Fatal systemic inflammatory response syndrome following early bilateral femoral nailing

In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation

OBJECTIVES

To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank.

METHODS

Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator.

RESULTS

Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001).

CONCLUSIONS

Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation.

LEVEL OF EVIDENCE

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

Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation

OBJECTIVES

We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5.

INTERVENTION

These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days).

MAIN OUTCOME MEASURES

Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications.

RESULTS

Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications.

CONCLUSIONS

Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications.

LEVEL OF EVIDENCE

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

Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

INTRODUCTION

Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles.

MATERIALS AND METHODS

This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression.

RESULTS

Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality.

DISCUSSION

Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients.

CONCLUSION

Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management.

LEVEL OF EVIDENCE

IV; retrospective study.

Timing of definitive fixation of major long bone fractures: Can fat embolism syndrome be prevented?

Fat embolism is common in patients with major fractures, but leads to devastating consequences, named fat embolism syndrome (FES) in some. Despite advances in treatment strategies regarding the timing of definitive fixation of major fractures, FES still occurs in patients. In this overview, current literature is reviewed and optimal treatment strategies for patients with multiple traumatic injuries, including major fractures, are discussed. Considering the multifactorial etiology of FES, including mechanical and biochemical pathways, FES cannot be prevented in all patients. However, screening for symptoms of FES should be standard in the pre-operative work-up of these patients, prior to definitive fixation of major fractures.

Fat embolism syndrome: What have we learned over the years?

Although its original clinical description dates from the nineteenth century, fat embolism syndrome remains a diagnostic challenge for clinicians. Fat emboli occur in all patients with long-bone fractures, but only few of them develop a multisystem disorder affecting the lung, brain, and skin, also known as fat embolism syndrome (FES). The incidence of FES varies and is often underestimated. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. Clinical manifestations consist of respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult and based mainly on clinical criteria. FES is a self-limiting disease and treatment needs to be mainly supportive. Surgical treatment of the coexistent injuries is still obscured by controversies and the treatment methods used provide inconclusive results. In this context, prevention focuses on the early identification of predisposing factors.

Orthopaedic Timing in Polytrauma in a Second Level Emergency Hospital. An Overrated Problem?

The main concern for orthopaedic treatment in polytrauma has always been the same for almost forty years, which also regards "where" and "when" to proceed; correct surgical timing and correct interpretation of the DCO concept are still being debated. In the last few years, several attempts have been made to classify patients based on their clinical presentation and by trying to figure out which vital parameters are able to predict the patient's outcome. This study evaluated all patients who presented with code red at the Emergency Department of our Hospital, a level II trauma center. For every patient, the following characteristics were noted: sex, age, day of hospitalization, orthopaedic trauma, time to surgery, presence of an associated surgical condition in the fields of general surgery, thoracic surgery, neurosurgery and vascular surgery, cardiac frequency, blood pressure, oxygen saturation, Glasgow Coma Scale and laboratory data. All patients included were divided into subgroups based on orthopaedic surgical timing. Two other subgroups were also identified and analyzed in detail: deceased and weekend traumas. A total of 208 patients were included. Our primary goal was to identify a correlation between the mortality and surgical timing of the orthopaedic procedures; our secondary goal was to recognize, if present, a statistically relevant association between historical, clinical and laboratory data, and mortality rate, defining any possible risk factor. A correlation between mortality and orthopaedic surgical timing was not found. Analyzing laboratory data revealed an interesting correlation between mortality and: blood pressure, platelet count, cardiac frequency, hematocrit, hemoglobin and age.

Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome?

INTRODUCTION

Long bone fractures are assumed to be an independent risk factor for systemic complications and death after trauma. Multiple studies have identified an increased risk for mortality and morbidity in patients with bilateral femoral fractures. Data about bilateral tibial shaft fractures is rare. The aim of our study was to analyze if patients with bilateral tibial shaft fractures are at higher risk for systemic complications.

METHODS

We performed a retrospective analysis of the TraumaRegister DGU® from 1993 to 2008. Inclusion criteria were unilateral or bilateral tibial shaft fractures and an age ≥16. Additionally to the overall collective we analyzed different subgroups (divided into different injury severities and treatment periods).

RESULTS

1899 patients with unilateral and 175 patients with bilateral tibial shaft fractures were included. Age, gender and mean ISS (25.8 vs. 26.2, p = 0.51) in the two groups were comparable. Regarding the entire study population, patients with bilateral tibial shaft fractures showed no significant higher incidence of respiratory organ failure (29.5% vs. 23.1%, p = 0.076) or mortality (20.0% vs. 16.3%, p = 0.203). However, subgroup analysis showed a significant higher rate of pulmonary organ failure for bilateral tibial shaft fractures as compared to unilateral tibial shaft fractures in the group ISS < 25 (20.7% vs. 11.7%, p = 0.023). Multivariate regression analysis identified the additional tibial shaft fracture as an independent risk factor for pulmonary organ failure (OR = 1.56) but not for mortality.

DISCUSSION

The additional tibial shaft fracture is an independent risk factor for pulmonary organ failure but not for multiple organ failure or mortality. The impact of the additional tibial shaft fracture is especially pronounced in less severely injured patients (ISS < 25). These findings are comparable to results of bilateral femoral fracture studies and we therefore suggest to treat patients with bilateral tibial shaft fractures with the same caution as those with bilateral femoral fractures.

Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits

PURPOSE AND METHODS

External fixation is a safe option for stabilisation of extremity lesions in the polytraumatised patient as well as in fractures with severe soft tissue damage. Nevertheless, long-term-complications are to be expected when external fixation is chosen as a definitive treatment. The purpose of this review article is twofold: primarily, to define the rationale of a procedural change from an external fixator to an intramedullary nail; secondarily, to assess the possible advantages and pitfalls of a single- or two-staged procedure.

RESULTS AND CONCLUSIONS

External fixation of the femur is recommended in multiply injured patients who are critically ill to avoid an additional inflammatory response caused by the surgical trauma of primary nailing. The conversion towards nailing must be done as soon as the clinical condition of the patient has been stabilised. Stable polytraumatised patients do not benefit from initial stabilisation with an external fixator and should immediately be treated with a definitive osteosynthesis. In tibial fractures, external fixation followed by intramedullary nailing is recommendable in fractures with severe soft tissue injuries. Conversion should be done as soon as the soft tissues allow before pin-tract infections occur and performed in a one-staged procedure.

A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society

BACKGROUND

Today, there is a trend toward damage-control orthopedics (DCO) in the management of multiple trauma patients with long bone fractures. However, there is no widely accepted concept. A risk-adapted approach seems to result in low acute morbidity and mortality. Multiple trauma patients with bilateral femoral shaft fractures (FSFs) are considered to be more severely injured. The objective of this study was to validate the risk-adapted approach in the management of multiple trauma patients with bilateral FSF.

METHODS

Data analysis is based on the trauma registry of the German Trauma Society (1993-2008, n = 42,248). Multiple trauma patients with bilateral FSF were analyzed in subgroups according to the type of primary operative strategy. Outcome parameters were mortality and major complications as (multiple) organ failure and sepsis.

RESULTS

A total of 379 patients with bilateral FSF were divided into four groups as follows: (1) no operation (8.4%), (2) bilateral temporary external fixation (DCO) (50.9%), bilateral primary definitive osteosynthesis (early total care [ETC]) (25.1%), and primary definitive osteosynthesis of one FSF and DCO contralaterally (mixed) (15.6%). Compared with the ETC group, the DCO group was more severely injured. The incidence of (multiple) organ failure and mortality rates were higher in the DCO group but without significance. Adjusted for injury severity, there was no significant difference of mortality rates between DCO and ETC. Injury severity and mortality rates were significantly increased in the no-operation group. The mixed group was similar to the ETC group regarding injury severity and outcome.

CONCLUSION

In Germany, both DCO and ETC are practiced in multiple trauma patients with bilateral FSF so far. The unstable or potentially unstable patient is reasonably treated with DCO. The clearly stable patient is reasonably treated with nailing. When in doubt, the patient is probably not totally stable, and the safest precaution may be to use DCO as a risk-adapted approach.

LEVEL OF EVIDENCE

Therapeutic study, level IV. Epidemiologic study, level III.

Role of interleukin-6 as an early marker of fat embolism syndrome: a clinical study

BACKGROUND

A few animal studies have shown that IL-6 can serve as an early marker of fat embolism syndrome. The degree to which this is true in human trauma victims is unknown.

QUESTIONS/PURPOSES

In this clinical study, we sought to determine (1) whether elevated serum IL-6 levels at 6, 12, and 24 hours in patients with skeletal trauma were associated with the development of fat embolism syndrome (FES) within 72 hours after injury, and (2) at what time after trauma peak IL-6 levels are observed.

METHODS

Forty-eight patients between 16 and 40 years old who presented to our tertiary trauma center within 6 hours of injury with long bone and/or pelvic fractures were included in this study. Serum IL-6 levels were measured at 6, 12, and 24 hours after injury. The patients were observed clinically and monitored for 72 hours for development of FES symptoms. Gurd's criteria were used to diagnose FES.

RESULTS

Elevated serum IL-6 levels 12 hours after trauma correlated with an increased likelihood of having FES develop; no significant relationship was observed between IL-6 levels at 6 or 24 hours and the development of FES. Patients with FES had a mean IL-6 level of 131 pg/mL, whereas those without FES had a mean IL-6 level of 72 pg/mL. Peak IL-6 levels were observed at 12 hours.

CONCLUSIONS

An elevated serum IL-6 level may be useful as an early marker of FES in patients with isolated skeletal trauma.

LEVEL OF EVIDENCE

Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control?

INTRODUCTION

Bilateral femoral shaft fractures have been reported to be an independent risk factor for morbidity and mortality; however, the value of these studies is limited due to small sample sizes and the timing of these studies before the establishment of damage control orthopaedics. The objective of this study was to compare the incidence of morbidity and mortality in patients with bilateral vs. unilateral femoral shaft fractures in the era of damage control orthopaedics.

METHODS

Retrospective analysis of the TraumaRegister DGU from 2002 to 2005. Inclusion criteria were uni- or bilateral femoral shaft fractures and complete demographic data documentation. Univariate data analysis and logistic regression analysis were performed with SPSS.

RESULTS

Between 2002 and 2005, 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures were identified. Patients with bilateral femoral shaft fractures had a significantly higher Injury Severity Score (ISS) (29.5 vs. 25.7 points), a significantly higher incidence of pulmonary (34.7% vs. 20.6%) and multiple organ failure (25.0% vs. 14.6%) as well as a significantly higher mortality rate (16.9% vs. 9.4%). In the overall patient population, early total care (ETC) was significantly more often performed in patients with unilateral femoral shaft fractures (50.9% vs. 33.6%). Logistic regression analysis revealed no significant association between bilateral femoral shaft fractures and multiple organ failure or mortality; however, bilateral femoral shaft fractures are an independent risk factor for pulmonary failure. Subgroup analysis revealed that the impact of the bilateral femoral shaft fracture was especially pronounced in patients with an ISS<25 points.

DISCUSSION

Bilateral femoral shaft fractures are an independent risk factor for pulmonary failure but not for multiple organ failure or mortality. The impact of the additional femoral shaft fracture for pulmonary failure appears to be especially pronounced in the less severely injured patients, whose injuries are often underestimated when stratified with the ISS. Patients with bilateral femoral shaft fractures have significantly more often severe abdominal injuries as well as severe blood loss which may account for the increased mortality rate. Therefore, the presence of bilateral femoral shaft fractures should be recognised as an increased risk for systemic complications.

Influence of preoperative 7.5% hypertonic saline on neutrophil activation after reamed intramedullary nailing of femur shaft fractures: a prospective randomized pilot study

OBJECTIVES

Femoral reaming and intramedullary nailing (IMN) primes polymorphonuclear leukocytes (PMNL) and thereby increases the posttraumatic systemic inflammatory response. Resuscitation with hypertonic saline (HTS) attenuates PMNL activation after trauma-hemorrhage. We hypothesized that preoperative administration of 7.5% HTS attenuates PMNL priming after IMN of unilateral femur shaft fractures compared with 0.9% normal saline.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Level I trauma center.

PATIENTS

Twenty patients between 18 and 80 years of age with an Injury Severity Score less than 25 and a unilateral femur shaft fracture amenable to IMN fixation within 24 hours after injury.

INTERVENTION

Patients were allocated to equally sized HTS or normal saline treatment groups (n = 10) before surgery. Solutions were administered in a blinded bag as a single bolus of 4 mL/kg body weight immediately before surgery. Whole blood samples were collected directly before saline application (t0) and at 6, 12, and 24 hours after surgery.

MAIN OUTCOME MEASUREMENTS

PMNL surface expression of CD11b and CD62L, as determined by flow cytometry analysis.

RESULTS

Demographic characteristics of both treatment groups were comparable. Baseline expression of CD11b and CD62L cell markers was in a similar range in the two cohorts. The expression levels of CD11b were comparable between the two groups throughout the observation time, whereas CD62L levels were significantly higher in the HTS group at 6 and 24 hours after surgery.

CONCLUSION AND SIGNIFICANCE

Preoperative infusion of HTS appears to exert an anti-inflammatory effect by attenuating the extent of postoperative PMNL activation after reamed IMN for femoral shaft fractures.

Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize

Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.

Bilateral femoral fractures: does intramedullary nailing increase systemic complications and mortality rates?

In order to evaluate the impact of simultaneous intramedullary nailing in patients with bilateral femoral fractures on systemic complications a comprehensive review of the literature was performed. Four studies reporting the results of 197 patients following trauma were analysed. The mean Injury Severity Score was 20.6 (range, 9-75). According to the data available, reamed intramedullary nailing was performed in 96% of the cases. The incidence of fat embolism was 4.1%, ARDS 14.6% and pulmonary embolism 6.9%. The overall mortality was 6%. The mean hospital stay was 17.9 days (range, 4-108). Bilateral femoral fractures have a high risk of complications and mortality. Damage control surgery should be considered in these cases where the clinician anticipates the development of systemic complications.

Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery

The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-saving measures are pivotal, followed by a damage control approach to their injuries.

Interleukin-6 as an early marker for fat embolism

BACKGROUND

Fat Embolism is a complication of long bone fractures, intramedullary fixation and joint arthroplasty. It may progress to fat embolism syndrome, which is rare but involves significant morbidity and can occasionally be fatal. Fat Embolism can be detected at the time of embolization by transoesophageal echocardiography or atrial blood sampling. Later, a combination of clinical signs and symptoms will point towards fat embolism but there is no specific test to confirm the diagnosis. We investigated serum Interleukin-6 (IL-6) as a possible early marker for fat embolism.

METHODS

An animal study was conducted to simulate a hip replacement in 31 adult male Sprague Dawley rats. The procedure was performed under general anesthesia and the animals divided into 3 groups: control, uncemented and cemented. Following surgery and recovery from anaesthesia, the rats allowed to freely mobilize in their cages. Blood was taken before surgery and at 6 hours, 12 hours and 24 hours to measure serum IL-6 levels. The rats were euthanized at 24 hours and lungs removed and stained for fat. The amount of fat seen was then correlated with serum IL-6 levels.

RESULTS

No rats in the control group had fat emboli. Numerous fat emboli were seen in both the uncemented and cemented implant groups. The interleukin levels were raised in all groups reaching a peak at 12 hours after surgery reaching 100 pg/ml in the control group and around 250 pg/ml in the uncemented and cemented implant groups. The IL-6 levels in the control group were significantly lower than any of the implant groups at 12 and 24 hours. At these time points, the serum IL-6 correlated with the amount of fat seen on lung histology.

CONCLUSION

Serum IL-6 is a possible early marker of fat embolism.

Stimulation of the local femoral inflammatory response to fracture and intramedullary reaming

We have undertaken a prospective study in patients with a fracture of the femoral shaft requiring intramedullary nailing to test the hypothesis that the femoral canal could be a potential source of the second hit phenomenon. We determined the local femoral intramedullary and peripheral release of interleukin-6 (IL-6) after fracture and subsequent intramedullary reaming.

In all patients, the fracture caused a significant increase in the local femoral concentrations of IL-6 compared to a femoral control group. The concentration of IL-6 in the local femoral environment was significantly higher than in the patients own matched blood samples from their peripheral circulation. The magnitude of the local femoral release of IL-6 after femoral fracture was independent of the injury severity score and whether the fracture was closed or open.

In patients who underwent intramedullary reaming of the femoral canal a further significant local release of IL-6 was demonstrated, providing evidence that intramedullary reaming can cause a significant local inflammatory reaction.

Femoral nailing-related coagulopathy determined by first-hit magnitude: an animal study

We asked whether coagulopathy worsened during femoral intramedullary nailing in the presence of lung contusion and hemorrhagic shock and whether reamed or unreamed nailing influenced these results. In 30 Merino sheep, we induced hemorrhagic shock and/or standardized lung contusion followed by femoral nailing. Six groups of five each were assigned as follows: thoracotomy control groups treated with reamed or unreamed nailing, lung contusion groups treated with reamed or unreamed nailing, and shock and lung contusion groups treated with reamed or unreamed nailing. After lung contusion alone (first hit), the serum values of antithrombin III, factor V, and fibrinogen were considerably altered after reamed and unreamed femoral nailing (second hit) 4 hours postoperatively. In the lung contusion and shock groups, we found a substantial reduction for all serum coagulative parameters between baseline and fixation after reamed and unreamed nailing. The magnitude of the first hit is increased if hemorrhagic shock is added to a lung contusion determined by hemostatic reactions. The magnitude of the injury appears equally important as the type of subsequent surgery and should be considered in planning for fracture fixation in patients at high risk for complications.

Surgical stress response

Recent advances in molecular medicine have allowed the characterization and quantification of inflammatory cascades following surgery and trauma. Activation of immune cells is followed by the release of various cytokines as well as by migration of leukocytes into inflamed tissues. Various methods have been developed in order to modulate the immune-inflammatory system and at the same time to prevent overreaction and unexpected complications. In this context, the magnitude of surgical stress exerted on the patient is of paramount importance. Several factors, either controllable or not, are known to contribute to the development and amplification of the 'surgical stress response'. Therefore, they should be taken into consideration by both surgical practitioners and other medical specialties involved in the management of the traumatised patient.

Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures

Few data are available in the literature regarding fat embolism in cases of bilateral femoral and pathological femoral fractures. The incidence of bilateral femoral fractures ranges from 2-9.5% of the total number of patients with femoral fractures, and they usually occur in high energy trauma and multi-trauma patients. Although injury severity scores tend to underestimate the severity of these injuries, fat embolism seems to occur in increased frequency ranging from 4.8-7.5%. Intramedullary nailing, which is the preferred surgical treatment, triggers a systemic inflammatory response that poses an additional burden to pulmonary function. In addition, the femur is a common site of metastatic bone disease. The treatment of impending and actual pathological fractures is complicated by increased rates of lung damage due to various factors. Fat embolism during treatment--mainly with intramedullary nails--generally seems to range from 0-10%.

[Damage control orthopedics]

BACKGROUND

In the management of patients with multiple injuries, the concept of damage control orthopedics (DCO) is still a matter of controversy. Thus, the clinical value of DCO remains unclear and should be evaluated on an evidence-based level by a review of the current literature.

RESULTS

The work of various authors has demonstrated an association between injury severity and the clinical immuno-inflammatory response and its prognostic relevance regarding organ dysfunction or organ failure and clinical outcome. Research data published by the authors and other investigators have clearly demonstrated an additional inflammatory response caused by surgical trauma which is significantly higher after primary intramedullary fracture treatment than after external fracture stabilization. In contrast, a generally minor inflammatory response seems to be associated with intramedullary nailing for secondary conversion osteosynthesis. Three retrospective cohort studies have shown a reduction of organ dysfunction and an improvement of survival with the DCO approach. Simultaneously, it was demonstrated that primary external fracture fixation and secondary conversion to definite osteosynthesis is not associated with an increased rate of local or systemic complications.

CONCLUSIONS

The advocates of DCO claim that patients with multiple injuries including severe brain and chest injuries as well as those with an unstable cardiopulmonary or circulatory condition are at high risk of developing a severe systemic immuno-inflammatory reaction during early total fracture care. Therefore, they recommend primary minimally invasive external fracture stabilization in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization of the patient in intensive care.

[ARDS after unreamed femoral nailing]

An 18-year-old male patient sustained right-sided femoral and 2nd degree open tibial shaft fractures following a motorcycle accident. Further injuries, and thoracic injury in particular, were excluded clinically and radiologically. Early stabilization of the fractures was achieved by external fixation of the tibia followed by unreamed femoral nailing.Postoperatively, severe deterioration of pulmonary function led to the progressive development of an adult respiratory distress syndrome (ARDS) and necessitated extracorporal membrane oxygenation (ECMO) of the ventilated patient for 89 h. Subsequently, the patient's gas exchange parameters improved allowing extubation 1 week after the accident. Secondary tibia nailing and further recovery of the patient were uneventful.

The immuno-inflammatory response to trauma

The systemic inflammatory response syndrome is a well recognized physiological entity being part of our homeostatic mechanisms. It represents the cascade of inflammatory reactions initiated in the immediate aftermath following trauma reflecting the state of alertness that our body undergoes in order to fight for survival. A variety of inflammatory mediators and cellular elements are involved during this process interacting amongst each other. This allows communication between the different organ systems and thus regulating local and systemic responses. We have just begun to characterize and quantify the immuno-inflammatory response to trauma and this has opened new horizons in the way we understand the pathophysiological response to injury. As our knowledge evolves new therapeutic agents and innovative treatment plans will be developed contributing to increased survival rates in patients with multiple injuries.

Risk factors for respiratory failure following femoral fractures: the role of multiple intramedullary nailing

Controversy exists on the relationship between intramedullary nailing (IMN) and the timing of fixation in the development of respiratory failure (RF) following femoral fractures. The purpose of this study is to identify risk factors for RF and evaluate the role of multiple IMN in the above setting. We prospectively observed 126 consecutive patients with femoral fractures for the development of RF. Twenty-one patients (17%) developed RF. This occurred before fracture fixation in 11 patients and after IMN in 10 patients; five after multiple IMN and five after a single IMN procedure. Patients who underwent multiple IMN demonstrated a significant increase of RF after fracture fixation (5/8,) compared to patients with one IMN procedure (5/114, 4.4%, p<0.001). Stepwise regression analysis identified two independent RF risk factors: thoracic injury and multiple IMN (odds ratios: 40.6 and 25.6, respectively). Thoracic injury and multiple IMN procedures are independent risk factors for RF in patients with femoral fractures, and the combination of the above conditions is highly predictive of the development of RF.

Secondary effects of femoral instrumentation on pulmonary physiology in a standardised sheep model: what is the effect of lung contusion and reaming?

Intramedullary nailing is the treatment of choice for patients with femoral shaft fractures. However, there is an ongoing debate in multiple trauma patients with associated lung contusion when primary or secondary definitive stabilisation of the long bone fracture should be performed, as nailing is thought to play an important role in the pathogenesis of adult respiratory distress syndrome (ARDS). In a standardised sheep model, this study aimed to quantify the development of acute pulmonary endothelial changes, to assess the activation of polymorphonuclear leucocytes (PMNL) and to observe the effects on the coagulation system associated with the reamed nailing procedure. Furthermore, the effect of coexisting lung contusion in an experimental model was evaluated. The animals were randomly assigned to one of four different groups (6 animals/group). In control groups, only a sham operation (thoracotomy) was performed, whereas in study groups, lung contusion was induced prior to femoral stabilisation either by external fixation or reamed femoral nailing. Using bronchoalveolar lavage (BAL) pulmonary permeability changes were quantified and PMNL activation was assessed by chemiluminescence. Additionally PMNL diapedesis and interstitial lung oedema were determined by histological analysis. All animals were sacrificed 4 h after the start of the femoral instrumentation. Without an associated lung injury, instrumentation of the femoral canal with the reamed nailing technique induced a transient increase in pulmonary permeability. In the face of an induced lung contusion, reamed femoral nailing resulted in significant increases in PMNL activation, pulmonary permeability and interstitial lung oedema, compared with external fixation. Without pulmonary contusion, reaming of the femoral canal was associated with a transient increase in pulmonary permeability. This was exacerbated in the presence of lung contusion along with increased PMNL activation. External fixation did not provoke similar changes. The findings of this study support the view that reaming of the femoral canal should be avoided in polytrauma patients with severe chest trauma as it could act as an additional stimulus for adverse outcome. Temporary external fixation appears to be a safe method for fracture stabilisation until inflammatory and coagulatory disturbances after trauma have been normalized.

Traumatic brain injury and stabilisation of long bone fractures: an update

In the era of "damage control orthopaedics", the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate. This review summarises the current evidence available regarding the management of these patients. There appear to be no clear treatment guidelines. Irrespective of the treatment protocol followed, if secondary brain damage is to be avoided at all times, ICP monitoring should be used, both in the intensive care unit and in the operating theatre during surgical procedures, since aggressive ICP management appears to be related to improved outcomes. Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures.

Current concepts of the inflammatory response after major trauma: an update

During the past century explosive developments have taken place in the field of molecular medicine and genetics, vastly expanding our understanding of the normal physiological response to injury. We have been able to characterise specific molecular and cell biological processes and apply some of this knowledge to the treatment of multiply injured patients. Despite the significant steps we have made, there still remains much work to be done in this area. This review article highlights the current concepts of post-traumatic immunological changes and their impact in the management of trauma patients.

Bone formation following intramedullary femoral reaming is decreased by indomethacin and antibodies to insulin-like growth factors

OBJECTIVE

We aimed to: 1). compare rates of in vitro bone formation following reamed and nonreamed intramedullary fixation in a murine model of femoral fracture healing; and 2). examine whether antibodies to insulin-like growth factor (IGF) I, IGF II, or indomethacin (an inhibitor of the inflammatory process) affect bone formation following intramedullary reaming.

DESIGN

Experimental study.

PARTICIPANTS

Twenty-four C57 black mice were randomized to two groups: reamed ( = 12), and nonreamed intramedullary nail insertion ( = 12).

INTERVENTION

In the reamed group, the femoral canals were successively reamed with 30-, 27-, 25-, and 23-gauge stainless steel pins and stabilized with a 27-gauge pin. In mice randomized to the nonreamed group, a 27-gauge pin was inserted. An external three-point bending force created a midshaft transverse femoral fracture. Seven days postsurgery, each mouse was killed, and the right femur was removed. Following pin removal, the callus was minced, the bone marrow was removed, and both were ultracentrifuged at 1200 rpm for 5 minutes. The supernatent was cocultured with 3-day-old murine calvarial cells in culture media. At day 5 of culture, reamed plasma and calvarial cell cocultures were exposed to either 1.0 micro g/mL of anti-IGF I, 1.0 micro g/mL of anti-IGF II, 2 micro M indomethacin, or served as controls (calvarial cells only). The cells were cultured for a total of 21 days.

MAIN OUTCOME MEASUREMENTS

The number of bone nodules was quantified by light microscopy.

RESULTS

Reamed pin insertion resulted in 4.1-fold and 8.9-fold increases in the mean number of bone nodules compared to pins inserted without reaming and controls, respectively (399 +/- 40.0 vs. 97.0 +/- 21.0, < 0.001). The positive effect of intramedullary reaming on bone nodule formation was reversed with the administration of antibodies to IGF I and IGF II. The addition of anti-IGF I or anti-IGF II to calvarial, or osteoblastlike, cells treated with supernatent from the callus and bone marrow of mice with prior intramedullary reaming resulted in significant declines in the mean number of bone nodules ( < 0.001). Specifically, treatment of osteoblastlike cells with anti-IGF I or anti-IGF II resulted in 7.0-fold and 5.4-fold declines in mean bone nodule formation compared to cells without such treatment.

CONCLUSIONS

Intramedullary reaming prior to pin insertion resulted in a significantly greater number of bone nodules than pin insertion only. Antibodies to IGF I, IGF II, and indomethacin reversed the stimulatory effect of reaming on bone nodule formation, suggesting their role in modulating the course of fracture healing following intramedullary reaming.

When should we operate on major fractures in patients with severe head injuries?

BACKGROUND

The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury.

DATA SOURCES

English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture.

CONCLUSIONS

The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place.