Reamed femoral nailing in patients with multiple injuries. Adverse effects of tourniquet use.
Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema. However, the association between femoral nailing followed by tourniquet ischemia and clinical lung injury has not been described. The authors reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation between 1987 and 1993. All femoral shaft fractures were treated with reamed intramedullary nails. Patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with (Group T, 34 patients) or without (Group NT, 38 patients) a tourniquet. Group T was subdivided based on tourniquet time: T1, less than or equal to 90 minutes; T2, greater than 90 minutes. Groups were matched for injury severity. Group NT had fewer ventilator dependent days and intensive care days than Group T (NT: ventilator dependent days, 2.5 +/- 5.2; intensive care days, 3.9 +/- 6.5; T: 5.1 +/- 6.4; intensive care days, 6.7 +/- 6.6). Ventilator dependent days and intensive care days increased with increasing tourniquet time (T1: ventilator dependent days, 3.2 +/- 3.6; intensive care days, 5.4 +/- 4.6; T2: ventilator dependent days, 7.5 +/- 8.5; intensive care days, 8.5 +/- 8.5), suggesting that in patients with multitrauma, combining reamed femoral nailing with fracture fixation under tourniquet control increases pulmonary morbidity. Further investigation to measure pulmonary injury associated with ischemia reperfusion and intramedullary nailing in patients with multitrauma is warranted.
Pollak, AN; Battistella, F; Pettey, J; Olson, SA; Chapman, MW
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