Renate Wildburger

Basic fibroblast growth factor (BFGF) immunoreactivity as a possible link between head injury and impaired bone fracture healing

Healing of fractures of long bones or large joints is often accelerated in patients with severe traumatic brain injury (TBI). However, in these patients an early fracture healing is accompanied by hypertrophic callus formation or heterotopic ossifications which might even result in an ankylosis of the affected joints. It seems that enhanced osteogenesis in patients suffering from TBI could be caused by some humoral factors, since the sera of these patients strongly promote the growth of osteoblast cells in vitro. However, humoral growth promoting factors which could perhaps induce enhanced osteogenesis are not yet identified. Hence, the aim of this study was to analyse if basic fibroblast growth factor (bFGF) could be related to the phenomenon of enhanced osteogenesis, since bFGF stimulates the growth of osteoblasts in vitro and could be found both in the brain and the bone tissue. For that purpose the values of bFGF immunoreactivity were determined in the sera of patients with TBI and bone fractures (n = 8) as well as in the sera of patients with either TBI alone (n = 10) or bone fractures alone (n = 7), during a period of three months after injury. Quantification of the bFGF immunoreactivity was done using the ELISA based on monoclonal antibodies raised against the recombinant human bFGF. The bFGF immunoreactivity values obtained were also compared with the values determined in the sera of normal, healthy persons (n = 9). In the group of patients with bone fractures alone only a transient increase of bFGF immunoreactivity (threefold above the normal values) was observed in the second week after injury. A similar increase of the values of bFGF immunoreactivity was also determined in the sera of patients with TBI only, but it lasted longer (from the 1st until the 7th to 8th week after injury). In the case of patients with TBI and bone fractures a specific pattern of post-traumatic dynamic change of the values of serum bFGF immunoreactivity was observed. Namely, the increase of bFGF immunoreactivity (up to seven-fold above the normal values) was determined even during the first week after injury. Afterwards, periods of high values of bFGF immunoreactivity observed during the 2nd, 4th and the 7-10th weeks after injury were interrupted by sudden decreases even to the normal values (during the 3rd and the 5-6th week after injury).(ABSTRACT TRUNCATED AT 400 WORDS)

Supraintercondylar fractures of the distal humerus: results of internal fixation.

Operative treatment is considered to be the primary method of treatment for supraintercondylar fractures of the distal end of the humerus. Anatomical reduction and stable fixation of the fracture allows for early postoperative functional treatment and, subsequently, better results than other methods. Two series of patients with supraintercondylar fractures of the humerus, one from 1969 to 1980, and the second from 1981 to 1988, are presented. Although these series do not differ widely in their final outcomes, certain philosophies and operative techniques did change for the better.

Comparison of the values of basic fibroblast growth factor determined by an immunoassay in the sera of patients with traumatic brain injury and enhanced osteogenesis and the effects of the same sera on the fibroblast growth in vitro.

In patients with severe traumatic brain injury, the early healing of fractures is accompanied by hypertrophic callus formation or heterotopic ossifications, which might even result in ankylosis of the affected joints. Analysis of the sera of patients with traumatic brain injury revealed post-traumatic dynamic changes of basic fibroblast growth factor immunoreactivity, similar to those observed during fracture healing associated with enhanced osteogenesis. The aim of this study was to determine whether such changes in basic fibroblast growth factor concentrations could be related to the phenomenon of enhanced osteogenesis. Basic fibroblast growth factor immunoreactivity was determined (using an IEMA kit) in the sera of patients with traumatic brain injury and bone fractures (n = 8) and in the sera of patients with either traumatic brain injury alone (n = 10) or bone fractures alone (n = 7), and the effects of these sera on L929 fibroblast growth were analysed in vitro. The results did not prove a causative relationship between the changes of basic fibroblast growth factor immunoreactivity and in vitro growth promoting effects of the sera. However, it is apparent that, in addition to changes in the growth-promoting activity and basic fibroblast growth factor concentration of serum, other as yet unknown post-traumatic changes can cause enhanced osteogenesis.

Post-traumatic dynamic change of carboxyterminal propeptide of type I procollagen, alkaline phosphatase and its isoenzymes as predictors for enhanced osteogenesis in patients with severe head injury

Patients suffering from severe head injury and fractures of long bones or large joints often show enhanced osteogenesis, with hypertrophic callus formation and/or heterotopic ossifications. The advantage of this phenomenon is early consolidation of the fractures. An extreme disadvantage is extensive periarticular calcification, resulting in complete ankylosis of the affected joint. In spite of numerous efforts aimed at clarifying the way in which severe head injury can influence osteogenesis at a distant site, this phenmenon is still not understood. The process, once started seems irreversible, but if diagnosed in time, could be prevented with non-steroid anti-inflammatory drugs that inhibit development of heterotopic ossifications. The major prerequisite for testing this possibility is to define parameters of an early diagnosis of enhanced osteogenesis. Thus, the aim of this study was to test whether serum values of some parameters related to bone regeneration could allow an early prediction of enhanced ossification following bone fracture in patients with severe head injury. Samples of sera were obtained from three groups of injured patients: fractures of long bones or large joints only (n=6), severe head injury only (n=8), severe head injury and fractures of long bones and large joints (n=7) and from a group of apparently healthy volunteers (n=10). The values for alkaline phosphatase (ALP), the bone isoenzyme, and the carboxy terminal propeptide of type I procollagen (PICP) were significantly higher (5–20 times as high) in patients with severe head injury and bone or joint fractures than in any other group. Significantly increased concentrations of PICP were already found in the 1st week after injury, and those of ALP and of the bone isoenzyme increased during the 2nd week after injury. Results show that these parameters are helpful for an early diagnosis of enhanced osteogenesis and heterotopic ossifications in patients with severe head injury and bone fractures. Further studies are necessary to verify these findings, while analysis of reasons for the specific patterns of dynamic change of these parameters could lead to better understanding of the mechanisms underlying the uncontrolled bone formation.

Interbody fusion of the lower cervical spine: a dangerous surgical method?

ZusammenfassungDie retrospektive Analyse unserer 175 ventralen Spondylodesen der unteren Halswirbelsäule hat den Zweck, Gefahren aufzuzeigen, die bei dieser sehr bewährten Operationsmethode an unserer Klinik auftraten. Im Zeitraum von 1976–1990 wurden 175 Patienten nach dieser Technik operiert, darunter fanden wir 150 Frakturen, Luxationsfrakturen und diskoligamentäre Instabilitäten. In 25 Fällen bestand die Indikation aus Tumoren und Metastasen, entzündlichen oder degenerativen Erkrankungen und chronischen Instabilitäten bei Zustand nach Laminektomien. Der Häufigkeit nach traten folgende intra- und postoperative Komplikationen auf: 4 Infekte, 3 postoperative Redislokationen, 2 ausgedehnte Metallockerungen, 1 einseitige Läsion der A. vertebralis, 1 Pseudarthrose mit Plattenbruch, 1 postoperative radikuläre Störung und 1 sekundär notwendige Erweiterung der ventralen Spondylodese nach primär nicht erkannter Zweisegmentläsion.SummaryOur follow-up study of 175 cases of interbody fusion of the lower cervical spine was conducted to show the complications that occurred in our department with what is considered to be a tried and tested method. From 1976 to 1990, 175 patients were treated with this method. These 175 cases included 150 fractures and/or dislocations. The indications for surgery in the remaining 25 cases were tumors and metastases, inflammatory or degenerative diseases and chronic instabilities following laminectomy. The following complications were seen: 4 cases of infection, 3 postoperative redislocations, 2 cases of extensive loosening of metal, 1 unilateral lesion of the vertebral artery, 1 nonunion with plate fracture, 1 post-operative radicular disorder in an otherwise neurologically normal patient, and 1 secondary extension of the interbody fusion required after failure to recognize a two-segment lesion.

Unstable fractures of the upper thoracic spine

ZusammenfassungInstabile Frakturen der oberen Brustwirbelsäule sind wegen der hohen Inzidenz an Begleitverletzungen und Rückenmarkläsionen eine therapeutische Herausforderung. Diese Kasuistik konzentriert sich auf die operative Therapie solcher Verletzungen. Wir präsentieren 9 Patienten mit instabilen Verletzungen der oberen Brustwirbesäule, nach der Einteilung von Magerl et al. handelt es sich um 7 Typ C- und 2 Typ B-Verletzungen. 8 Patienten hatten komplette Querschnittsläsionen, bei 1 Patient bestand eine unauffällige neurologische Situation. Alle Patienten wiesen Begleitverletzungen auf, 9 hatten Rippenfrakturen, 3 ein frakturiertes Sternum und 3 einen schweren Hämatothorax. Alle wurden operiert; 6 alleinige dorsale Fusionen, 2 alleinige ventrale Fusionen nach Thorakotomien wegen stark blutender rupturierter Interkostalarterien und eine kombinierte Fusion nach fehlgeschlagener posteriorer Stabilisierung wurden ausgeführt. Die Behandlung solcher Patienten sollte individuell gestaltet werden, abhängig von den Begleitverletzungen, vom Blutverlust aufgrund von frakturierten Rippen und rupturierten Gefäßen und vom Schmerz, verursacht durch einen instabilen Thorax. Im allgemeinen bevorzugen wir den dorsalen Zugang bei instabilen Verletzungen der Brustwirbelsäule.AbstractUnstable fractures of the upper thoracic spine are a therapeutic challenge because of the high rate of associated injuries and frequent occurrence of spinal cord lesions. This study focuses on the operative treatment of these injuries. We present nine patients with unstable injuries of the upper thoracic spine. According to the classification of Magerl et al., there are seven type C and two type B fractures. Eight patients had complete transverse lesions of the cord and one had no evidence of spinal cord injury. All patients presented associated injuries: nine patients had fractured ribs, three a fractured sternum and three a severe haemothorax. All underwent operative treatment: six posterior fusions only, two anterior interbody fusions only after thoractotomy owing to severe bleeding from ruptured intercostal arteries, and one a combined fusion after failure of posterior fusion. The treatment of these patients should be individualized, depending on the associated injuries, loss of blood owing to fractured spine and ruptured vessels and depending on the back pain resulting from an unstable thorax. In general, we prefer the posterior approach to unstable fractures of the upper thoracic spine.

PMN-related parameters for the monitoring of wound healing in traumatology.

SummaryIn the search for objective methods to monitor the course of wound healing, the proteinase PMN elastase (n=56 pat.), the lipid peroxidation product malondialdehyde (MDA) (n=18 pat.), and polymorphonuclear neutrophil granulocytes (PMN) migratory behaviour were measured [1, 6, 7, 11]. This “stimulated PMN-locomotion” was quantified by a new PMN migration filter assay (n=10 pat.) [2]. We determined the clinical course during “per primam (pp)” wound healing (group 1), “pp” wound healing with secondary inflammatory disease (group 2), manifestation of a bacterial wound infection during healing-“per secundam (ps)” (group 3) and manifest wound infection (“ps”) at the time of admission (group 4).In group 1 PMN elastase returned to normal values on the 10th postsurgical day. Median values in group 3 reflected a highly significant difference (p<0,01) on day 4 and 5 compared with group 1. In group 2 and 4 medians reflected consistent high values without reaching normal ranges throughout. MDA did not exceed the normal range in group 1, in group 3 low levels persisted, and in group 4 a recurring increase was noticed.The total migration index median (TMI) in Group I, which quantifies the percentage of stimulated PMN, reflected its highest value immediately post-surgically and dropped to the lowest on the 13th postsurgical day (decrease by 54%). The mean invasion depth (T/2), a parameter of PMN distribution, showed only slight variation with time. In a group 3-patient, T/2 reflected a maximal migratory stimulation on day 6, 4 days before clinical infection signs could be noticed; then it dropped to the lowest on day 10. This decrease probably reflects a PMN behavioural change from migration to phagocytosis [9].RésuméLa protéinase PMN élastase (n=56 malades), le produit de la peroxidation lipidique malon dialdehyde (MDA) (n=18) aussi bien que la migration des granulocytes neutrophiles polymorphonucléaires (PMN) ont été mesurées dans le cadre de la recherche de méthodes pour surveiller le cours de la cicatrisation. Cette “PMN Locomotion simulée” a été quantifiée par un nouvel essai pour la migration des PMN (n=10). Nous avons déterminé le cours clinique de la cicatrisation dans un groupe de cicatrisation “per primam” (pp) (groupe 1), “pp” cicatrisation et surinfection secondaire (groupe 2), surinfection bactérienne durant la cicatrisation “per secundam” (ps) (groupe 3) et infection initiale au moment de l’admission (groupe 4).Dans le groupe 1 l’élastase PMN est retournée à des valeurs normales au dixième jour après l’intervention. Les valeurs moyennes du groupe 3 ont montré une différence significative (p<0,01) le quatrième et cinquième jour par rapport au groupe 1. Dans les groupes 2 et 4 les moyennes ont montré des valeurs élevées permanentes sans atteindre des valeurs normales. MDA est resté dans les limites de la normale dans le groupe 1; dans le groupe 3 les valeurs sont restées basses et dans le groupe 4 on a pu constater un accroissement répété des valeurs.Dans la migration PMN (concernant le groupe 1), la moyenne de l’index total de migration (TMI), qui mesure le pourcentage de PMN stimulé, présente la valeur la plus élevée immédiatement après l’intervention pour tomber au plus bas le treizième jour après l’intervention (diminution de 54%). La profondeur moyenne d’invasion (T/2), un paramètre de distribution de PMN, a montré seulement une légère variation avec le temps. Avec un malade du groupe 3, T/2 a montré une stimulation migratoire maximale le sixième jour, 4 jours avant que des signes cliniques d’infection aient pu être remarqués; puis T/2 est tombé au plus bas le dixième jour. cette diminution de T/2 reflète probablement des conditions de PMN changeant de la migration à la phagocytose.

Polymorphonuclear leucocyte migration response in uneventful wound healing following trauma surgery

In a study of the clinical importance of polymorphonuclear granulocytes (PMN) for the monitoring of wound healing we investigated the postsurgical course of nine patients all of whom had undergone trauma surgery and had no wound complications. The “stimulated random PMN locomotion” was evaluated by a new migration filter device which preserves the cells in their genuine priming state, simulating in vivo conditions. The percentage of all activated PMN, expressed by the total migration index (TMI) reflected the highest median immediately after surgery (zmax = 30.1 %) and dropped to the lowest value on day 13 (zmax = 13.9%). The mean invasion depth (T/2) of the cells along the migration distance into the filter showed only slight variations over time. The neutrophil migration activity (NMA), described by T/2 and TMI, behaved in a similar way to TMI. In studying physiological healing, preliminary results indate that TMI, which expresses PMN activation, is an efficient tool in the postoperative monitoring of patients, and might in the future serve as a basis for an early warning system for wound healing complications.

Dorsal stabilization of thoracolumbar spinal instability

Many unstable fractures and fracture dislocations of the lower thoracic and the lumbar spine are treated operatively. Internal fixation is mostly done via a posterior approach, anchoring the screws in the pedicles of the vertebrae. In the Traumatology Section of the Department of Surgery, Graz University, three different implantation systems have been employed in recent years. Sixty of all the patients operated on were available for follow-up an average of 36 months after operation. We compared them with respect to type of implant, paying special attention to any loss of reduction.

MR findings and treatment of four patients with cervical spinal cord injuries

We report the value of magnetic resonance imaging (MRI) in the assessment of cervical spine injuries with neurological deficit and the implications such information might have in the management of acute spinal cord injuries. Four cases are presented that were neurologically classified according to the 5-step Frankel scale. Three patients presented with an intramedullary hemorrhage. One of these patients showed additional mild compression of the spinal cord due to a retropulsed bony fragment, and one an epidural hematoma without any evidence of spinal cord compression. The fourth patient had compression of the spinal cord secondary to bony fragments from a burst fracture. We carried out two decompressions of the spinal cord by removing the disc and bony fragments. In addition, we performed two interbody fusions. In one patient we applied a halo vest, and in one case surgical intervention was not necessary after MRI assessment.ZusammenfassungDas Ziel dieses Kasuistik ist es, anhand von 4 Fallbeispielen zervikaler Rückenmarkverletzungen die möglichen therapeutischen Konsequenzen zu erläutern, die sich aus der Magnetresonanztomographie ergeben. Die neurologischen Defizite wurden nach der 5stufigen Frankel-Klassifikation eingeteilt. Bei 3 Verletzten wurden intramedulläre Hämatome dargestellt, wobei zusätzlich eine Kompression von außen in Form eines Knochenfragments und einmal ein epidurales Hämatom ohne Kompression bestanden. Ein Patient wurde wegen neurologischer Ausfälle von einem auswärtigen Krankenhaus direkt der Magnetresonanztomographie zugewiesen, wobei sich als Ursache eine Spinalkanalstenose bei einer Berstungsfraktur zeigte. Therapeutisch war 2mal eine Rückenmarkdekompression mit ventraler Spondylodese und einmal die Montage eines Halofixateurs erforderlich. Bei einem Patienten konnte aufgrund der Magnetresonanztomographie auf jegliche chirurgische Intervention verzichtet wurden.