The timing of definitive fracture fixation after Damage Control Surgery (DCS) remains a problem. Our unit employs a pragmatic approach, timing definitive surgery when the patient's clinical condition is judged satisfactory. Previous data implies fixation may result in a significant ‘second hit’ if executed <5 days after admission and DCS. The response to definitive fracture fixation in adult major trauma patients requiring DCS (MT ISS>25, n= 11) with fractures of the femoral shaft, pelvis or acetabulum were studied in comparison to patients with those fractures in isolation (IF n=21) and uninjured comparable surgical controls (SC n=12). Interleukin-8 (IL-8), IL-6 and sIL-6R levels, and neutrophil CD11b & monocyte HLA-DR expression were studied at admission, preoperatively and on days 2 & 5 post-operatively. Patients were divided into those undergoing definitive surgery within the first 5 days of admission (MT1st5 & IF1st5) or later (MTL & IFL). IL-8 levels were elevated in MT patients throughout, suggesting a proinflammatory state, whereas IL-6 levels were elevated but then declined steadily. This was independant of timing of surgery. The only post-operative rise observed was in IL-6 in SC patients. sIL-6R levels were increased in MT compared to IF patients post surgery. This elevated state, following increased IL-6 levels may be associated with resolution of the inflammatory response. CD11b expression in the MT group was unaffected. HLA-DR expression was reduced in the MT1st5 group, and post surgery in SC and IF1st5 groups. No post op cases of ARDS/MODS were diagnosed. These data suggest there is no associated detrimental effect upon the systemic inflammatory response even when undertaken less than 5 days from admission & DCS, and thus support a pragmatic approach in timing definitive fracture surgery based upon the patient's clinical improvement.
Alumina has been the dominant ceramic used in orthopaedics since 1970. It is near diamond hardness is superior to all other biomaterials and its wettability has been a great benefit for tribological reasons. Over the past 30 years, this ceramic has gradually been optimized with superior processing, higher purity, greater density, and somewhat higher strength. Also serial numbers have been added to uniquely identify implant components and proof-testing now ensures that every implant is pre-clinically tested, compared to prior methods of sampling only 2–3% for destructive tests. The clinical downside remaining has been the small but troublesome fracture incidence of alumina implants. Historically, this has averaged 0.015% (15 per 100,000 cases) overall but varied from 0.08% up to 13% in those clinical series experiencing fractures (Heros, Sem. Arthrop-98). As well as creating patient hardships, fracture of any implant in the USA frequently leads to major lawsuits. Thus ceramic implants must be treated w While there has as yet been no FDA-approval given to market ceramic cups in the USA, there are a number of ceramic candidates being developed for both THR and TKR. These include zir-conia-alumina composites as well as new zironia/zirconia or zirconia/alumina combinations for THR. In addition, there are new combinations of toughened aluminas and also other choices such as silicone nitrides proposed for use with either metal CoCr heads or CoCr cups. Finally an alternate approach has been to provide a metal zirconium knee joint with a ceramic zirconia coating for improved bearing performance. Thus, the state of the art of alumina implants will be reviewed and put into perspective with the “new and improved” ceramics currently on the horizon. This survey will put into perspective the physical and mechanical attributes as well as the clinical performance of ceramic implants.
