Biochemical changes after trauma and skeletal surgery of the lower extremity: Quantification of the operative burden

Objective: To quantify changes in variables of inflammation, coagulation, a nd fibrinolysis in blunt trauma patients with tower extremity fractures who underwent different types of surgical procedures. Design: Prospective, cohort study. Setting: Level I university trauma center. Patients: We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. Interventions: In 34 multiply traumatized patients with femoral fracture (g roup PTFF) and in 28 patients with an isolated femoral fracture (group IFF) , primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 con trol patients, an isolated ankle fracture (group AF) was acutely stabilized . Measurements and Main Results:From serially sampled central venous blood, t he perioperative concentrations of interleukin (IL)-6, of tumor necrosis fa ctor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fib rin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 min s postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable wi th group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertio n, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated signific antly (p = .0002) higher IL-6 concentrations than all other groups througho ut the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/ml; p =.003), whereas no perioperative change was seen in group AF. T he highest IL-6 increases were associated with a longer ventilation time (g roup PTFF) and a longer period of positive fluid balances (groups PTFF, IFF , THA). The coagulatory variables demonstrated similar perioperative increa ses in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentr ations and the prothrombin fragments 1 + 2 concentrations correlated betwee n groups THA and IFF at 30 mins and at 1 hr after surgery (r(2) = .64, p < .02). In all patients the clinical variables were stable perioperatively. Conclusions: Major surgery of the lower extremity causes changes to the inf lammatory, fibrinolytic, and coagulatory cascades in patients with stable c ardiopulmonary function. The inflammatory response induced by femoral naili ng is biochemically comparable to that induced by uncemented total hip arth roplasty. In multiple trauma patients, increases, which occurred in additio n to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burd en to the patient with blunt trauma. A careful preoperative investigation i s required to evaluate whether primary definitive stabilization can be perf ormed safely.