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.
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.


CONCLUSIONS
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.


BACKGROUND
ClinicalTrials.gov: NCT00981877.
Department of Orthopedics, Oslo University Hospital, Ullevaal, Norway. i.e.e.husebye@medisin.uio.no
Elisabeth E
EE
Husebye
Torstein
T
Lyberg
Helge
H
Opdahl
Trude
T
Aspelin
Ragnhild O
RO
Støen
Jan Erik
JE
Madsen
Olav
O
Røise
D000058:Accidental Falls / Q000706:statistics & numerical data; D000063:Accidents, Traffic / Q000706:statistics & numerical data; D000293:Adolescent; D000368:Aged; D003167:Complement Activation; D016207:Cytokines / Q000097:blood; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D005342:Fibrinolysis; D005594:Fracture Fixation, Intramedullary; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000453:epidemiology; D009104:Multiple Trauma / Q000628:therapy*; D010100:Oxygen / Q000097:blood; D011446:Prospective Studies; D018746:Systemic Inflammatory Response Syndrome / Q000453:epidemiology; D014655:Vascular Resistance / Q000502:physiology; D055815:Young Adult
D016207:Cytokines; D010100:Oxygen