Abstract
Proximal femur fractures represent a major healthcare problem in the aging society. High rates of post-operative infections are linked to risk factors that seem to affect local microcirculation. Patterns and time courses of alterations in microcirculation have, however, not been previously investigated. The aim of this prospective cohort study was to evaluate perioperative changes in microcirculation after trochanteric femur fractures using non-invasive laser-Doppler spectrophotometry to analyze how oxygen saturation (SO2), hemoglobin content (Hb) and blood flow changed before and after surgery, and how these parameters were altered by implant type, gender, smoking, diabetes and age. Measurements were separately recorded for nine locations around the greater trochanter in 2, 8, and 15 mm depths, before surgery and 8, 24, 48 h, 4, 7, and 12 days after surgery in 48 patients. Three implants were compared: Dynamic Hip Screw, Gamma3 Nail, and Percutaneous Compression Plate. Surgery resulted in significant differences between the healthy and injured leg in SO2, Hb and flow. Each parameter showed comparable values for both legs prior to surgery. Significantly higher values in SO2 and flow were registered in women compared to men before and after surgery. Smoking caused significant increases in SO2, Hb, and flow only in the superficial layer of the skin after surgery. Diabetes decreased blood flow at 2 and 8 mm depth and increased SO2 at 8 and 15 mm depth after surgery. Age revealed a significant negative correlation with flow. The ability to increase the flow rate after surgery decreased with age. Comparison of implants indicated the minimally invasive implant PCCP altered microcirculation less than the DHS or the Gamma3 nail. Overall, the proximal femur fracture alone did not alter local skin microcirculation significantly in a way comparable to the effect caused by surgery. In conclusion, microcirculation after proximal femur fractures is highly affected by surgery, gender, smoking, diabetes, age and implant in ways specified in this study.
Highlights
Fractures of the proximal femur are associated with high morbidity and mortality and represent a major healthcare problem in the aging society (Knobe and Siebert, 2014; Neuerburg et al, 2015; Carow et al, 2017)
Our finding of significantly increased values in SO2 and flow in women compared to men after proximal femur fractures is new, and further investigations are necessary to confirm these results
Microcirculation after proximal femur fractures is highly altered by surgery, gender, smoking, diabetes and age
Summary
Fractures of the proximal femur are associated with high morbidity and mortality and represent a major healthcare problem in the aging society (Knobe and Siebert, 2014; Neuerburg et al, 2015; Carow et al, 2017). Post-operative rates of surgical site infection after surgery of proximal femur fractures were reported between 1.7 and 10% in arthroplasty or hemiarthroplasty and under 3% in femur nails, dynamic hip screws and minimally invasive implants (Knobe et al, 2009, 2012, 2013; Noailles et al, 2016; de Jong et al, 2017). Most risk factors are associated with inhibition in local microcirculation and subsequent decrease in oxygen supply, hypoxia, acidosis, collection of metabolites and oxidative/nitroxidative stress (Soneja et al, 2005; Bentov and Reed, 2014). Differences in microcirculation were found between surgical approaches in spine surgery, i.e., less impairment of microcirculation in minimally invasive surgery of the spine compared to open surgery (Ganse et al, 2017). Distinctions in microcirculation between approaches in Achilles tendon surgery in healthy subjects (Klos et al, 2018), gender differences in skin microcirculation over the calcaneus (Carow et al, 2018) and effects of pulsed ultrasound therapy in the foot were published (Kösters et al, 2017)
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