Systemic Inflammatory Response After Extremity or Truncal Fracture Operations

Background. The purpose of this study was to assess proinflammatory markers in blunt trauma patients regarding the relationship of these and blood loss and duration of surgery in different fracture locations. Design: Prospective, multicenter, non-randomized cohort study. Setting: Three level I trauma centers. Patients: Sixty-eight blunt trauma patients, who did not require emergency operations and had sustained truncal or extremity fractures, were included. In two index patient groups, patients with spinal fractures (group SF, n = 24) and pelvic and acetabular fractures (group PAIF, n = 21) underwent fixation of their fractures and were compared with a group of patients with isolated fractures (group FF, n = 28). Ten healthy volunteers served as controls. Intervention: Internal fixation of pelvic, acetabular and spinal fractures, intramedullary nailing of femoral fractures, measurement of proinflammatory cytokines. Main outcome measures: From serially sampled central venous blood, the perioperative concentrations of interleukin-6 (IL-6) and IL-8 were evaluated during a 24-hour period and set into relation with the duration of surgery and the degree of blood loss. Results: Intramedullary instrumentation for isolated PAIF caused a significant perioperative increase in the concentrations of IL-6 (preoperative: 16 pg/mL +/- 12 pg/mL, 7 hours: 89 pg/mL +/- 15 pg/mL, and 24 hours: 107 pg/mL +/- 27 pg/mL, p < 0.05). This increase was comparable with the isolated femoral fracture (group FF: IL-6 preoperative, 52 pg/mL +/- 12pg/mL; 7 hours, 78 pg/mL +/- 14pg/mL; and 24 hours, 120 pg/mL +/- 23 pg/mL, p = 0.02). The changes observed after spinal fracture fixations (group SF) were considerably lower (IL-6 preoperative: 11 pg/mL +/- 6 pg/mL, 7 hours: 16 pg/mL +/- 11 pg/mL, and 24 hours: 56 pg/mL +/- 19 pg/mL). The percent change of baseline IL-6 and IL-8 concent rations, and the blood loss in group PAF at 24 hours were positively correlated (IL-6 r = 0.72, p < 0.03, IL-8 0.67, p = 004) after insertion. No correlation with the duration of surgery was found. Conclusions: The release of proinflammatory cytokines was higher in patients when their pelvic fractures were operated than in patients with spine fracture fixations, and was associated with the degree or blood loss. A higher increase in cytokine levels occurred when they were performed early (day 1-2) across all patient groups. The level of the released markers seems to be related to the magnitude of surgery, rather than to the duration of the procedure. This study supports the value of immunologic markers in determining subclinical changes during and after orthopedic surgical procedures.