Abstract
The timing of definitive fracture fixation after Damage Control Surgery (DCS) remains a problem. Our unit employs a pragmatic approach, timing definitive surgery when the patient's clinical condition is judged satisfactory. Previous data implies fixation may result in a significant ‘second hit’ if executed <5 days after admission and DCS.
The response to definitive fracture fixation in adult major trauma patients requiring DCS (MT ISS>25, n= 11) with fractures of the femoral shaft, pelvis or acetabulum were studied in comparison to patients with those fractures in isolation (IF n=21) and uninjured comparable surgical controls (SC n=12). Interleukin-8 (IL-8), IL-6 and sIL-6R levels, and neutrophil CD11b & monocyte HLA-DR expression were studied at admission, preoperatively and on days 2 & 5 post-operatively. Patients were divided into those undergoing definitive surgery within the first 5 days of admission (MT1st5 & IF1st5) or later (MTL & IFL).
IL-8 levels were elevated in MT patients throughout, suggesting a proinflammatory state, whereas IL-6 levels were elevated but then declined steadily. This was independant of timing of surgery. The only post-operative rise observed was in IL-6 in SC patients.
sIL-6R levels were increased in MT compared to IF patients post surgery. This elevated state, following increased IL-6 levels may be associated with resolution of the inflammatory response.
CD11b expression in the MT group was unaffected. HLA-DR expression was reduced in the MT1st5 group, and post surgery in SC and IF1st5 groups.
No post op cases of ARDS/MODS were diagnosed.
These data suggest there is no associated detrimental effect upon the systemic inflammatory response even when undertaken less than 5 days from admission & DCS, and thus support a pragmatic approach in timing definitive fracture surgery based upon the patient's clinical improvement.
