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

Abstract

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.

Conclusion: 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.

Trial registration: ClinicalTrials.gov: NCT00981877.

Figure 1

Flow chart of patients admitted with femoral shaft fracture and included in the study.

Figure 2

The figure shows the arterial thrombin-antithrombin-complex (TAT) (2a), soluble tissure factor (sTF) (2b), tissue plasminogen activator (t-PA) antigen (2c) and plasminogen activator inhibitor (PAI-1) activity (2d) (median and 25/75 percentiles) at admission (A), skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first (G1), second (H1) and third (I) day after nail insertion.

Figure 3

The figure shows the arterial tumor necrosis factor-alpha (TNF-α) (3a), interleukin-6 (IL-6) (3b) and interleukin-10 (IL-10) (3c) (median and 25/75 percentiles) at admission (A), skin incision (B), 30 minutes (D), two (E) and six (F) hours, the first (G1), second (H1) and third (I) day after nail insertion.

Figure 4

The figure shows alveolo-arterial oxygen (PAO2 - PaO2) difference (Figure 4a), arterial (SaO2) (Figure 4b) and mixed venous (SvO2) saturation (Figure 4c) (mean ± S.E.M.) at skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first (G1 and G2), second (H1 and H2) and third (I) day after nail insertion.

Figure 5

The figure shows the time course (mean ± S. E. M.) for cardiac index (CI) (Figure 5a), indexed systemic vascular resistance (SVRI) (Figure 5b), mean pulmonary artery pressure (MPAP) (Figure 5c) and indexed pulmonary vascular resistance (PVRI) (Figure 5d) at admission (A), skin incision (B), after nail insertion (C) and 30 minutes (D), two (E) and six (F) hours, the first- (G1 and G2), second- (H1 and H2) and third (I) day after primary IMN.