012; 380:1109-19. [PMID: 22998720 DOI: 10.1016/s0140-6736(12)60991-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.
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Affiliation(s)
- Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
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Mace JE, Park MS, Mora AG, Chung KK, Martini W, White CE, Holcomb JB, Merrill GA, Dubick MA, Wolf SE, Wade CE, Schwacha MG. Differential expression of the immunoinflammatory response in trauma patients: Burn vs. non-burn. Burns 2012; 38:599-606. [DOI: 10.1016/j.burns.2011.10.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 10/21/2011] [Accepted: 10/27/2011] [Indexed: 11/26/2022]
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Husebye EE, Lyberg T, Opdahl H, Aspelin T, Støen RO, Madsen JE, Røise O. Intramedullary nailing of femoral shaft fractures in polytraumatized patients. a longitudinal, prospective and observational study of the procedure-related impact on cardiopulmonary- and inflammatory responses. Scand J Trauma Resusc Emerg Med 2012; 20:2. [PMID: 22221511 PMCID: PMC3285514 DOI: 10.1186/1757-7241-20-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 01/05/2012] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Early intramedullary nailing (IMN) of long bone fractures in severely injured patients has been evaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and morbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients. METHODS Twelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples were collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed pulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded peri- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily. RESULTS Mean Injury Severity Score (ISS) was 31 ± 2.6. No procedure-related effect of the primary IMN on coagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-α) increased significantly from 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the first to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related transient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post procedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute lung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection. CONCLUSION In the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. We could not demonstrate any major additional IMN-related impact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be interpreted carefully due to the relatively few patients included. TRIAL REGISTRATION ClinicalTrials.gov: NCT00981877.
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The effect of C1-esterase inhibitor on systemic inflammation in trauma patients with a femur fracture - The CAESAR study: study protocol for a randomized controlled trial. Trials 2011; 12:223. [PMID: 21988742 PMCID: PMC3198691 DOI: 10.1186/1745-6215-12-223] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 10/11/2011] [Indexed: 01/21/2023] Open
Abstract
Background Systemic inflammation in response to a femur fracture and the additional fixation is associated with inflammatory complications, such as acute respiratory distress syndrome and multiple organ dysfunction syndrome. The injury itself, but also the additional procedure of femoral fixation induces a release of pro-inflammatory cytokines such as interleukin-6. This results in an aggravation of the initial systemic inflammatory response, and can cause an increased risk for the development of inflammatory complications. Recent studies have shown that administration of the serum protein C1-esterase inhibitor can significantly reduce the release of circulating pro-inflammatory cytokines in response to acute systemic inflammation. Objective Attenuation of the surgery-induced additional systemic inflammatory response by perioperative treatment with C1-esterase inhibitor of trauma patients with a femur fracture. Methods The study is designed as a double-blind randomized placebo-controlled trial. Trauma patients with a femur fracture, Injury Severity Score ≥ 18 and age 18-80 years are included after obtaining informed consent. They are randomized for administration of 200 U/kg C1-esterase inhibitor intravenously or placebo (saline 0.9%) just before the start of the procedure of femoral fixation. The primary endpoint of the study is Δ interleukin-6, measured at t = 0, just before start of the femur fixation surgery and administration of C1-esterase inhibitor, and t = 6, 6 hours after administration of C1-esterase inhibitor and the femur fixation. Conclusion This study intents to identify C1-esterase inhibitor as a safe and potent anti-inflammatory agent, that is capable of suppressing systemic inflammation in trauma patients. This might facilitate early total care procedures by lowering the risk of inflammation in response to the surgical intervention. This could result in increased functional outcomes and reduced health care related costs. Trial registration clinicaltrials.gov NCT01275976 (January 12th 2011)
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Lasanianos NG, Kanakaris NK, Dimitriou R, Pape HC, Giannoudis PV. Second hit phenomenon: existing evidence of clinical implications. Injury 2011; 42:617-29. [PMID: 21459378 DOI: 10.1016/j.injury.2011.02.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The last two decades extensive research evidence has been accumulated regarding the pathophysiology of trauma and the sequelae of interventions that follow. Aim of this analysis has been to collect and categorise the existing data on the so-called "second hit" phenomenon that includes the biochemical and physiologic alterations occurring in patients having surgery after major trauma. Articles were extracted from the PubMed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was utilised for quality assessment of the outcomes. Twenty-six articles were eligible for the final analysis, referring to a total of 8262 patients that underwent surgery after major trauma. Sixteen retrospective clinical studies including 7322 patients and 10 prospective ones, including 940 patients were evaluated. Several variables able to reproduce a post-operative second hit were identified; mostly related to pulmonary dysfunction, coagulopathy, fat or pulmonary embolism, and the inflammatory immune system. Indicative conclusions were extracted, as well as the need for further prospective randomised trials. Suggestions on the content and the rationale of future studies are provided.
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Affiliation(s)
- N G Lasanianos
- Academic Department of Trauma and Orthopaedics, LIMM Section Musculoskeletal Disease, Leeds Biomedical Research Unit, LGI, Clarendon Wing, Level A, Great George Street, LS1 3EX, Leeds, United Kingdom.
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Coagulation, fibrinolysis and cytokine responses to intramedullary nailing of the femur: an experimental study in pigs comparing traditional reaming and reaming with a one-step reamer-irrigator-aspirator system. Injury 2011; 42:630-7. [PMID: 20650454 DOI: 10.1016/j.injury.2010.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/23/2010] [Accepted: 06/23/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR). MATERIALS AND METHODS Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR (n=8) and the RIA (n=7) reaming systems were compared to a control group (n=7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn. RESULTS Significantly procedure-related increased levels were found for thrombin-antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group. CONCLUSION A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group.
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Xiang L, Hester RL, Fuller WL, Sebai ME, Mittwede PN, Jones EK, Aneja A, Russell GV. Orthopedic trauma-induced pulmonary injury in the obese Zucker rat. Microcirculation 2011; 17:650-9. [PMID: 21044219 DOI: 10.1111/j.1549-8719.2010.00061.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Obese subjects with orthopedic trauma exhibit increased inflammation and an increased risk of pulmonary edema. Prostaglandin E(2) (PGE(2) ) production is elevated during inflammation and associated with increased vascular permeability. We hypothesize that pulmonary edema in obesity following orthopedic trauma is due to elevated PGE(2) and resultant increases in pulmonary permeability. METHODS Orthopedic trauma was induced in both hindlimbs in lean (LZ) and obese Zucker rats (OZ). On the following day, plasma interleukin-6 (IL-6) and PGE(2) levels, pulmonary edema, and pulmonary gas exchange capability were compared between groups: LZ, OZ, LZ with trauma (LZT), and OZ with trauma (OZT). Vascular permeability in isolated lungs was measured in LZ and OZ before and after application of PGE(2) . RESULTS As compared with the other groups, the OZT exhibited elevated plasma IL-6 and PGE(2) levels, increased lung wet/dry weight ratio and bronchoalveolar protein concentration, and an impaired pulmonary gas exchange. Indomethacin treatment normalized plasma PGE(2) levels and pulmonary edema. Basal pulmonary permeability in isolated lungs was higher in OZ than LZ, with a further increase in permeability following treatment with PGE(2) . CONCLUSIONS These results suggest that pulmonary edema in OZ following orthopedic trauma is due to an elevated PGE(2) and resultant increases in pulmonary permeability.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Giannoudis PV, Mallina R, Harwood P, Perry S, Sante ED, Pape HC. Pattern of release and relationship between HMGB-1 and IL-6 following blunt trauma. Injury 2010; 41:1323-7. [PMID: 20887988 DOI: 10.1016/j.injury.2010.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 09/06/2010] [Accepted: 09/07/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND High mobility group box-1 (HMGB-1), a recently identified inflammatory cytokine, is implicated in the pathogenesis of several inflammatory, infective and neoplastic processes. Patterns of expression following blunt trauma have not been adequately reported in the literature. This study aimed to quantify the serum concentrations of HMGB-1 following blunt trauma, and assess its relationship with the more established interleukin 6 (IL-6). PATIENTS AND METHODS 20 patients with median injury severity score 17 (range 9-36) sustaining closed diaphyseal fractures of the femur treated by intramedullary nailing were included in the study. Serum concentrations of HMGB-1 and IL-6 were measured at several time points during their treatment. RESULTS A strong correlation was observed between admission and day 1 post-op concentrations of IL-6 and both the injury severity score (ISS) and the requirement for intensive care unit treatment. Serum concentrations of HMGB-1 did not demonstrate such a correlation. Around day 3 when IL-6 concentrations begin to fall, serum HMGB-1 concentrations were observed to increase. CONCLUSIONS IL-6 concentration measured early after admission is again shown to be strongly associated with overall injury severity and requirement for intensive care unit treatment. In contrast, HMGB-1 appears to be a late inflammatory mediator with levels becoming elevated once serum concentrations of IL-6 begin to fall. However, we were unable to demonstrate any relationship with injury severity or requirement for ICU care at any stage. These preliminary findings may form the basis for future research in this area.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, LIMM Section Musculoskeletal Disease, School of Medicine, University of Leeds, UK
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Hartsock LA, Barfield WR, Kokko KP, Liles LL, Wind T, Green J, Giannoudis PV. Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN). Injury 2010; 41 Suppl 2:S94-8. [PMID: 21144938 DOI: 10.1016/s0020-1383(10)70018-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate whether inflammatory markers are improved among patients with traumatic femur fractures who undergo RIA reamed intramedullary nailing (IMN) prior to fixation when compared to patients treated with standard reamed (SR) IMN. METHODS A prospective, randomized, single-blind trial was conducted on patients who had a closed femoral shaft fracture amenable to reamed IMN. Patients were randomized to undergo IMN with standard reaming or IMN with the RIA in a 1:1 ratio. Patients were stratified by Injury Severity Score (ISS) and by presence or absence of chest injury with AIS > 3. Patients had blood samples and bronchioalveolar lavage samples taken at specified time points pre- and postoperatively. Specimens from SR and RIA cohorts were compared for the presence of IL-2, IL-6, IL-8, TNF, and IL-10 in plasma and IL-1b and IL-8 in bronchioalveolar lavage (BAL) samples to determine the relationship between inflammatory markers and intramedullary reaming. RESULTS Nineteen consecutive patients participated in the study with 9 assigned in the RIA group and 10 in SR group. Significant differences existed for ISS between SR and RIA groups (p=0.04). Bronchial lavage data showed no statistical significant differences when RIA and standard reamers were compared and when ISS >16 and <16 were compared, however there were differences for the bronchial IL-8 change when those with chest injury were compared to those without chest injury. Plasma samples showed a trend towards increased IL-6 and IL-10 levels after reaming consistent with the second hit impact. A trend towards higher levels for IL-6 in the SR group was noted at 24 hours post-operatively whereas the IL-10 levels at the post-reaming time point were higher in the RIA group. CONCLUSIONS This prospective study of reamer type indicates that RIA may be protective of systemic inflammation. This is supported by data showing decreased levels of IL-8 in the bronchial washings and increased level of IL-10 in the serum. Reaming and intramedullary fixation may cause an increase in IL-6 levels regardless of reamer type. Further investigations with a larger cohort of patients are desirable.
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Affiliation(s)
- Langdon A Hartsock
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
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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 Suppl 2:S57-61. [PMID: 21144930 DOI: 10.1016/s0020-1383(10)70011-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We evaluated the peripheral release of inflammatory mediators after femoral fracture and subsequent intramedullary reaming using the RIA reamers. IL-6 was elevated after trauma, and reaming with RIA induced a measurable second hit response. However, despite a higher ISS, the levels of IL-6 in the RIA group were similar to the levels measured in a group of patients where reaming of the femoral canal was performed using conventional reamers. There was one death related to fat embolism syndrome in the conventional reamers group. However, the overall incidence of complications was low and similar between the 2 groups of studied patients. In polytrauma patients, large scale studies are desirable to evaluate further the immuno-inflammatory response using the RIA reamers prior to the instrumentation of the femoral canal.
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Affiliation(s)
- P V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, School of Medicine, University of Leeds, UK.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department Orthopaedic Trauma Surgery, Leeds University, Leeds, UK
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Intramedullary nailing as a 'second hit' phenomenon in experimental research: lessons learned and future directions. Clin Orthop Relat Res 2010; 468:2514-29. [PMID: 20012236 PMCID: PMC2919890 DOI: 10.1007/s11999-009-1191-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 11/23/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND The 'second hit' phenomenon is based on the fundamental concept that sequential insults, which are individually innocuous, can lead to overwhelming physiologic reactions. This response can be expressed in several organic systems and can be examined by measurement of several parameters. PURPOSES The purpose of this study was to evaluate the incidence of systemic effects of intramedullary nailing and the role of concurrent head and thoracic injuries as they have been recorded in vivo. We also wanted to determine what would be the optimal animal model for future research and what variables should be investigated. METHODS We reviewed the available literature of animal studies that used surgery, and particularly nailing, as a second hit. The reviewed studies were retrieved through an electronic search of the MEDLINE database. We analyzed the methods of creating the first and second hits (nailing), the characteristics of the animal models, the variables examined, and the pathophysiologic responses, which appeared after the second hit. RESULTS Second hit reamed intramedullary nailing was found to provoke consumption of coagulation factors, whereas the effect of unreamed nailing on coagulation factors appears inconsistent. Hemodynamic factors were affected only transiently by the second hit, whereas the pulmonary function was affected only when the first hit included lung injury. CONCLUSIONS Thoracic and head injuries predispose to an aggravated second hit. Primate animal models are considered to be closer to clinical reality and should be preferred for future studies. Future studies should include measurements of proinflammatory and antiinflammatory markers.
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Shah RK, Moncayo VM, Smitson RD, Pierre-Jerome C, Terk MR. Recombinant human bone morphogenetic protein 2-induced heterotopic ossification of the retroperitoneum, psoas muscle, pelvis and abdominal wall following lumbar spinal fusion. Skeletal Radiol 2010; 39:501-4. [PMID: 20162273 DOI: 10.1007/s00256-010-0890-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 01/06/2010] [Accepted: 01/19/2010] [Indexed: 02/02/2023]
Abstract
A 45-year-old man presented with vertebral collapse at L5 as an initial manifestation of multiple myeloma and underwent spinal fusion surgery using recombinant human bone morphogenetic protein-2 (rhBMP-2). Subsequent computed tomography (CT) scans and X-rays revealed heterotopic ossification of the left psoas muscle, pelvis, and anterior abdominal wall. While the occurrence of heterotopic ossification has previously been reported when rhBMP-2 has been used for spinal fusion surgery, this case demonstrates that it can occur to a much greater degree than previously seen.
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Affiliation(s)
- Raj K Shah
- The George Washington University School of Medicine, 2300 Eye Street NW, Washington, DC 20037, USA.
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Abstract
Intramedullary fixation has advanced to the standard of care for fractures of the femoral shaft. Current controversies center on whether to prepare the intramedullary canal by reaming, particularly in certain subsets of patients. As understanding of the local and systemic effects of reaming deepens, there is a role for maximizing the benefits of intramedullary preparation before nail fixation, while attempting to minimize the major disadvantages of this technique. Several treatment strategies have emerged to address the downsides of intramedullary reaming. The purpose of this review is to discuss the history and current knowledge of intramedullary reaming with respect to problems associated with its use and the evolution of treatment modalities and their clinical applicability for orthopaedic trauma care.
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Pathoanatomy and clinical correlates of the immunoinflammatory response following orthopaedic trauma. J Am Acad Orthop Surg 2009; 17:255-65. [PMID: 19307674 PMCID: PMC2675552 DOI: 10.5435/00124635-200904000-00006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The natural inflammatory response to major trauma may be associated with the development of a systemic inflammatory state, remote multiorgan failure, and death. Although a controlled inflammatory response is beneficial, an exaggerated response can cause serious adverse systemic effects. Early identification of high-risk patients, based on inflammatory markers and genomic predisposition, should help direct intervention in terms of surgical stabilization and biologic response modification. Currently, two markers of immune reactivity, interleukin-6 and human leukocyte antigen-DR class II molecules, appear to have the most potential for regular use in predicting the clinical course and outcome in trauma patients; however, the ability to measure markers of inflammation is still limited at many hospitals. With improving technology and increasing research interest, understanding of the significance of the immunoinflammatory response system in injured patients will continue to evolve.
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