Purpose

There are concerns with regard to the physiological effects of reamed intramedullary femoral fracture stabilisation in patients who have received a pulmonary injury. This large animal study used invasive monitoring techniques to obtain sensitive cardiopulmonary measurements and compared the responses to Early Total Care (reamed intramedullary femoral fracture fixation) to Damage Control Orthopaedics (external fixation), after the induction of acute lung injury. We hypothesised a greater cardiopulmonary response to intramedullary fracture fixation.

Using an established canine model of fat embolization, the effect of temporary mechanical blockade of embolic load during medullary canal pressurization was studied. Haemodynamic measurements, echocardiography and postmortem histomorphometry were used as outcome measures. There was statistically significant difference between the filter and the control groups, when the pulmonary vascular resistance, the percentage area of lungs occupied by fat and the percentage of pulmonary vasculature occupied by fat were compared. We have shown that mechanical blockade by a filter does stop the adverse effect on the lungs during canal pressurization.

Acute intramedullary stabilization of femoral fractures in multiply injured patients still remains controversial. Intravasation of medullary fat has been suspected to trigger ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization.

Using an established canine model, twelve mongrel dogs were randomized into two groups. A special filter was inserted percutaneously into the left common iliac vein in half the dogs where as the other half served as controls. In all dogs, the left femora and tibiae were pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiography images were recorded continuously. After sacrifice, the lungs were harvested for analysis.

The mean pulmonary artery pressure at three minutes of pressurization was 12 mm of Hg in the filter group and 28mm of Hg in the control group. The pulmonary vascular resistance in the control group was increased from the 3^rd minute of pressurization throughout the experiment. This was statistically significant when compared with the baseline. There was no such change seen in the filter group. Transesophageal echocardiography showed less embolic shower in the filter group and histomorphometry demonstrated statistically signifant difference, when the percentage area of lungs and the percentage of pulmonary vasculature occupied by fat in the filter group as compared to the control group.

This canine study has demonstrated that mechanical blockade by a venous filters can significantly reduce the embolic load on the lungs during canal pressurization.

Introduction: Early stabilization of the skeleton in multiply injured patients has shown to reduce mortality and chest morbidity. Reamed intramedullary nailing is the current method of choice for stablizing femoral and tibial shaft fracture. However several investigators have highlighted the adverse effect of early reamed nailing in polytrauma patients. Intravasation of medullary fat during canal pressurizaton has been suspected to produce a ‘second hit’ and trigger pneumonia and ARDS. The objective of this study is to investigate the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization.

Methods: Using an established model of fat embolization, twelve mongrel dogs were randomized into two groups. Under general anaesthesia, cannulations of carotids and jugular veins and transesophageal echo-cardiography were performed in all animals. Under fluoroscopy control, a special filter was inserted percutaneously into the left common iliac vein in half the animals, where as the other half served as controls. In all dogs, the left knee was exposed; the femor and tiiba were sequentially reamed and then pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and trans-esophageal echocardiography images were recorded continuously during the surgical procedure. After 45 minutes from pressurization, the dogs were sacrificed and the lungs and kidneys were harvested and fixed for histological analysis.

Results: There was significant difference noticed in the right-sided pressures and oxygen tension between the filter and the control groups. The mean pulmonary artery pressure at 3 minutes of pressurization was 12mm of Hg in the filter group and 28mm of Hg in the control group. Transesophageal echocardiography showed less embolic shower in the filter group and also lesser dilatation of right ventricles. Histomorphometry with special staining demonstrated much less proportion of lungs to be occupied by fat in the filter group as compared to the control group.

Discussion and Conclusion: This canine study has demonstrated that mechanical blockade by a venous filter can significantly reduce the emobilic load on the lungs in an established model of fat embolization. A suitable filter with suction system is being designed for possible use in high-risk patients.

Introduction and Aims: Acute intramedullary stabilisation of femoral shaft fractures in multiply injured patients remains controversial. Intravasation of medullary fat during nailing has been suspected to trigger ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurisation in a canine experiment.

Method: Using an established model, 12 mongrel dogs were randomised into two groups. Under general anesthesia, cannulations were performed to measure left and right-sided pressures. Transoesophageal echocardiography was performed in all dogs. A special ‘TRAP ‘filter was inserted percutaneously into the left common iliac vein in six dogs, whereas the other six served as controls. In all dogs, the left femora and tibiae were then pressurised by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiography images were recorded continuously. After one hour, the animals were sacrificed and the lungs were harvested for histomorphommetric analysis.

Results: The mean pulmonary artery pressure at three minutes of pressurisation was 12mm of Hg in the filter group and 28mm of Hg in the control group. There was increase in the peak systolic pulmonary artery pressure and the right ventricular pressure after canal pressurisation in the control group, whereas no such changes were observed in the filter groups. The pulmonary vascular resistance as denoted by the difference between the mean pulmonary artery pressure and the end diastolic left ventricular pressure increased significantly (p< 0.05) at three, five, 10,15 and 30 minutes after pressurisation in the control group when compared to the baseline value. In the filter group, the pulmonary vascular resistance increased only slightly after pressurisation. Transesophageal echocardiography images were analysed by a blinded echocardiologist. There was evidence of moderate to severe embolisation in the control group with detection of large echogenic particles. In comparison, there was mild grade of embolisation in the filter group. Histological analysis showed statistically significant difference between the two groups, when comparison of the percentage of area of lung tissue occupied by fat, the percentage of pulmonary vasculature occupied by fat and the maximum size of the embolus were made (p< 0.05).

Conclusion: This study has conclusively demonstrated that mechanical blockade by venous filters prior to medullary canal pressurisation, significantly reduces the embolic load and its effect on the lungs. A retrievable filter with a system to remove the accumulated marrow content is being developed for use in high-risk patients.