Session V - Polytrauma
*The Impact of Fracture Fixation on the Systemic Cytokine Response in Stable Polytrauma Patients - A Prospective Randomized Analysis of Intramedullary Instrumentation versus Damage Control for Femoral Fractures
Hans-Christoph Pape, MD1; Kai M. Grimme, MD1; Peter V. Giannoudis, MD, FRCS1; Andrea L. Sott, MD2; Frank Hildebrand, MD1; Christian Krettek, MD, FRACS1;
Purpose: Primary fracture stabilization is a pivotal goal in polytraumatized patients, but the impact of primary surgery also has to be considered. Recently, damage control orthopaedics (DCO) has been advocated for patients at high risk of complications. The systemic burden induced by a surgical procedure can be determined by measuring systemic cytokine levels. We compared the influence of different types of initial surgical procedures on the systemic inflammatory response in patients with blunt multiple injuries.
Methods: We carried out a prospective randomized trial in two institutions from November 2001 to 2002. The inclusion criteria included long bone shaft fracture of the lower extremity, age of 18 to 65 years, total injury severity (ISS) score of more than 16 points or at least 3 extremity injuries of Abbreviated Injury Score (AIS) of 2 or more in association with an injury of another body region with an AIS of 2 or more, and a thoracic AIS of less than 4 points. All patients were randomized to either 1° femoral nailing (reamed or unreamed) (1°FN) or 1° damage control by initial external fixation (DCO, 1°Ex.fix.) and secondary femoral nailing (DCO, 2°FN). In the group that underwent 2°FN, intraoperative measurements were performed as well. Interleukin-6 serum levels were monitored perioperatively. The Kruskal-Wallis test and Wilcoxon test were used for statistical analysis with P<0.05 (agroup difference, bdifference from preoperative value).
Results:
Patients were divided into two groups.
| N | Mean age | Mean ISS | AIS thorax | P value | |
| UFN (I°FN) | 17 | 28.6 | 21.5 | 2.1 | n.s. |
| DCO (I°Ex.Fix.) | 18 | 29.9 | 22.9 | 2.3 | n.s |
Levels of Interleukin-6
| Preoperative |
|
|
| |
| UFN (1°FN) | 55 ± 33 | 99 ± 42 | a, b 234 ± 55 | a, b 188 ± 38 |
| DCO (1°Ex.Fix.) | 71 ± 42 | 51 ± 31 | 62 ± 34 | 44 ± 22 |
| DCO (2°FN) | 33 ± 21 | 55 ± 41 | 38 ± 21 | 26 ± 21 |
Conclusion: In this prospective randomized study, the highest inflammatory response was found after primary (<24 hours) intramedullary instrumentation of the femur. In contrast, secondary conversion to an intramedullary implant was not associated with a similar cytokine release. These findings demonstrate the impact of surgery on the systemic inflammatory response even in patients who are clinically in a stable condition. The subclinical findings may become clinically relevant in patients at high risk of developing complications. In these, DCO appears to be an adequate alternative for patients at high risk of posttraumatic complications.
* If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options and e-consultant or employee.