H.-C. Pape

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group.

BACKGROUND Damage control orthopedic surgery has recently been advocated for the management of femoral shaft fractures in severely injured patients because surgical procedures were found to represent a second-hit phenomenon regarding the operative burden. It has been attempted to determine the operative burden by means of proinflammatory cytokines. In this study in clinically stable patients with multiple injuries, the effects induced by different types of primary fracture stabilization on the systemic release of proinflammatory cytokines were evaluated. METHODS This was a prospective, randomized, multicenter intervention study. Inclusion criteria were long bone shaft fracture of the lower extremity; age 18 to 65 years; Injury Severity Score > 16 or more than three extremity injuries (Abbreviated Injury Scale [AIS] score of 2 or more) in association with another injury (AIS score of 2 or more); and thoracic AIS score < 4. After informed consent, randomization for the treatment of the femoral shaft fracture was performed at admission. Groups were as follows: group I degrees FN (primary, < 24 hours) intramedullary nailing, and group DCO (DCO, I degrees ex.fix.) damage control orthopedic surgery and external fixation. In DCO patients, measurements were also performed at the time of conversion to the intramedullary procedure (DCO II degrees FN). Parameters included clinical parameters and complications (acute respiratory distress syndrome, multiple organ failure, sepsis). From serially sampled central venous blood, the perioperative concentrations of interleukin IL-1, IL-6, and IL-8 were determined. RESULTS Thirty-five patients were included (I degrees FN, n = 17; DCO, n = 18). In I degrees FN-patients, a perioperative increase of IL-6 levels was measured (preoperatively, 55 +/- 33 pg/dL; 24 hours postoperatively, +254 +/- 55 pg/dL; p = 0.03), which was not found in subgroup DCO I degrees Ex.fix.: preoperatively, 71 +/- 42 pg/dL; 24 hours postoperatively, 68 +/- 34 pg/dL; not significant [NS] or in group DCO II degrees FN: preoperatively, 36 +/- 21 pg/dL; 24 hours postoperatively, +39 +/- 25 pg/dL; NS. Likewise, in I degrees FN patients, a perioperative increase of IL-8 levels was measured only at the 7-hour time point (preoperatively, 35 +/- 29 pg/dL; 7 hours postoperatively, 95 +/- 23 pg/dL; p < 0.05), which was not found in group DCO I degrees Ex.fix.: preoperatively, 43 +/- 38 pg/dL; 24 hours postoperatively, 69 +/- 39 pg/dL; NS or in group DCO II degrees FN: preoperatively, 25 +/- 20 pg/dL; 24 hours postoperatively, 36 +/- 29 pg/dL; NS. There were no differences in the complication rate in terms of acute respiratory distress syndrome, sepsis, or multiple organ failure. CONCLUSION In this prospective, randomized, multicenter study, a sustained inflammatory response was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. These findings may become clinically relevant in patients at high risk of developing complications. It confirms previous studies in that damage control orthopedic surgery appears to minimize the additional surgical impact induced by acute stabilization of the femur.

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

&NA; 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, lifesaving measures are pivotal, followed by a damage control approach to their injuries.

The importance of cytokines in the posttraumatic inflammatory reaction

ZusammenfassungVeränderungen der Immunantwort nach Polytrauma, posttraumatischer Sepsis und operativen Eingriffen stellen eine physiologische Reaktion des Organismus zur Aufrechterhaltung der Homöostase dar. Das Ausmaß dieser immunologischen Reaktionen korreliert dabei mit der Schwere des Gewebeschadens sowie dem Ausmaß der Hämorrhagie und Ischämie. Zytokine werden als integraler Bestandteil der Immunantwort angesehen.Die lokale Freisetzung von pro- und antiinflammatorischen Zytokinen nach Polytrauma kann systemische Organreaktionen beeinflussen und damit den klinischen Verlauf maßgeblich beeinträchtigen. Bei einem Überwiegen der proinflammatorischen Zytokine kommt es zu einer systemischen Entzündungsreaktion („systemic inflammatory response syndrome“, SIRS), wohingegen eine Überproduktion antiinflammatorischer Mediatoren in einer Immunsuppression mit einem erhöhten Risiko infektiologischer Komplikationen resultieren kann. Sowohl das SIRS als auch die Immunsuppression scheinen bei der Entwicklung eines „Multiorgandysfunktionssyndroms“ (MODS) eine signifikante Rolle zu spielen.Tumornekrosefaktor-α (TNF-α), Interleukin–1β (IL-1β), Interleukin-6 (IL-6) and Interleukin-8 (IL-8) stellen die wesentlichen proinflammatorischen Zytokine für den posttraumatischen Verlauf dar. Diese Zytokine vermitteln eine Vielzahl von teilweise auch üperlappenden und additiven Effekten. TNF-α and IL-1β sind frühe Regulatoren der Immunantwort, und beide können die Freisetzung sekundärer Zytokine, wie IL-6 und IL-8 induzieren. Interleukin-10 (IL-10) ist ein antiinflammatorisches Zytokin, das die Synthese proinflammatorischer Mediatoren reduziert. Andere wichtige antiinflammatorische Mediatoren sind lösliche TNF-Rezeptoren (TNF-RI und -RII) und der IL-1-Rezeptorantagonist (IL-1ra), die mit den Wirkungen des TNF-α and IL-1β interferieren.Die frühe Einschätzung der Prognose und des klinischen Zustands der polytraumatisierten Patienten stellt sich als äußerst schwierig dar. In einer Vielzahl von Studien sind daher Zytokinkonzentrationen im posttraumatischen Verlauf bestimmt worden, um prognostische Marker für das Outcome der Patienten zu identifizieren. Des Weiteren wurden ebenso systemische Zytokinspiegel bestimmt, um den günstigsten Zeitpunkt für den chirurgischen Eingriff nach einem Polytrauma festzulegen und das Ausmaß des Eingriffs zu quantifizieren. Das Ziel dieser Arbeit ist es, den aktuellen Wissensstand bezüglich der Assoziation zwischen posttraumatischen Zytokinsynthese und der Entwicklung von Komplikationen zusammenzufassen. Ein verbessertes Verständnis dieser Mechanismen könnte zur Erstellung neuer diagnostischer und therapeutischer Behandlungsstrategien im klinischen Alltag beitragen.AbstractAlterations in the immune response after multiple trauma, posttraumatic sepsis and surgery are recognized as physiological reactions of the organism to restore homeostasis. The level of these immunological changes correlates with the degree of tissue damage as well as with the severity of haemorrhage and ischaemia. Cytokines are known to be integral components of this immune response. The local release of pro- and antiinflammatory cytokines after severe trauma indicates their potential to induce systemic immunological alterations. It appears that the balance or imbalance of these different cytokines partly controls the clinical course in these patients. Overproduction of either proinflammatory cytokines or antiinflammatory mediators may result in organ dysfunction. Whereas predominance of the proinflammatory response leads to the systemic inflammatory response syndrome (SIRS), the antiinflammatory reaction may result in immune suppression with an enhanced risk of infectious complications. Systemic inflammation, as well as immune suppression, are thought to play a decisive role in the development of multiple organ dysfunction syndrome (MODS).The major proinflammatory cytokines involved in the response to trauma and surgery include tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6 and IL-8. These cytokines, which are predominantly produced by monocytes and macrophages, mediate a variety of frequently overlapping effects, and their actions can be additive. TNF-α and IL-1β are early regulators of the immune response and both induce the release of secondary cytokines, such as IL-6 and IL-8. IL-10 is an antiinflammatory cytokine which reduces the synthesis of proinflammatory mediators. Other important antiinflammatory mediators are soluble TNF receptors and the IL-1 receptor antagonist, which interfere with the effects of TNF-α and IL-1β.Early evaluation of the prognosis of polytraumatized patients and assessment of their clinical status is known to be difficult. Therefore, in several clinical studies, cytokine levels during the posttraumatic course have been determined with the aim of finding predictive markers of patient outcome. The purpose of this review was to highlight our current knowledge on the interaction of posttraumatic immune reactivity and the development of complications. A better understanding of these mechanisms might lead to the introduction of preventive and therapeutic strategies into clinical practice.Alterations in the immune response after multiple trauma, posttraumatic sepsis and surgery are recognized as physiological reactions of the organism to restore homeostasis. The level of these immunological changes correlates with the degree of tissue damage as well as with the severity of haemorrhage and ischaemia. Cytokines are known to be integral components of this immune response. The local release of pro- and antiinflammatory cytokines after severe trauma indicates their potential to induce systemic immunological alterations. It appears that the balance or imbalance of these different cytokines partly controls the clinical course in these patients. Overproduction of either proinflammatory cytokines or antiinflammatory mediators may result in organ dysfunction. Whereas predominance of the proinflammatory response leads to the systemic inflammatory response syndrome (SIRS), the antiinflammatory reaction may result in immune suppression with an enhanced risk of infectious complications. Systemic inflammation, as well as immune suppression, are thought to play a decisive role in the development of multiple organ dysfunction syndrome (MODS). The major proinflammatory cytokines involved in the response to trauma and surgery include tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6 and IL-8. These cytokines, which are predominantly produced by monocytes and macrophages, mediate a variety of frequently overlapping effects, and their actions can be additive. TNF-alpha and IL-1beta are early regulators of the immune response and both induce the release of secondary cytokines, such as IL-6 and IL-8. IL-10 is an antiinflammatory cytokine which reduces the synthesis of proinflammatory mediators. Other important antiinflammatory mediators are soluble TNF receptors and the IL-1 receptor antagonist, which interfere with the effects of TNF-alpha and IL-1beta.Early evaluation of the prognosis of polytraumatized patients and assessment of their clinical status is known to be difficult. Therefore, in several clinical studies, cytokine levels during the posttraumatic course have been determined with the aim of finding predictive markers of patient outcome. The purpose of this review was to highlight our current knowledge on the interaction of posttraumatic immune reactivity and the development of complications. A better understanding of these mechanisms might lead to the introduction of preventive and therapeutic strategies into clinical practice.

Severe and multiple trauma in older patients; incidence and mortality

OBJECTIVE To examine the differences between severely injured older patients (aged over 65 years) compared with similarly injured younger adults in terms of incidence, inpatient mortality and factors predicting outcome. METHODS Data prospectively entered into the Trauma Audit and Research Network (TARN) database from our level I trauma unit over a 5-year period were retrospectively examined, with 3172 patients included in the final analysis. RESULTS Older patients accounted for 13.8% of those with severe injuries (Injury Severity Score 16 or more) and almost 2% of our trauma admissions overall. High energy injuries were responsible for the majority of these injuries though relatively minor trauma became increasingly important in older patients. Mortality rates in the older patients were more than twice those seen in the adult population (19% in the under 40s to almost 50% in the over 75s). Age, Injury Severity Score and Glasgow Coma Score continued to be predictive of mortality in older patients but other factors relevant in younger adults were not. CONCLUSIONS Patients in the older group without physiological derangement on admission were still at a relatively high risk of inpatient mortality. This was in contrast to the younger patients, suggesting that it might be more difficult to predict which older patients might benefit from more aggressive monitoring or treatment. Despite increased mortality in older patients, significant survival rates were achieved even in the oldest. Active treatment should not be withdrawn on the basis of age alone.

Percutaneous fixation of the pelvic ring: AN UPDATE

With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution.

Objective To investigate the incidence and distribution of heterotopic ossifications in patients with blunt multiple trauma with and without associated head trauma. Design Retrospective. Setting Level I trauma center. Patients Patients were included if they were treated between August 1987 and September 1995. Inclusion criteria included age between 16 and 65 years, injury severity score (ISS) of more than twenty points, and clinical reexamination performed more than three years after the initial injury. Methods The records of each patient were abstracted to determine the ISS, the Glasgow coma score (GCS), and parameters describing the course of intensive care. For each patient, a reexamination was performed between January and September 1998. Patients with multiple trauma and associated head trauma (Group PTH, polytrauma, GCS less than nine points, and head computed tomography scan abnormalities) and patients with multiple trauma without associated head trauma (Group PT, polytrauma, GCS of at least nine points, and normal head computed tomography scans) were compared. A clinical reexamination was performed to evaluate functional outcome. Results Sixty-four patients belonged to Group PTH and 124 patients belonged to Group PT. There were no differences in the age (Group PTH, 28.9 ± 1.6 years; Group PT, 29.2 ± 2.1 years) or severity of injury (ISS Group PTH, 31.0 ± 5.3 points; ISS Group PT, 33.0 ± 6.1 points) among patients in the two groups. The overall incidence of periarticular heterotopic ossification was comparable in patients with multiple trauma with and without head injury (Group PTH, 30 of 64 patients [46.9 percent]; Group PT, 53 of 124 patients [42.7 percent]). The duration of ventilation was significantly higher in Group PT (Group PTH, 9.3 ± 2.4 days; Group PT, 14.2 ± 3.1 days;p = 0.02). In the subgroups in which heterotopic ossification developed (PT-HO and PTH-HO), patients in PT-HO had a significantly higher incidence of heterotopic ossification, as compared with patients in PTH-HO at initially uninjured joints (Group PTH-HO, 1 of 30 patients [3.3 percent]; Group PT-HO, 10 of 53 patients [18.9 percent];p = 0.04). Conclusions There was a high incidence of heterotopic ossification around those joints that were initially classified as uninjured in patients without head trauma. This finding suggests that pathogenic pathways independent of head trauma, such as long-term ventilation, play a main role. Causative factors for the development of heterotopic ossification at initially uninjured joints in long-term ventilated patients with multiple trauma with and without head trauma remain to be elucidated.

The genetic predisposition to adverse outcome after trauma

Technological advances and shorter rescue times have allowed early and effective resuscitation after trauma and brought attention to the host response to injury. Trauma patients are at risk of progressive organ dysfunction from what appears to be an uncontrolled immune response. The availability of improved techniques of molecular diagnosis has allowed investigation of the role of genetic variations in the inflammatory response to post-traumatic complications and particularly to sepsis. This review examines the current evidence for the genetic predisposition to adverse outcome after trauma. While there is evidence supporting the involvement of different polymorphic variants of genes in determining the post-traumatic course and the development of complications, larger-scale studies are needed to improve the understanding of how genetic variability influences the responses to post-traumatic complications and pharmacotherapy.

[Voluminous bone graft harvesting of the femoral marrow cavity for autologous transplantation. An indication for the"Reamer-Irrigator-Aspirator-" (RIA-)technique].

ZusammenfassungAutologe Knochentransplantate haben aufgrund ihrer hervorragenden osteoinduktiven, osteogenetischen sowie osteokonduktiven Eigenschaften biomechanische Vorteile gegenüber künstlichen Knochenpräparaten. Auch im Vergleich zu Kadavertransplantaten oder Xenotransplantaten sind diese aufgrund fehlender immunologischer Abstoßung oder Übertragung infektiöser Erkrankungen vorteilhaft. Die limitierte Verfügbarkeit der autologen Knochenspongiosa bedingt es jedoch, bei großen Knochendefekten auf oben genannte Knochenersatzstoffe zurückzugreifen.Seit kurzem ist eine neue Technik verfügbar, welche die Gewinnung größerer Volumina an autologer Knochenspongiosa erlaubt. Wir berichten über die Verwendung der „Reamer-Irrigator-Aspirator-“ (RIA-)Technik zur Gewinnung von Knochenspongiosa bei einem Patienten mit Pseudarthrose bei großer Defektzone des proximalen Femurs. Hierzu wurde das kontralaterale Femur in gesamter Länge aufgebohrt und die gewonnene Knochenspongiosa im Bereich der Pseudarthrose angelagert. Klinisch und radiologisch zeigte sich im Verlauf eine Ausheilung der Pseudarthrose ohne Entnahmemorbidität.AbstractDue to their excellent osteoinductive, osteogenetic, and osteoconductive properties, autologous bone grafts possess biomechanical advantages over synthetic bone substitutes. Furthermore, unlike cadaveric allografts and xenografts, they carry no risk of immunogenic response or transmission of infectious diseases. However, the limited availability of autologous bone grafts requires the use of the above-mentioned bone substitutes for management of large bone defects.The“Reamer-Irrigator-Aspirator-” (RIA-)technique may present an alternative method for harvesting a larger volume of autologous bone graft as compared with conventional harvesting procedures. We report on intramedullary reaming by the RIA technique to obtain autologous bone graft for a nonunion of the proximal femur. The contralateral femur was reamed and the bone graft was applied to the nonunion. The patient showed clinical and radiological healing of the nonunion without donor site complications.