Peter V. Giannoudis

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.

Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma.

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Mesenchymal stem cell tissue engineering: Techniques for isolation, expansion and application

Mesenchymal stem cells (MSCs) are undifferentiated multipotent cells which reside in various human tissues and have the potential to differentiate into osteoblasts, chondrocytes, adipocytes, fibroblasts and other tissues of mesenchymal origin. In the human body they could be regarded as readily available reservoirs of reparative cells capable to mobilize, proliferate and differentiate to the appropriate cell type in response to certain signals. These properties have triggered a variety of MSC-based therapies for pathologies including nonunions, osteogenesis imperfecta, cartilage damage and myocardial infarction. The outcome of these approaches is influenced by the methodologies and materials used during the cycle from the isolation of MSCs to their re-implantation. This review article focuses on the pathways that are followed from the isolation of MSCs, expansion and implantation.

Predicting outcome after multiple trauma: which scoring system?

We have undertaken a review of the commonly used scoring systems to identify advantages and possible pitfalls involved in their use. Currently, there is a variety of systems available for scoring trauma severity. Some of them are based on the anatomical description of the injuries, whilst others are based on physiological parameters. The most widely used systems for the purpose of predicting outcome after trauma are based on combined anatomical and physiological parameters. Systems such as the Injury Severity Score (ISS) and the Trauma Injury Severity Score (TRISS) have served some useful purposes and have proved popular over time, but it now seems that there is no ideal scoring system available. The task of incorporating various factors such as pre-existing morbidity, age, immunological differences and different genetic predispositions has made the prospect of creating a universally acceptable and applicable trauma-scoring system extremely arduous, if not impossible. Therefore caution should be exercised when using any of the existing scoring systems until an ideal one becomes available.

The diamond concept - open questions

SUMMARY In the Trauma and Orthopaedic discipline, tissue engineering attempts to convert scientific knowledge into new products and methods of treatment in order to advance the repair, replacement, or regeneration of tissues such as bone, cartilage, tendon and ligament. Currently, tissue engineering strategies are based mainly on cell and tissue-based approaches. We have previously reported that the standard tissue engineering approach to provide solutions for impaired fracture healing, bone restoration and regeneration must include the utilisation of growth factors, scaffolds, mesenchymal stem cells and an optimal mechanical environment (diamond concept). These strategies are already benefiting patients, but as our understanding of the physiological processes increases, a number of questions come up requiring clarification and answers. In this article, important issues which continue to remain obscured are discussed.

Early management of proximal humeral fractures with hemiarthroplasty: A SYSTEMATIC REVIEW

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7 degrees (10 degrees to 180 degrees) and the mean abduction to 92.4 degrees (15 degrees to 170 degrees). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.

Application of BMP-7 to tibial non-unions: A 3-year multicenter experience

SUMMARY The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9-317 mo). Patients had undergone a median of 2 (range 0-11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3-15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute.

Current concepts in the development of heterotopic ossification

H. C. Pape, MD, Professor C. Krettek, ProfessorDepartment of Trauma, Hannover Medical School, Unfallchirurgische Klinic, Hannover 305625, Germany. S. Marsh, MB, BS, House SurgeonTrauma & Orthopaedics, St James’s University Hospital, Leeds, UK. J. R. Morley, FRCS (Ed), Lecturer P. V. Giannoudis, MD, EEC (Ortho), ProfessorTrauma & Orthopaedics, School of Medicine, University of Leeds, St. James’s Hospital University Hospital, Beckett Street, Leeds LS9 7TF, UK.Correspondence should be sent to Professor P. V. Giannoudis.©2004 British EditorialSociety of Bone andJoint Surgerydoi:10.1302/0301-620X.86B6.15356

Hemorrhage in pelvic fracture: who needs angiography?

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Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis

Pelvic fractures are rare but potentially devastating injuries. An understanding of the bony and peripelvic anatomy along with common patterns and the classification of the injury are of critical importance in their management. These form the basis for a general treatment algorithm for pelvic fracture patients. Angiographic embolization is time-consuming and often delayed. Hemodynamic instability with unstable pelvic fracture is therefore best approached with a combination of pelvic emergency stabilization (C-clamp) and surgical hemostasis by pelvic tamponade. This is especially true for critically injured patients in extremis.