Pertrochanteric fractures are common injuries in adults and source of morbidity and mortality among the elderly. Different surgical techniques were recommended for their treatment but undoubtedly they add an additional inflammatory trauma along the fracture itself. Many attempts to quantify the degree of approach-related trauma are carried out through measurements of systemic inflammatory parameters. In this study we prospectively analyzed laboratory data of 20 patients over eighty with pertrochanteric fracture of the femur treated with proximal femoral nail antirotation (PFNA). This is an excellent device for osteosynthesis because it can be easily and quickly inserted by a mini-incision providing stable fixation and early full mobilization. Serum tumor necrosis factor-alpha (TNF-
The absolute number of pertrochanteric fractures may increase in the years to come, along with the increase of population’s aging and osteoporosis, with absolute indication for surgery. A surgical intervention as the osteosynthesis of pertrochanteric fracture is a posttraumatic immune stimulus which contributes to the systemic inflammatory response syndrome representing the “second hit” for these patients after the first trauma [
The body’s response to trauma is a highly complex and heterogeneous sequence of events, and specific cytokine patterns, truly predictive of outcomes, are yet to be established.
Inflammatory cells that contribute to the clearance and the repair of necrotic tissue dominate the local response to injury [
Literature evidence suggests that IL-6 levels provide an estimate of not only local tissue trauma but also the subsequent systemic response to trauma [
In case of a major, but standardized, musculoskeletal injury like trochanteric fractures, the total hip replacement induced significant increments in serum levels of the proinflammatory cytokines in the postoperative course, at 6 hours and at 24 hours after surgery [
Recent developments in orthopaedic surgery indicate that pertrochanteric fractures can be successfully treated using advanced implants. Dynamic hip screws (DHSs) and proximal femoral nails (PFNs) are commonly used and both produce good results [
The protocol was approved by the Ethics Committee at our institution. Written informed consent was obtained from each patient enrolled in the study, according to the Declaration of Helsinki.
The clinical data from 20 patients planned for PFNA at the Gemelli Hospital of Catholic University, Department of Orthopaedic Sciences and Traumatology, were collected and analyzed prospectively from November 2011 to September 2012. Inclusion criteria were pertrochanteric fracture of the femur (3.1 type-A according to the AO classification of fractures) (
For each patient, the following was recorded: the age at surgery, the gender, the comorbidity, the preoperative waiting hours, and the operative time (Table
Clinical features of the studied patients.
Patients, number | 20 |
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Gender | 15 females, 5 males |
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Mean age, years, range | 84 (68–94) |
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Time from hospitalization to surgery (hours, range) | 45 h 30′ (99 h 41′–14 h 33′) |
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Total duration of surgery (minutes, ranges) | 36′ (17′–71′) |
All patients were operated for fracture reduction and fixation with intramedullary nail PFNA, (Synthes, Switzerland) with percutaneous technique. This method involves closed reduction of the fracture by pulling the fractured limb on a special operating table and fluoroscopic control. The nail is inserted into the medullary canal of the proximal femur through a mini-incision of about 10 cm length at the level of greater trochanter. The fixing system involves the insertion of a blade along the femoral neck and up to the head and a screw passing through the two cortical of the femur and the distal portion of the nail. This was performed with a percutaneous technique, which is using two small incisions sufficient to the passage of the screws.
Samples of venous blood were obtained at 1 hour preoperatively and at 24 hours postoperatively. After centrifugation at 3000 rpm for 5 minutes sera were collected, divided in 3 aliquots for each sample, and stored at −80°C until dosages were performed. They were analyzed anonymously. To check the inflammatory stimulus induced by the intervention blood levels of TNF-
Plasma levels of creatine kinase (CK) were measured by absorption photometry (Cobas 8000, Roche Diagnostics, Switzerland), at admittance of the patients in the emergency room and 24 hours after surgery, as indicator of muscle necrosis; normal value ≤190 UI/L.
Data were analyzed using student’s
The patients’ clinical features are shown in Table
The values of serum TNF-
It shows the data of the cytokines TNF-
Surgery | Range | Mean value ± Standard deviation |
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TNF- |
pre | 0.1–14.3 | 2.27 ± 4.09 | n.s. |
post | 0.1–18.3 | 3.84 ± 5.74 | ||
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IL-6 |
pre | 0.1–45.9 | 16.15 ± 14.96 | n.s. |
post | 0.1–32.7 | 16.64 ± 9.04 | ||
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CRP |
pre | 14.2–111.0 | 63.08 ± 33.72 |
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post | 29.8–162.0 | 104.46 ± 38.69 | ||
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CK |
pre | 24.0–230.0 | 84.35 ± 44.81 |
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post | 34.0–632.0 | 218.06 ± 155.93 |
The preoperative mean level of IL-6 was 16.14 ± 14.96 pg/mL, nearly threefold the value of normality though with a very wide range of variation, while the mean level after 24 hours postoperatively was 16.64 ± 9.04 pg/mL: this difference was not statistically significant.
Before surgery, the CRP level was high in all patients (>3 mg/L) with a very wide range of variation,
The preoperative plasma CK was within the normal range (30–190 UI/L) for all patients, with a mean value of 84.35 ± 44.81 UI/L. There was a statistically significant increase during the first 24 postoperative hours (with a mean value of
Correlation between CK levels and duration of the surgery.
Fractures of the proximal femur and hip are relatively common injuries in adults and common source of morbidity and mortality among the elderly. Incidence of fractures is increasing, which is not unexpected because the general life expectancy of the population has increased significantly during the past few decades. Many methods for the treatment of pertrochanteric fractures have been recommended. PFNA is an excellent device for osteosynthesis, as it can be easily inserted. Moreover, it provides for stable fixation, which allows early full mobilization of the patient [
On this background, the aim of this study was to evaluate the second inflammatory hit, correlated to soft-tissue invasiveness, in 20 patients with fractures of the hip treated in our institution with PFNA.
To this purpose, we analyzed the changes in plasma levels of the inflammatory cytokines TNF-
The markers analyzed varied widely between studies. IL-6, a major proinflammatory cytokine, is mainly produced by monocytes and activated macrophages, even though other cells (such as fibroblasts and myoblasts) may also synthesize it [
In our study, waiting time before surgery ranged from 99 h 41′ to 14 h 33′ (average 45 h 30′), which is sufficient for cytokines to become detectable in serum [
Before surgery, IL-6 was detectable in 16/20 patients with an average value that was nearly threefold the value of normality, without correlation with waiting time; the maximum value was 45.9 pg/mL in a patient who had waited only 14 hours. However also for IL-6 we did not find any statistically significant difference between the preoperative and the postoperative average value (
CRP is an acute phase protein that can be used as a marker for changes in the orthopedic postoperative inflammatory response and its levels may depend on the region of trauma. CRP levels increase rapidly after surgery, peaking on day 2, but already after 24 hours the increase starts to decline to plateau [
In addition, many reports have confirmed CK as a possible indicator of soft tissue damage during surgery. CK changes in plasma have been reported as a result of a skeletal muscle injury and correlated with surgical incision length, approach, and operative time. A trend of CK increase was observed in elderly patients undergoing surgery for hip fracture with the peak values on day 1 postoperatively [
To analyse and compare serum soft-tissue marker differences after the minimal invasive DHS and PFN fixation, Hong and coworkers found that both methods showed similar patterns of change for CK and CRP pre- and postoperatively (up to 72 h) without significative differences, suggesting that both approaches produce similar levels of soft-tissue damage [
In conclusion, in the treatment of pertrochanteric fracture, secretion of inflammatory markers is lower when minimally invasive techniques are used compared with traditional surgery. Good results have been reported for intramedullary devices. We confirm that, for the markers analyzed here, PFNA has a low biomechanical-inflammatory profile that represents an advantage over other techniques. Above all, it depends on a short surgical time. Average time for the synthesis of a trochanteric fracture by a skilled operator is 25 minutes (by incision to suture). The reduced surgical time together with the minimal surgical incision, not longer than 10 cm, represents the useful features of this method. Further, closed reduction of the fracture performed under fluoroscopic control avoids a second incision at the level of the fracture. This allows a minimum of trauma to soft tissue, resulting in a lower inflammatory stimulus compared to methods that involve exposure of the fracture site.
The authors declare that there is no conflict of interests.