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European Journal of Trauma and Emergency Surgery

, Volume 44, Issue 5, pp 689–696 | Cite as

Early local microcirculation is improved after intramedullary nailing in comparison to external fixation in a porcine model with a femur fracture

  • Yannik Kalbas
  • Zhi Qiao
  • Klemens Horst
  • Michel Teuben
  • René H. Tolba
  • Frank Hildebrand
  • Hans-Christoph Pape
  • Roman Pfeifer
  • TREAT Research Group
Original Article

Abstract

Introduction

The local circulatory changes induced by intramedullary reaming are not fully understood. This study aimed to analyse the short-term local microcirculation associated with different surgical strategies in a porcine model with a mid-shaft fracture.

Methods

German landrace pigs were subjected to a standardised femoral fracture under standard anaesthesia and intensive care monitoring. One group was subjected to intramedullary reaming and nailing (nail group), while a second group was stabilised with external fixation (fix ex group). Microcirculation [e.g. relative blood flow (flow), oxygen saturation and relative haemoglobin concentration] was measured in the vastus lateralis muscle adjacent to the fracture using an O2C (oxygen to see, LEA Medizintechnik GMBH) device at 0 (before fracture, baseline), 6 (90-min posttreatment), 24, 48 and 72 h.

Results

A total of 24 male pigs were used (nail group, n = 12; fix ex group, n = 12). During the observation period, a significant increase of flow was found at 6 (P = 0.048), 48 (P = 0.023) and 72 h (P = 0.042) in comparison with baseline levels. Local oxygen delivery was significantly higher at 48 (P = 0.017) and 72 h (P = 0.021) in animals in the nail group compared to animals in the external fixation group.

Conclusion

This study used a standardised porcine femoral fracture model and determined a significant increase in local blood microcirculation (e.g. flow and oxygen delivery) in animals treated with intramedullary reaming compared to external fixation. These changes may be of importance for fracture healing and local and systemic inflammatory responses. Further studies in this area are justified.

Keywords

Nailing Intramedullary nailing Microcirculation Femoral fracture Osyteosythesis Trauma 

Notes

Acknowledgements

TREAT Research Group: B. Auner, Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. P. Stormann, Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. B. Relja, Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. I. Marzi, Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. T.-P. Simon, Department of Intensive Care and Intermediate Care, RWTH Aachen University, Germany. G. Marx, Department of Intensive Care and Intermediate Care, RWTH Aachen University, Germany. A. Haug, Department of Trauma Surgery, Technical University Munich, Germany. L. Egerer, Department of Trauma Surgery, Technical University Munich, Germany. M. V. Griensven, Department of Trauma Surgery, Technical University Munich, Germany. M. Kalbitz, Department of Orthopaedic Trauma, Hand-, Plastic-, and Reconstructive Surgery, University of Ulm, Germany. M. Huber-Lang, Department of Orthopaedic Trauma, Hand-, Plastic-, and Reconstructive Surgery, University of Ulm, Germany. R. Tolba, Institute for Laboratory Animal Science and Experimental Surgery, RWTH Aachen University, Germany. K. Reiss, Institute of Pharmacology and Toxicology, RWTH Aachen University, Germany. S. Uhlig, Institute of Pharmacology and Toxicology, RWTH Aachen University, Germany. K. Horst, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. M. Teuben, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. R. Pfeifer, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. K. Almahmoud, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. Y. Kalbas, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. H. Luken, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. K. Almahmoud, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. F. Hildebrand, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland. H. C. Pape, Department of Orthopaedic Trauma, RWTH Aachen University, Germany; University Hospital Zurich, University of Zurich; Ramistr. 100, 8091 Zurich, Switzerland.

Funding

Project no. S-14-14P was supported by the AO Foundation. Zhi Qiao is supported by a scholarship from the Chinese Scholarship Council.

Compliance with ethical standards

Conflict of interest

There are no other conflicts of interest.

Research involving human participants and/or animals

Animals were involved in these experiments: the experiments were approved by the local authority (“Landesamt für Natur, Umwelt und Verbraucherschutz”: LANUV-NRW, Germany, AZ TV-Nr. 84-02.04.2014.A265).

Informed consent

All authors have read this manuscript and agreed for publication.

References

  1. 1.
    Bong MR, et al. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97–106.CrossRefGoogle Scholar
  2. 2.
    Kuntscher GB. The Kuntscher method of intramedullary fixation. J Bone Jt Surg Am. 1958;40-a(1):17–26.CrossRefGoogle Scholar
  3. 3.
    Hupel TM, Aksenov SA, Schemitsch EH. Muscle perfusion after intramedullary nailing of the canine tibia. J Trauma. 1998;45(2):256–62.CrossRefGoogle Scholar
  4. 4.
    Hupel TM, Aksenov SA, Schemitsch EH. Effect of limited and standard reaming on cortical bone blood flow and early strength of union following segmental fracture. J Orthop Trauma. 1998;12(6):400–6.CrossRefGoogle Scholar
  5. 5.
    Hupel TM, Aksenov SA, Schemitsch EH. Cortical bone blood flow in loose and tight fitting locked unreamed intramedullary nailing: a canine segmental tibia fracture model. J Orthop Trauma. 1998;12(2):127–35.CrossRefGoogle Scholar
  6. 6.
    Frolke JP, et al. Reaming debris in osteotomized sheep tibiae. J Trauma. 2001;50(1):65–9 (discussion 69–70).CrossRefGoogle Scholar
  7. 7.
    Baumgart F, Kohler G, Ochsner PE. The physics of heat generation during reaming of the medullary cavity. Injury. 1998;29:11–25.CrossRefGoogle Scholar
  8. 8.
    Klein MP, et al. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg. 1990;109(6):314–6.CrossRefGoogle Scholar
  9. 9.
    Mueller CA, Rahn BA. Intramedullary pressure increase and increase in cortical temperature during reaming of the femoral medullary cavity: the effect of draining the medullary contents before reaming. J Trauma. 2003;55(3):495–503 (discussion 503)CrossRefGoogle Scholar
  10. 10.
    Pfeifer R, Sellei R, Pape HC. The biology of intramedullary reaming. Injury. 2010;41(Suppl 2):S4–8.CrossRefGoogle Scholar
  11. 11.
    Horst K, et al. Characterization of blunt chest trauma in a long-term porcine model of severe multiple trauma. Sci Rep. 2016;6:39659.CrossRefGoogle Scholar
  12. 12.
    Beck C, et al. The beneficial effects of acute hypercapnia on microcirculatory oxygenation in an animal model of sepsis are independent of K(+)ATP channels. Microvasc Res. 2015;99:78–85.CrossRefGoogle Scholar
  13. 13.
    Kelly PJ. Anatomy, physiology, and pathology of the blood supply of bones. J Bone Jt Surg Am. 1968;50(4):766–83.CrossRefGoogle Scholar
  14. 14.
    Trueta J. Blood supply and the rate of healing of tibial fractures. Clin Orthop Relat Res. 1974;105:11–26.CrossRefGoogle Scholar
  15. 15.
    Grundnes O, Utvag SE, Reikeras O. Effects of graded reaming on fracture healing: blood flow and healing studied in rat femurs. Acta Orthop Scand. 1994;65(1):32–6.CrossRefGoogle Scholar
  16. 16.
    Grundnes O, Utvåg SE, Reikerås O. Restoration of bone flow following fracture and reaming in rat femora. Acta Orthop Scand. 1994;65(2):185–90.CrossRefGoogle Scholar
  17. 17.
    Schemitsch EH, Kowalski MJ, Swiontkowski MF. Soft-tissue blood flow following reamed versus unreamed locked intramedullary nailing: a fractured sheep tibia model. Ann Plast Surg. 1996;36(1):70–5.CrossRefGoogle Scholar
  18. 18.
    Shaw NE. Observations on the physiology of the circulation in bones. Ann R Coll Surg Engl. 1964;35:214–33.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Frölke J. Intramedullary reaming of long bones, in practice of intramedullary locked nails. Berlin: Springer; 2006. p. 43–56.Google Scholar
  20. 20.
    Nassif JM, et al. Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study. J Orthop Trauma. 2000;14(8):554–8.CrossRefGoogle Scholar
  21. 21.
    Manson J, Thiemermann C, Brohi K. Trauma alarmins as activators of damage-induced inflammation. Br J Surg. 2012;99(Suppl 1):12–20.CrossRefGoogle Scholar
  22. 22.
    Schmidmaier G, et al. Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation. Bone. 2006;39(5):1156–63.CrossRefGoogle Scholar
  23. 23.
    Wenisch S, et al. Human reaming debris: a source of multipotent stem cells. Bone. 2005;36(1):74–83.CrossRefGoogle Scholar
  24. 24.
    Horst K, et al. Local inflammation in fracture hematoma: results from a combined trauma model in pigs. Mediators Inflamm. 2015;2015:126060.CrossRefGoogle Scholar
  25. 25.
    Hauser CJ, et al. The immune microenvironment of human fracture/soft-tissue hematomas and its relationship to systemic immunity. J Trauma. 1997;42(5):895–903 (discussion 903–4)CrossRefGoogle Scholar
  26. 26.
    Brochner AC, Toft P. Pathophysiology of the systemic inflammatory response after major accidental trauma. Scand J Trauma Resusc Emerg Med. 2009;17:43.CrossRefGoogle Scholar
  27. 27.
    Scaffidi P, Misteli T, Bianchi ME. Release of chromatin protein HMGB1 by necrotic cells triggers inflammation. Nature. 2002;418(6894):191.CrossRefGoogle Scholar
  28. 28.
    Qiao Z, et al. Analysis of skeletal muscle microcirculation in a porcine polytrauma model with haemorrhagic shock. J Orthop Res, 2017;36:1377–1382CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Yannik Kalbas
    • 2
  • Zhi Qiao
    • 1
  • Klemens Horst
    • 1
  • Michel Teuben
    • 2
  • René H. Tolba
    • 3
  • Frank Hildebrand
    • 1
  • Hans-Christoph Pape
    • 2
  • Roman Pfeifer
    • 2
  • TREAT Research Group
  1. 1.Department of Trauma and Reconstructive SurgeryRWTH Aachen University Hospital AachenAachenGermany
  2. 2.Department of Trauma Surgery and Harald-Tscherne LaboratoryUniversity Hospital Zurich, University of ZurichZurichSwitzerland
  3. 3.Institute for Laboratory Animal Science and Experimental SurgeryRWTH Aachen UniversityAachenGermany

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