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

Elisabeth E Husebye, Torstein Lyberg, Helge Opdahl, Trude Aspelin, Ragnhild O Støen, Jan Erik Madsen, Olav Røise, Elisabeth E Husebye, Torstein Lyberg, Helge Opdahl, Trude Aspelin, Ragnhild O Støen, Jan Erik Madsen, Olav Røise

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.

Figures

Figure 1
Figure 1
Flow chart of patients admitted with femoral shaft fracture and included in the study.
Figure 2
Figure 2
The figure shows the arterial thrombin-antithrombin-complex (TAT) (2a), soluble tissure factor (sTF) (2b), tissue plasminogen activator (t-PA) antigen (2c) and plasminogen activator inhibitor (PAI-1) activity (2d) (median and 25/75 percentiles) at admission (A), skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first (G1), second (H1) and third (I) day after nail insertion.
Figure 3
Figure 3
The figure shows the arterial tumor necrosis factor-alpha (TNF-α) (3a), interleukin-6 (IL-6) (3b) and interleukin-10 (IL-10) (3c) (median and 25/75 percentiles) at admission (A), skin incision (B), 30 minutes (D), two (E) and six (F) hours, the first (G1), second (H1) and third (I) day after nail insertion.
Figure 4
Figure 4
The figure shows alveolo-arterial oxygen (PAO2 - PaO2) difference (Figure 4a), arterial (SaO2) (Figure 4b) and mixed venous (SvO2) saturation (Figure 4c) (mean ± S.E.M.) at skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first (G1 and G2), second (H1 and H2) and third (I) day after nail insertion.
Figure 5
Figure 5
The figure shows the time course (mean ± S. E. M.) for cardiac index (CI) (Figure 5a), indexed systemic vascular resistance (SVRI) (Figure 5b), mean pulmonary artery pressure (MPAP) (Figure 5c) and indexed pulmonary vascular resistance (PVRI) (Figure 5d) at admission (A), skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first- (G1 and G2), second- (H1 and H2) and third (I) day after primary IMN.

References

    1. Enninghorst N, Toth L, King KL, McDougall D, Mackenzie S, Balogh ZJ. Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option. J Trauma. 2010;68:935–941. doi: 10.1097/TA.0b013e3181d27b48.
    1. O'Toole RV, O'Brien M, Scalea TM, Habashi N, Pollak AN, Turen CH. Resuscitation Before Stabilization of Femoral Fractures Limits Acute Respiratory Distress Syndrome in Patients With Multiple Traumatic Injuries Despite Low Use of Damage Control Orthopedics. J Trauma. 2009;67:1013–1021. doi: 10.1097/TA.0b013e3181b890be.
    1. Pape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26:1478–1484. doi: 10.1002/jor.20697.
    1. Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, Gruner A, Oestern HJ, Bayeff-Filoff M, Garving C. et al.Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients) Ann Surg. 2007;246:491–499; discussion 499-501. doi: 10.1097/SLA.0b013e3181485750.
    1. Pape HC, Tornetta P, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17:541–549.
    1. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71:336–340.
    1. Bosse MJ, MacKenzie EJ, Riemer BL, Brumback RJ, McCarthy ML, Burgess AR, Gens DR, Yasui Y. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am. 1997;79:799–809.
    1. Goris RJ, Gimbrere JS, van Niekerk JL, Schoots FJ, Booy LH. Early osteosynthesis and prophylactic mechanical ventilation in the multitrauma patient. J Trauma. 1982;22:895–903. doi: 10.1097/00005373-198211000-00002.
    1. Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma. 1985;25:375–384. doi: 10.1097/00005373-198505000-00001.
    1. Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury. 1976;8:110–116. doi: 10.1016/0020-1383(76)90043-7.
    1. Waydhas C, Nast-Kolb D, Trupka A, Zettl R, Kick M, Wiesholler J, Schweiberer L, Jochum M. Posttraumatic inflammatory response, secondary operations, and late multiple organ failure. J Trauma. 1996;40:624–630. doi: 10.1097/00005373-199604000-00018. discussion 630-621.
    1. Pape HC, Schmidt RE, Rice J, van Griensven M, das Gupta R, Krettek C, Tscherne H. Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit Care Med. 2000;28:3441–3448. doi: 10.1097/00003246-200010000-00012.
    1. Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br. 1999;81:356–361. doi: 10.1302/0301-620X.81B2.8988.
    1. Pape HC, Grimme K, van Griensven M, Sott AH, Giannoudis P, Morley J, Roise O, Ellingsen E, Hildebrand F, Wiese B. et al.Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55:7–13. doi: 10.1097/01.TA.0000075787.69695.4E.
    1. White TO, Clutton RE, Salter D, Swann D, Christie J, Robinson CM. The early response to major trauma and intramedullary nailing. J Bone Joint Surg Br. 2006;88:823–827. doi: 10.1302/0301-620X.88B6.17359.
    1. Association for the Advancement of Automotive medicine, 1998. The Abbreviated Injury Scale (1990 Revision) Update 98. Des Plaines, IL
    1. Ullevaal Trauma Registry. Ullevaal University Hospital Trauma Registry
    1. Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43:922–925. doi: 10.1097/00005373-199712000-00009. discussion 925-926.
    1. Balogh Z, Offner PJ, Moore EE, Biffl WL. NISS predicts postinjury multiple organ failure better than the ISS. J Trauma. 2000;48:624–627. doi: 10.1097/00005373-200004000-00007. discussion 627-628.
    1. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma. 1987;27:370–378. doi: 10.1097/00005373-198704000-00005.
    1. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr, Flanagan ME, Frey CF. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. 1990;30:1356–1365. doi: 10.1097/00005373-199011000-00008.
    1. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864–874. doi: 10.1097/00003246-199206000-00025.
    1. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R. Report of the American-European Consensus conference on acute respiratory distress syndrome: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Consensus Committee. J Crit Care. 1994;9:72–81. doi: 10.1016/0883-9441(94)90033-7.
    1. Mollnes TE, Redl H, Hogasen K, Bengtsson A, Garred P, Speilberg L, Lea T, Oppermann M, Gotze O, Schlag G. Complement activation in septic baboons detected by neoepitope-specific assays for C3b/iC3b/C3c, C5a and the terminal C5b-9 complement complex (TCC) Clin Exp Immunol. 1993;91:295–300.
    1. Kluft C, Verheijen JH, Jie AF, Rijken DC, Preston FE, Sue-Ling HM, Jespersen J, Aasen AO. The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast-acting inhibitor of tissue-type plasminogen activator after trauma. Scand J Clin Lab Invest. 1985;45:605–610. doi: 10.3109/00365518509155267.
    1. Dahl OE, Westvik AB, Kierulf P, Lyberg T. Effect of monomethylmethacrylate on procoagulant activities of human monocytes and umbilical vein endothelial cells in vitro. Thromb Res. 1994;74:377–387. doi: 10.1016/0049-3848(94)90153-8.
    1. Esmon CT. Crosstalk between inflammation and thrombosis. Maturitas. 2004;47:305–314. doi: 10.1016/j.maturitas.2003.10.015.
    1. Giercksky KE, Bjorklid E, Prydz H, Renck H. Circulating tissue thromboplastin during hip surgery. Eur Surg Res. 1979;11:296–300. doi: 10.1159/000128078.
    1. Gebhard F, Pfetsch H, Steinbach G, Strecker W, Kinzl L, Bruckner UB. Is interleukin 6 an early marker of injury severity following major trauma in humans? Arch Surg. 2000;135:291–295. doi: 10.1001/archsurg.135.3.291.
    1. Giannoudis PV, Harwood PJ, Loughenbury P, Van Griensven M, Krettek C, Pape HC. Correlation between IL-6 levels and the systemic inflammatory response score: can an IL-6 cutoff predict a SIRS state? J Trauma. 2008;65:646–652. doi: 10.1097/TA.0b013e3181820d48.
    1. Hoch RC, Rodriguez R, Manning T, Bishop M, Mead P, Shoemaker WC, Abraham E. Effects of accidental trauma on cytokine and endotoxin production. Crit Care Med. 1993;21:839–845. doi: 10.1097/00003246-199306000-00010.
    1. Pape HC, Tsukamoto T, Kobbe P, Tarkin I, Katsoulis S, Peitzman A. Assessment of the clinical course with inflammatory parameters. Injury. 2007;38:1358–1364. doi: 10.1016/j.injury.2007.09.026.
    1. Spielmann S, Kerner T, Ahlers O, Keh D, Gerlach M, Gerlach H. Early detection of increased tumour necrosis factor alpha (TNFalpha) and soluble TNF receptor protein plasma levels after trauma reveals associations with the clinical course. Acta Anaesthesiol Scand. 2001;45:364–370. doi: 10.1034/j.1399-6576.2001.045003364.x.
    1. Kobbe P, Vodovotz Y, Kaczorowski DJ, Mollen KP, Billiar TR, Pape HC. Patterns of cytokine release and evolution of remote organ dysfunction after bilateral femur fracture. Shock. 2008;30:43–47. doi: 10.1097/SHK.0b013e31815d190b.
    1. Lin E, Calvano SE, Lowry SF. Inflammatory cytokines and cell response in surgery. Surgery. 2000;127:117–126. doi: 10.1067/msy.2000.101584.
    1. Pape HC, Griensven MV, Hildebrand FF, Tzioupis CT, Sommer KL, Krettek CC, Giannoudis PV. Systemic inflammatory response after extremity or truncal fracture operations. J Trauma. 2008;65:1379–1384. doi: 10.1097/TA.0b013e31818c8e8c.
    1. Morley JR, Smith RM, Pape HC, MacDonald DA, Trejdosiewitz LK, Giannoudis PV. Stimulation of the local femoral inflammatory response to fracture and intramedullary reaming: a preliminary study of the source of the second hit phenomenon. J Bone Joint Surg Br. 2008;90:393–399.
    1. Husebye EE, Opdahl H, Roise O, Aspelin T, Lyberg T. 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;42:630–637. doi: 10.1016/j.injury.2010.06.025.
    1. Bone RC. Toward a theory regarding the pathogenesis of the systemic inflammatory response syndrome: what we do and do not know about cytokine regulation. Crit Care Med. 1996;24:163–172. doi: 10.1097/00003246-199601000-00026.
    1. Smith RM, Giannoudis PV, Bellamy MC, Perry SL, Dickson RA, Guillou PJ. Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing. Clin Orthop Relat Res. 2000. pp. 233–240.
    1. Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002;52:299–307. doi: 10.1097/00005373-200202000-00016.
    1. Fakhry SM, Rutledge R, Dahners LE, Kessler D. Incidence, management, and outcome of femoral shaft fracture: a statewide population-based analysis of 2805 adult patients in a rural state. J Trauma. 1994;37:255–260. doi: 10.1097/00005373-199408000-00018. discussion 260-251.
    1. Pape HC, Auf'm'Kolk M, Paffrath T, Regel G, Sturm JA, Tscherne H. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion--a cause of posttraumatic ARDS? J Trauma. 1993;34:540–547. doi: 10.1097/00005373-199304000-00010. discussion 547-548.
    1. Cannada LK, Taghizadeh S, Murali J, Obremskey WT, DeCook C, Bosse MJ. Retrograde intramedullary nailing in treatment of bilateral femur fractures. J Orthop Trauma. 2008;22:530–534. doi: 10.1097/BOT.0b013e318183eb48.
    1. Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet. 2007;369:1553–1564. doi: 10.1016/S0140-6736(07)60604-7.
    1. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121:877–905. doi: 10.1378/chest.121.3.877.
    1. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol. 1971;28:288–294. doi: 10.1016/0002-9149(71)90116-0.

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