title: Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden.
abstract: OBJECTIVE
  To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures.
  
  
  METHODS
  Prospective, cohort study.
  
  
  METHODS
  Level I university trauma center.
  
  
  METHODS
  We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups.
  
  
  METHODS
  In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized.
  
  
  RESULTS
  From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively.
  
  
  CONCLUSIONS
  Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.
authors.affiliation: Department of Clinical Immunology, Hannover Medical School, Germany.
authors.forename: H C
authors.initials: HC
authors.lastname: Pape
authors.forename: R E
authors.initials: RE
authors.lastname: Schmidt
authors.forename: J
authors.initials: J
authors.lastname: Rice
authors.forename: M
authors.initials: M
authors.lastname: van Griensven
authors.forename: R
authors.initials: R
authors.lastname: das Gupta
authors.forename: C
authors.initials: C
authors.lastname: Krettek
authors.forename: H
authors.initials: H
authors.lastname: Tscherne
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000276:immunology / Q000378:metabolism / Q000601:surgery; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects; D001778:Blood Coagulation Disorders / Q000209:etiology* / Q000276:immunology / Q000378:metabolism*; D005260:Female; D005264:Femoral Fractures / Q000150:complications / Q000276:immunology / Q000378:metabolism* / Q000601:surgery*; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects*; D005596:Fractures, Closed / Q000150:complications / Q000276:immunology / Q000378:metabolism* / Q000601:surgery*; D006801:Humans; D007249:Inflammation / Q000209:etiology* / Q000276:immunology / Q000378:metabolism*; D015850:Interleukin-6 / Q000097:blood; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000378:metabolism; D011446:Prospective Studies; D011498:Protein Precursors / Q000378:metabolism; D011516:Prothrombin / Q000378:metabolism; D012121:Respiration, Artificial / Q000009:adverse effects; D012307:Risk Factors; D014409:Tumor Necrosis Factor-alpha / Q000378:metabolism; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000276:immunology / Q000378:metabolism* / Q000601:surgery*
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; D015850:Interleukin-6; D010446:Peptide Fragments; D011498:Protein Precursors; D014409:Tumor Necrosis Factor-alpha; C036309:fibrin fragment D; C029733:prothrombin fragment 1; C044183:prothrombin fragment 2; D011516:Prothrombin