Neutrophil functions in patients with fractures of the upper end of the femur

Humoral Factors From Musculoskeletal Polytrauma Patients Impair Antibacterial Responses Of Neutrophils In vitro

Polytrauma is associated with increased risk of sepsis, but the risk for implant infection is less clear. Neutrophil antibacterial responses are significantly reduced in polytrauma patients (n= 9, ISS≥15) for at least 5 days compared to healthy controls. Reduced neutrophil activity could influence implant infection in addition to sepsis.

Older Patients Are Immunocompromised by Cytokine Depletion and Loss of Innate Immune Function After HIP Fracture Surgery

PURPOSE/INTRODUCTION

We have examined the immune status of elderly patients who underwent surgery for a hip fracture, an injury associated with poor postoperative outcomes, to identify specific immune defects.

METHODS

In a cohort observational study, 16 patients undergoing surgery for hip fractures had immune function evaluation prior to surgery, and then at 3 and 7 days postoperatively, using flow cytometry for phenotype and for monocyte and granulocyte phagocytic function and respiratory burst. Serum samples were stored and batch analyzed using a human cytokine 25-plex panel.

RESULTS

We report significant loss of innate immune function, related specifically to reduced granulocyte numbers by day 7 (P < .0001, flow cytometry; P < .05 white blood cells), and although granulocyte ability to take up opsonized Escherichia coli was increased (P < .05), the ability of those cells to generate a respiratory burst was reduced at days 3 and 7 (P < .05). Monocyte respiratory burst was also significantly reduced (P < .05). Serum cytokine levels indicated very poor T-cell function.

CONCLUSION

We have demonstrated that the antimicrobial immune response is profoundly reduced after surgery in elderly patients with hip fractures. The effect was sustained up to 7 days postoperatively, identifying these patients as particularly vulnerable to bacterial infections.

Altered neutrophil functions in elderly patients during a 6-month follow-up period after a hip fracture

BACKGROUND

Fracture of the hip (HF) is a significant cause of morbidity and mortality in elderly individuals. HF is an acute stress that triggers a state of inflammation which may affect immune responses and physical recovery.

METHODS

Longitudinal study of the impact of HF on the functions of polymorphonuclear neutrophils (PMNs) in elderly subjects. Data were recorded prior to surgery, 6weeks and 6months later.

RESULTS

PMN functions were severely impaired shortly after HF (chemotaxis, phagocytosis, superoxide production) but there was a time-related recovery of some PMN functions (chemotaxis, phagocytosis) over time, except in the case of superoxide production. Whereas FcγRII (CD32) expression remained unchanged, FcγRIII (CD16) increased from low values before surgery to levels of controls 6months post-surgery. This was also the case for the C5a complement receptor and CD11b. TLR2 and TLR4 expressions were unchanged. Cytokine and chemokine secretions by stimulated PMN were altered. TNFα and IL-10 secretions were increased following HF but IL-8 secretion was decreased. Impaired PMN functions prior to surgery were related to alterations in PI3K and NF-κB signaling pathways. Recovery of these functions paralleled increased PI3K activity, although superoxide production remained low. Sustained activation of the NF-κB pathway by TNFα has been reported to involve upregulation of IKKβ kinase activity. Activated IKKβ kinase inhibits ERK1/2 and results in concomitant downstream inhibition of NADPH oxidase complex which can account for sustained impaired production of ROS in HF patients.

CONCLUSION

Our data showed that the stress caused by HF negatively affects initial PMN responses shortly after the event and that may negatively influence clinical outcomes such as resolving long-term inflammation and recovery, as well as explaining susceptibility to opportunistic infections.

Immunologic responses to critical injury and sepsis

Almost 2 million patients are admitted to hospitals in the United States each year for treatment of traumatic injuries, and these patients are at increased risk of late infections and complications of systemic inflammation as a result of injury. Host response to injury involves a general activation of multiple systems in defending the organism from hemorrhagic or infectious death. Clinicians have the capability to support the critically injured through their traumatic insult with surgery and improved critical care, but the inflammatory response generated by such injuries creates new challenges in the management of these patients. It has long been known that local tissue injury induces systemic changes in the traumatized patient that are often maladaptive. This article reviews the effects of injury on the function of immune system cells and highlights some of the clinical sequelae of this deranged inflammatory-immune interaction.

Orthopaedic management of hip fracture

The MEDOS study was a prospective, multicentre study of the incidence of hip fractures, carried out in six Mediterranean countries over a 12-month period (1988-1989). The majority of hip fractures recorded were extra-capsular and usually required a stable internal fixation to avoid instability and deformation or pseudoarthrosis. Surgery was performed in the majority of cases (85% of extra-capsular fractures and 84% of intra-capsular fractures), although this proportion also varied between centres. The type of operation performed depended on the type of fracture; the most common operation for intra-capsular fracture was hip replacement (67% of cases), while in extra-capsular fracture the most common intervention was stable fixation (50% of cases). Again, there were substantial differences between centres. During the period of hospitalisation, 26% of patients experienced minor complications, but only 2.4% experienced serious complications, with further surgery required in 2%. Mortality during hospitalisation was 5.1% overall (4.8% and 5.7% in intra- and extra-capsular fracture cases, respectively). The average duration of hospital stay was 24 days, but this varied between centres, with a tendency for shorter stays to be associated with a greater proportion of cases treated surgically.