The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

Abstract

We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation.The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F 1+2 and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in ␤-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming.The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours.Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain.Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications.

Factors affecting rates of infection and nonunion in intramedullary nailing

“…7 Unreamed nailing does not have this effect, but no clinical study has shown a convincing difference in cardiorespiratory complications between the two methods of nailing. 8 Advocates of the unreamed nail suggest that the risk of infection increases with reaming as a result of disturbing the endosteal blood supply, especially in open tibial fractures in which the pre-carious blood supply and lack of soft-tissue cover predispose to nonunion and infection. 9,10 There is a lack of randomised, controlled trials in the literature which compare the rates of infection and nonunion in unreamed and reamed IM nailing.…”

Invited Commentary

“…31 Previous large animal studies involving hemorrhagic shock, lung contusion, and reamed intramedullary nailing have demonstrated a similar consumptive coagulopathy with reduction in levels of fibrinogen and AT III. 31 Previous large animal studies involving hemorrhagic shock, lung contusion, and reamed intramedullary nailing have demonstrated a similar consumptive coagulopathy with reduction in levels of fibrinogen and AT III.…”

“…31 Previous large animal studies involving hemorrhagic shock, lung contusion, and reamed intramedullary nailing have demonstrated a similar consumptive coagulopathy with reduction in levels of fibrinogen and AT III. 31 The most severe embolic and coagulative responses were measured again after the intramedullary stabilization of pathologic fractures and those with delayed (ie, .48 hours) surgery. 31 The most severe embolic and coagulative responses were measured again after the intramedullary stabilization of pathologic fractures and those with delayed (ie, .48 hours) surgery.…”

Overview on Miss Management in Turn over Time in Orthopaedic Operative Room

“…Delays can arise from human error and system inefficiency [5]. Delay in preoperative treatment can be associated with negative outcomes including increased morbidity and mortality [6][7][8]. Unlike preoperative delays, which can include a prolonged waiting time or postponement, perioperative delays occur on the planned day of surgery and include delays getting to the OR and during surgery.…”