Severe muscle trauma triggers heightened and prolonged local musculoskeletal inflammation and impairs adjacent tibia fracture healing.

OBJECTIVES: Complicated fracture healing is often associated with the severity of surrounding muscle tissue trauma. Since inflammation is a primary determinant of musculoskeletal health and regeneration, it is plausible that delayed healing and non-unions are partly caused by compounding local inflammation in response to concomitant muscle trauma. METHODS AND RESULTS: To investigate this possibility, a Lewis rat open fracture model [tibia osteotomy with adjacent tibialis anterior (TA) muscle volumetric muscle loss (VML) injury] was interrogated. We observed that VML injury impaired tibia healing, as indicated by diminished mechanical strength and decreased mineralized bone within the fracture callus, as well as continued presence of cartilage instead of woven bone 28 days post-injury. The VML injured muscle presented innate and adaptive immune responses that were atypical of canonical muscle injury healing. Additionally, the VML injury resulted in a perturbation of the inflammatory phase of fracture healing, as indicated by elevations of CD3(+) lymphocytes and CD68+ macrophages in the fracture callus at 3 and 14d post-injury, respectively. CONCLUSIONS: These data indicate that heightened and sustained innate and adaptive immune responses to traumatized muscle are associated with impaired fracture healing and may be targeted for the prevention of delayed and non-union following musculoskeletal trauma.

Vacuum-assisted closure therapy increases local interleukin-8 and vascular endothelial growth factor levels in traumatic wounds.

BACKGROUND: Clinical observations are suggesting accelerated granulation tissue formation in traumatic wounds treated with vacuum-assisted closure (VAC). Aim of this study was to determine the impact of VAC therapy versus alternative Epigard application on local inflammation and neovascularization in traumatic soft tissue wounds. METHODS: Thirty-two patients with traumatic wounds requiring temporary coverage (VAC n = 16; Epigard n = 16) were included. At each change of dressing, samples of wound fluid and serum were collected (n = 80). The cytokines interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), and fibroblast growth factor-2 were measured by ELISA. Wound biopsies were examined histologically for inflammatory cells and degree of neovascularization present. RESULTS: All cytokines were found to be elevated in wound fluids during both VAC and Epigard treatment, whereas serum concentrations were negligible or not detectable. In wound fluids, significantly higher IL-8 (p < 0.001) and VEGF (p < 0.05) levels were detected during VAC therapy. Furthermore, histologic examination revealed increased neovascularization (p < 0.05) illustrated by CD31 and von Willebrand factor immunohistochemistry in wound biopsies of VAC treatment. In addition, there was an accumulation of neutrophils as well as an augmented expression of VEGF (p < 0.005) in VAC wound biopsies. CONCLUSION: This study suggests that VAC therapy of traumatic wounds leads to increased local IL-8 and VEGF concentrations, which may trigger accumulation of neutrophils and angiogenesis and thus, accelerate neovascularization.

[Influence of V.A.C.-therapy on cytokines and growth factors in traumatic wounds]. / Einfluss der V.A.C.-Therapie auf Zytokine und Wachstumsfaktoren in Traumatischen Wunden.

OBJECTIVE: Clinical observations have shown an accelerated wound healing in wounds of patients treated by Vacuum Assisted Closure (V.A.C.)-therapy. The mechanisms of improved wound healing on cellular level have been hitherto less investigated. In this study the levels of proinflammatory interleukins (IL-6, IL-8, IL-10) and growth factors (VEGF, FGF-2) in serum and wound were monitored. METHODS: The study included 21 patients with traumatic wounds that could not be closed during the first surgical intervention. The soft tissue defects (n = 21) were closed temporarily by Epigard. During the first second-look operation after 2.0 +/- 0.2 days in an average, Epigard was used for another 2.5 +/- 0.4 days as temporary soft tissue coverage in 13 patients (group A). In the remaining 8 patients the wound conditioning was done by V.A.C.(R) for 2.4 +/- 0.3 days (group B). A total of 428 samples of serum and wound fluid samples were collected during the first and second look operation. Levels of IL-6, IL-8, IL-10, VEGF and FGF were measured specific by ELISA. RESULTS: In all interleukins and growth factors there were significant lower serum level concentrations compared with those in wound fluids. During the first temporary dressing change after wound coverage with Epigard the wound samples showed the following levels [Mean (SEM)]: IL-6 49 816 (19 889) pg/ml, IL-8 54 (16) ng/ml, IL-10 314 (44) pg/ml, VEGF 4 746 (766) pg/ml, FGF-2 494 (89) pg/ml. During the second dressing changes we monitored the following levels in group A: IL-6 7 218 (2 542) pg/ml, IL-8 69 (27) ng/ml, IL-10 261 (58) pg/ml, VEGF 3 551 (661) pg/ml, FGF-2 355 (67) pg/ml. In group B the samples of the wound fluid showed the following results: IL-6 16 966 (4 124) pg/ml [p = 0.02], IL-8 223 (91) ng/ml [p = 0.03], IL-10 233 (76) pg/ml [p = 0.38], VEGF 7 490 (1 565) pg/ml [p = 0.01], FGF-2 352 (43) pg/ml [p = 0.48]. CONCLUSION: The increased local release of IL-6, IL-8 and VEGF in wounds after V.A.C.-therapy may be involved in the accumulation of neutrophil granulocytes and angiogenesis, which seams to play a crucial role for the accelerated granulation tissue formation after V.A.C.-therapy compared to wounds treated by Epigard.

[Diagnostic and prognostic clinical immunological criteria for evaluating the course of the posttraumatic period in patients with open mandibular fractures]. / Diagnosticheskie i prognosticheskie kliniko-immunologicheskie kriterii kharaktera techeniia posttravmaticheskogo perioda u lits s otkrytymi perelomami nizhnei cheliusti.

A total of 136 patients with open mandibular fractures were examined, 53 of these at risk of inflammatory complications in the posttraumatic period. Analysis of the wound cytology, hematological changes, local and system immunity reactions suggest that phagocytosis dysfunction, imbalance of local immunity factors (primarily production, complex formation, and secretion of serum IgA) are significant factors in the development of posttraumatic immune deficiency. Statistical analysis showed clear-cut correlation between local immunity parameters (serum IgA, salivary IgG, levels of circulating immune complexes and medium-weight molecules in the saliva) and hematological values (leukocyte and lymphocyte counts, leukocytic intoxication index, and Rietes coefficient), which confirmed the reliability of prediction of inflammatory complications and necessity of immunocorrection in this patient population.

Heridas de fracturas expuestas, bacteriología cuantitativa e inmunología humoral: estudio de heridas de fracturas expuestas a las que se les realizó bacteriología cuantitativa y correlación con estudio de biometría hemática, pruebas de funcionamiento / Open fracture wounds, quantitative bacteriology and humor immunology: a series of open fractures that were studied by quentitative bacteriology and its relationship to blood cell count, liver functioning, blood chemical analysis and immunoglobulin assessment

Las fracturas expuestas, las que se consideran emergencias quirúrgicas y deben manejarse como si fueran amputaciones incompletas. El problema de las fracturas expuestas radica en la contaminación y los factores que predisponen a la aparición de infección. Se estudiaron once heridas de diez pacientes que ingresaron al Servicio de Urgencias del Hospital Central Militar del 11 de noviembre de 1997 al 6 de mayo de 1998, en los cuales se clasificó la lesión y se tomaron fotografías, muestras para bacteriología cuantitativa de los bordes de las heridas y estudios de sangre para laboratorio. Un grupo de seis pacientes con fractura cerrada se utilizó como grupo control. De las once heridas por fracturas expuestas cuatro de ellas presentaron infección, en tres de los cultivos habían sido positivos, dos con más de 100,000 UFC (Unidades Formadoras de Colonias) y una con menos de 100,000 UFC. En las fracturas expuestas comparadas con las cerradas la biometría hemática presentó un aumento en el número de leucocitos y granulocitos, aumento en la transaminasa glutámico oxaloacética, y además disminución de los niveles de inmunoglobulinas. Se concluyó que toda herida por fractura expuesta con una mayor concentración de 1000,000 UFC tiene alta probabilidad de infección y que una lesión ósea aunada a la lesión de tejidos blandos es un factor que induce a la inmunosupresión y es factor predisponente de infección

Irrigation and traction therapy for open fracture with large-sized full-thickness skin-deficit and severely infected wound.

In this paper the results of skeletal traction and irrigation therapy (STIT) used for open fracture complicated with large-sized full-thickness skin-deficit and infection wounds (OFIW) were presented. Fourteen patients of OFIW were treated by the plaster cast and wound dressing (PCWD), and 30 patients of OFIW were treated by STIT. The results indicated that after one week of treatment, the white blood cell count in the STIT group, compared to 17.6 +/- 1.0 x 10(9)/L from before treatment, returned to 8.8 +/- 0.8 x 10(9)/L, and in contrast, the cell count of the PCWD group was about 13.0 +/- 1.4 x 10(9)/L. All of wound exudate culture in the STIT group was negative, and those of 7 cases (7/14) in PCWD group were positive (P < 0.01). The symptoms and signs such as pain, fever and septic exudate on the wound in the STIT group were much milder than those in the PCWD group. There were 5 cases (35.7%) of toxicemia and septicemia, 2 cases (14.3%) of osteomyelitis, 2 cases (14.3%) of amputation, 1 case (7.1%) of delayed union and 3 cases (21.4%) of malunion in the PCWD group, and no complications in the STIT group.

Open tibial fracture infections in asymptomatic HIV antibody-positive patients.

Fourteen patients with 15 open tibial fractures were examined retrospectively to compare postoperative infection rates of asymptomatic patients who tested positive or negative for the human immunodeficiency virus antibody (HIVab). All patients were treated with a standard open-fracture protocol. All of the HIVab-positive patients developed postoperative infections. There were five postoperative infections in 4 patients; 3 of the 4 patients were HIVab-positive and 2 of these patients developed chronic osteomyelitis. The only other infection, in an HIVab-negative patient with insulin-dependent diabetes, resolved without complication. All other HIVab-negative patients had no complications. The infection rate for asymptomatic HIVab-positive patients with open tibial fractures was higher than that for HIVab-negative patients in our study. These data suggest that the HIV status of patients with open tibial fractures is relevant to treatment outcome.

Complex sorption therapy of locomotor system traumatic suppurative complications.

Complex sorption therapy efficacy in treating 271 patients with suppurative complications of extremity traumas is analyzed. All patients underwent 1-3 enterosorption courses, the wounds were treated with application of sorbents against the background of traditional therapy. In the event of aggravating intoxication, developing first symptoms of sepsic condition, or the desease chronic course 1-5 hemosorption sessions were performed. Clinical and laboratory-instrumental examination demonstrated positive effect of the complex of sorption methods on the patient' general state, temperature curve dynamics, blood indices, microcirculation, function of liver, kidneys, and immune system status. Pathogenic flora stability decreased, wound cleaning and healing was 1.5 times faster. The total therapeutic period was 28% shorter compared to the control group of patients, treated without sorption methods.

[Enhanced activity of the protective factors in patients with suppurative surgical infection using interferon preparations]. / Povyshenie aktivnosti faktorov zashchity u bol'nykh s gnoinoi khirurgicheskoi infektsiei pri primenenii preparatov interferona.

Administration of leukocytic interferon to patients with sepsis and purulent resorptive fever resulted in a reliable increase in the indices of the host protective factors with respect to the infections. Addition of interferon to the surgical and antibacterial treatment promoted a decrease in the periods providing the clinical effect to 19.8 days against 43.8 days in the treatment without interferon.