J Oral Maxillofac
Surg
49:464-467,1991
Changes in C-Reactive Protein Associated With Surgical Treatment of Mandibular Fractures TATEYUKI IIZUKA, MD, DDS,* AND CHRISTIAN LINDQVIST, MD, DDS, PHDt C-reactive protein (CRP) levels were determined in 80 patients (67 male, 13 female), each with a single mandibular fracture in either the symphysis, body, or angle region. All patients underwent osteosynthesis (63 with rigid plate fixation following the AO/ASIF principle, 17 with miniplates). Creactive protein levels were measured on admission and daily during hospitalization. Preoperative CRP levels (mean, 28.5 mg/L) varied according to the time that had elapsed since injury. After surgery, there was always an increase in CRP level. The level reached its maximum (mean, 73.2 mg/L) on the second day after operation. Postoperative CRP levels were significantly influenced by the time between trauma and surgery. Significant differences were also observed with different types of fixation. Fixation with rigid plates was associated with smaller increases in CRP level than was fixation with miniplates. The location of the fracture, associated condylar fractures, the use of maxillomandibular fixation, the presence or absence of a tooth at the fracture site, and the surgical approach did not affect the CRP levels. The significance of CRP measurement for interpretation of postoperative situations is discussed and examples of cases in which there was infection are described.
postoperative infection, determination of CRP levels is also superior to determination of ESR because it is quicker. 5-’’ An increase in CRP level or a high CRP level persisting for 2 to 3 weeks after operation is usually indicative of postoperative infection. Creactive protein, which is synthesized by hepatocytes, is one of the “acute phase proteins” in the plasma. The primary signal for synthesis of this protein is production of interleukin-1 by macrophages at tissue injury sites.4 The CRP level is less than 10 mg/L in 99% of healthy individuals.12 Although several studies of CRP levels have been conducted in patients undergoing various types of surgical intervention,5-” studies of CRP levels in the patients surgically treated for fractures have seldom been undertaken; CRP levels in cases of surgical treatment of facial bone fractures have not been reported so far. Mandibular fractures are often exposed to contamination by oral bacteria and, therefore, the possibility of infection always needs to be taken into account. Posttraumatic and/or postoperative swelling makes it difficult to differentiate
Erythrocyte sedimentation rates (ESR) and white blood cell counts are laboratory parameters often used to diagnose infection. Both parameters are fairly nonspecific and are influenced in trauma cases by both the extent of injury and the type of surgical treatment. Determination of serum levels of C-reactive protein (CRP) has, therefore, been suggested for the early diagnosis of bacterial infection. The value of determining CRP levels for the assessment of acute infection and tissue destruction has been well documented.“4 In the diagnosis of Received from the Department of Oral and Maxillofacial Surgery, Helsinki University Central Hospital, Helsinki, Finland. * Resident. t Head. Address correspondence and reprint requests to Dr lizuka: Department of Or& and Maxillofacial Surgery, Helsinki University Central Hospital, Kasarmikatu 11-13, SF-00130 Helsinki 13, Finland. 0 1991 geons
American
Association
of Oral
and Maxillofacial
Sur-
0278-2391/91/4905-0004$3.00/O
464
IIZUKA AND LINDQVIST
between infection and a normal reaction to surgical intervention. The information provided by CRP levels could therefore lead to a more rapid diagnosis. The aim of this study was to determine the degree and timing of the natural serum CRP response to mandibular fracture and its surgical treatment. Materials and Methods Open reduction and plate fixation of acute mandibular fractures were undertaken in 252 patients in the Department of Maxillofacial Surgery, Helsinki University Central Hospital, during the period of June 1, 1986 to November 30, 1989. This study included patients who had only a single fracture (other than one involving the condyloid process) in the symphysis, body, or angle region, and who underwent only one osteosynthesis. Patients with multiple injuries or who were suffering from any systemic disease were excluded. Some patients were also excluded because insufficient laboratory data were available. Three patients had an infected fracture site on admission. Eighty patients were ultimately studied (67 male, 13 female). Their mean age was 34.8 years (range, 12 to 83 years). The mean duration of hospitalization was 4.9 days (range, 3 to 15 days). In all 80 cases, open reduction and plate fixation were indicated because of displacement or instability of the fracture. In 63 cases, the fracture was treated using rigid fixation following the A0 principle.” Of these 63 cases, osteosynthesis was performed in 14 cases using an intraoral approach. In 49 cases, the extraoral approach was used. In patients treated with rigid fixation, there were associated condylar fractures in 20 cases. Six of these required maxillomandibular fixation for 2 to 4 weeks postoperatively, but the others were not immobilized. In general, neither elastic nor rigid maxillomandibular fixation was used postoperatively in the patient group treated with A0 rigid fixation. In 17 cases, the fracture was treated with miniplates using the intraoral approach. When a miniplate was used, the patient was always placed in maxillomandibular fixation for 2 to 4 weeks postoperatively. A condylar fracture was also diagnosed in 13 of the patients treated with miniplates. Fifty of the mandibles were dentulous, 30 were edentulous. The median delay before surgery was 2.0 days (range, 0 to 9 days). Fractures healed normally in all patients except one with preoperative infection. This patient’s osteosynthesis plate had to be removed about 1 month after surgery because of persistent infection. Serum CRP levels were measured routinely on
admission, then daily during hospitalization. The CRP level was determined immunoturbidimetrically at 340 nm using a Hitachi 704 analyzer and CRP antiserum (Kallestad Diagnostics, Chaska, MN) and CRP buffer (cat. no. D-179) and CRP standards (cat. no. D-274) from Orion Diagnostica, Espoo, Finland. The upper normal CRP limit is 10 mg/L. Values were reported as means and standard deviations (SD). Analysis of variance was used to assess the statistical significance of differences between groups. Student’s t test for paired values was used to assess the statistical significances of differences within groups. P values less than .05 were considered to indicate statistical significance. Results Preoperative serum CRP values ranged from 1 mg/L to 146 mg/L, depending on the time that had elapsed since the initial trauma (Fig 1). Significantly higher levels of CRP were observed between 12 and 84 hours after injury than at other times. When CRP levels were measured within 12 hours of injury, the mean level was 10.5 mg/L (SD, rt 9.5 mg/L). Between 12 and 84 hours after injury the mean level was 33.1 mg/L (SD, t 25.8 mg/L). By the fourth day after injury, and subsequently, CRP levels were markedly lower (mean, 11.5 mg/L; SD, + 6.2 mg/L) and virtually constant, irrespective of the time that had elapsed since injury. The age and sex of the patients, location of the fracture, associated condylar fractures, and the presence or absence of a tooth at the fracture site did not affect CRP increases caused by injury. Surgical intervention resulted in significant increases in CRP values (Fig 2). The mean serum CRP level was 28.5 mg/L (SD, -+ 25.7 mg/L) preopTime 36
0
1
in hours
60
2 Time
from
64
injury
106
3
4
in days
from
132
5
156
6
160
7
injury
FIGURE 1. Preoperative CRP levels in relation to the time elapsed since injury. The bars represent standard deviations of the means for each period of time.
466
C-REACTIVE
CRP (mg/l) 120,
60 -
60 40 21.3
20 1
o!
f
. ,
Pre-op
-
I
-
2
1
1
*
I
.
1
I
4 days
3 Postoperative
5
FIGURE 2. Mean postoperative increases in CRP levels. The bars represent standard deviations of the means for each period of time.
eratively on the day of surgical treatment. Maximum postoperative CRP levels were observed in 82% of cases on the second day after the operation (mean, 73.2 mg/L; SD, + 34.9 mg/L). CRP levels began to decrease on the third day after the operation. The maximum serum CRP level (mean, 75.3 mg/L; SD, + 35.3 mg/L) exceeded 100 mg/L in only 14 patients (17.7%). The highest CRP level recorded was 157 mg/L. The increase in serum CRP level depended on the time that had elapsed between trauma and surgery. The patients were divided into three groups on this basis. Thirty-nine patients were operated within 36 hours of injury (group A), 29 patients between 36 and 84 hours after injury (group B), and 12 patients 84 hours or more after injury (group C). In groups A and B, the increases in serum CRP level were significantly higher (P < .OOl)than in group C (Fig 3). There was no significant difference between groups CRP 100 -
(mg/l)
I30 -
FRACTURES
A and B. The location of the fracture, the type of plate, the surgical approach, the use of maxillomandibular fixation, associated condylar fractures, the presence or absence of a tooth at the fracture site, and the sex and age of the patients had no effect on serum CRP levels. In groups A and B (n = 68), patients who underwent intraoral surgery were found to exhibit higher serum CRP values than those who underwent extraoral surgery (Fig 4). This difference was associated with the type of fixation, however, and not the surgical approach, because a similar difference was also observed between the two types of fixation (Fig 5). Rigid fixation resulted in fairly similar CRP curves, irrespective of the surgical approach (Fig 6). Neither did the use of maxillomandibular Iixation affect CRP increases caused by surgery in the patient group treated with A0 rigid fixation. Three patients with clinically obvious infections of their fracture sites underwent extraoral open reduction and rigid fixation. All had markedly high preoperative serum CRP values (Fig 7). Rigid fixation resulted in steady decreases in and ultimate normalization of CRP levels in two of these patients. The postoperative courses in these two patients were uneventful. In the third patient (patient 1, Fig 7) there was a delay in the normalization of the CRP level after operation. Postoperative infection of the fracture site required removal of the osteosynthesis plate after 36 days. Discussion
Determination of serum CRP levels was introduced to allow early detection of infection because it is quicker and more specific than determination of ESR. Determination of CRP levels is, however, still far from ideal because of its low specificity in patients who have sustained musculoskeletal trauma
GROUP A
e e +
A l-l
PROTEIN AND MANDIBULAR
GWPB GRCUPC
60 40 20 0.
,
Pre-op
-
1
1
*
I
-
I
3 2 Postoperative
=
I
4 days
-
1
’
5
FIGURE 3. Mean postoperative increases in CRP levels in relation to time between injury and surgery. Surgical treatment took place within 36 hours of injury in group A, between 36 and 84 hours after injury in group B, and more than 84 hours after injury in group C (* P < .05; ** P < .Ol; *** P < .OOl).
Pre-op
1
2
3
Postoperative
4
5
days
FIGURE 4. Mean postoperative increases in CRF levels in relation to surgical approach (* P < .05; ** P < .Ol).
467
IIZUKA AND LINDQVIST
CRP (ma/l)
Patient 1 Patlent 2 Patlent 3
U + +
RIGID PLATE MINIPLATE
+ + 100 -
60 80 40 -
60 40 -
20 -
o!
20 -
1 1
.
,
Pre-op
.
,
.
,
2
1
.
,
.
4
3 Postoperative
I
,
0.
5
days
or undergone surgical treatment. Shortly after operation, CRP values can be high because of both the initial trauma and the subsequent surgery. Other factors that raise CRP levels, for example pneumonia, urinary tract infection7 thrombophlebitis, acute pancreatitis3 and myocardial infarction,* can also be associated with an acute fracture. These possibilities make the interpretation of high serum CRP values in trauma patients difficult. CRP values in surgical intervention are clearly greater when the operation is undertaken within 3 days of injury than when it occurs 4 or more days after injury. This significantly high increase in serum CRP levels caused by both injury and surgical intervention has not been noted previously. Rises in serum CRP levels seemed also to be related to the type of fixation. In the patients treated with miniplates, maxillomandibular fixation was removed after surgery for safe extubation of the trachea, and the mouth was kept open until full recovery from general anesthesia, CRP (mgil) 100 7 +
EXTRA-ORAL
+
INTRA-ORAL
80 -
60 -
40 -
, Pre-op
.
, 1
.
, 2
*
, 3
Postoperative
FIGURE lation to following between
.
.
, 1
.
, 2
.
, 3
PostoperatIve
FIGURE 5. Mean postoperative increases in CRP levels in relation to type of fixation (* P < .05; ** P < .Ol).
20.
, Pre-op
, 4
.
,
,
5
days
6. Mean postoperative increases in CRP levels in resurgical approach in patients treated by rigid fixation the A0 principle. There were no significant differences the two groups.
.
, 4
.
,
1
5
days
FIGURE 7. Changes in CRP levels in three patients with infections of their fracture sites on admission.
usually for the first postoperative day. This might cause some movement in the fracture line and contribute to the more elevated CRP levels seen on the second and third postoperative days. References 1. Fisher CL, Gill C, Forrester MG, et al: Quantitation of “acute phase proteins” postoperatively. Value in detection and monitoring of complications. Am J Clin Path01 66:840, 1976 2. Pepys MB: C-reactive protein-fifty years on. Lancet 1:653, 1981 3. Mayer AD, McMahon MJ, Bowen M, et al: C-reactive protein: An aid to assessment and monitoring of acute pancreatitis. J Clin Path01 37:207, 1984 4. Stahl WM: Acute phase response to tissue injury. Critical Care Medicine 15:545, 1987 5. Aalto K, Gsterman K, Peltola H: Changes in erythmcyte sedimentation rate and C-reactive protein after total hip arthroplasty. Clin Orthop 184: 118, 1984 6. Maury CPJ, Teppo A-M, Raunio P: Control of the acute phase serum amyloid A and C-reactive protein response: Comparison of total replacement of the hip and knee. Eur J Clinical Invest 14:323, 1984 7. Mustard RA, Bohnen JMA, Haseeb S, et al: C-reactive protein values predict postoperative septic complications. Arch Surg 122:69, 1987 8. Fasching G, Kurz R, Wendler M: EinBuR von Operationen auf Entziindungsparameter. (The effect of surgical trauma on parameters of inflammation.) Z Kinderchir 43:3, 1988 9. Kock-Jensen C, Brandslund I, Sogaard I: Lumbar disc surgery and variations in C-reactive protein, erythrocyte sedimentation rate and complement split product C 3d. Acta Neurochir 90:42, 1988 10. Shih L-Y, Wu J-J, Yang D-J: Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop 255:238, 1988 Il. Vainionpti S, Wilppula E, Lalla M, et al: Cefamandole and isoxazol penicillin in antibiotic prophylaxis of patients undergoing total hip or knee-joint arthroplasty. Arch Orthop Trauma Surg 107:228, 1988 12. Shine B, deBeer FC, Pepys MB: Solid phase radioimmunoassays for human C-reactive protein. Clin Chim Acta 117:13, 1981 13. Spiessl B: Internal fixation of the mandible. Berlin Heidelberg, Springer-Verlag. 1989, p 128
Surg
49:464-467,1991
Changes in C-Reactive Protein Associated With Surgical Treatment of Mandibular Fractures TATEYUKI IIZUKA, MD, DDS,* AND CHRISTIAN LINDQVIST, MD, DDS, PHDt C-reactive protein (CRP) levels were determined in 80 patients (67 male, 13 female), each with a single mandibular fracture in either the symphysis, body, or angle region. All patients underwent osteosynthesis (63 with rigid plate fixation following the AO/ASIF principle, 17 with miniplates). Creactive protein levels were measured on admission and daily during hospitalization. Preoperative CRP levels (mean, 28.5 mg/L) varied according to the time that had elapsed since injury. After surgery, there was always an increase in CRP level. The level reached its maximum (mean, 73.2 mg/L) on the second day after operation. Postoperative CRP levels were significantly influenced by the time between trauma and surgery. Significant differences were also observed with different types of fixation. Fixation with rigid plates was associated with smaller increases in CRP level than was fixation with miniplates. The location of the fracture, associated condylar fractures, the use of maxillomandibular fixation, the presence or absence of a tooth at the fracture site, and the surgical approach did not affect the CRP levels. The significance of CRP measurement for interpretation of postoperative situations is discussed and examples of cases in which there was infection are described.
postoperative infection, determination of CRP levels is also superior to determination of ESR because it is quicker. 5-’’ An increase in CRP level or a high CRP level persisting for 2 to 3 weeks after operation is usually indicative of postoperative infection. Creactive protein, which is synthesized by hepatocytes, is one of the “acute phase proteins” in the plasma. The primary signal for synthesis of this protein is production of interleukin-1 by macrophages at tissue injury sites.4 The CRP level is less than 10 mg/L in 99% of healthy individuals.12 Although several studies of CRP levels have been conducted in patients undergoing various types of surgical intervention,5-” studies of CRP levels in the patients surgically treated for fractures have seldom been undertaken; CRP levels in cases of surgical treatment of facial bone fractures have not been reported so far. Mandibular fractures are often exposed to contamination by oral bacteria and, therefore, the possibility of infection always needs to be taken into account. Posttraumatic and/or postoperative swelling makes it difficult to differentiate
Erythrocyte sedimentation rates (ESR) and white blood cell counts are laboratory parameters often used to diagnose infection. Both parameters are fairly nonspecific and are influenced in trauma cases by both the extent of injury and the type of surgical treatment. Determination of serum levels of C-reactive protein (CRP) has, therefore, been suggested for the early diagnosis of bacterial infection. The value of determining CRP levels for the assessment of acute infection and tissue destruction has been well documented.“4 In the diagnosis of Received from the Department of Oral and Maxillofacial Surgery, Helsinki University Central Hospital, Helsinki, Finland. * Resident. t Head. Address correspondence and reprint requests to Dr lizuka: Department of Or& and Maxillofacial Surgery, Helsinki University Central Hospital, Kasarmikatu 11-13, SF-00130 Helsinki 13, Finland. 0 1991 geons
American
Association
of Oral
and Maxillofacial
Sur-
0278-2391/91/4905-0004$3.00/O
464
IIZUKA AND LINDQVIST
between infection and a normal reaction to surgical intervention. The information provided by CRP levels could therefore lead to a more rapid diagnosis. The aim of this study was to determine the degree and timing of the natural serum CRP response to mandibular fracture and its surgical treatment. Materials and Methods Open reduction and plate fixation of acute mandibular fractures were undertaken in 252 patients in the Department of Maxillofacial Surgery, Helsinki University Central Hospital, during the period of June 1, 1986 to November 30, 1989. This study included patients who had only a single fracture (other than one involving the condyloid process) in the symphysis, body, or angle region, and who underwent only one osteosynthesis. Patients with multiple injuries or who were suffering from any systemic disease were excluded. Some patients were also excluded because insufficient laboratory data were available. Three patients had an infected fracture site on admission. Eighty patients were ultimately studied (67 male, 13 female). Their mean age was 34.8 years (range, 12 to 83 years). The mean duration of hospitalization was 4.9 days (range, 3 to 15 days). In all 80 cases, open reduction and plate fixation were indicated because of displacement or instability of the fracture. In 63 cases, the fracture was treated using rigid fixation following the A0 principle.” Of these 63 cases, osteosynthesis was performed in 14 cases using an intraoral approach. In 49 cases, the extraoral approach was used. In patients treated with rigid fixation, there were associated condylar fractures in 20 cases. Six of these required maxillomandibular fixation for 2 to 4 weeks postoperatively, but the others were not immobilized. In general, neither elastic nor rigid maxillomandibular fixation was used postoperatively in the patient group treated with A0 rigid fixation. In 17 cases, the fracture was treated with miniplates using the intraoral approach. When a miniplate was used, the patient was always placed in maxillomandibular fixation for 2 to 4 weeks postoperatively. A condylar fracture was also diagnosed in 13 of the patients treated with miniplates. Fifty of the mandibles were dentulous, 30 were edentulous. The median delay before surgery was 2.0 days (range, 0 to 9 days). Fractures healed normally in all patients except one with preoperative infection. This patient’s osteosynthesis plate had to be removed about 1 month after surgery because of persistent infection. Serum CRP levels were measured routinely on
admission, then daily during hospitalization. The CRP level was determined immunoturbidimetrically at 340 nm using a Hitachi 704 analyzer and CRP antiserum (Kallestad Diagnostics, Chaska, MN) and CRP buffer (cat. no. D-179) and CRP standards (cat. no. D-274) from Orion Diagnostica, Espoo, Finland. The upper normal CRP limit is 10 mg/L. Values were reported as means and standard deviations (SD). Analysis of variance was used to assess the statistical significance of differences between groups. Student’s t test for paired values was used to assess the statistical significances of differences within groups. P values less than .05 were considered to indicate statistical significance. Results Preoperative serum CRP values ranged from 1 mg/L to 146 mg/L, depending on the time that had elapsed since the initial trauma (Fig 1). Significantly higher levels of CRP were observed between 12 and 84 hours after injury than at other times. When CRP levels were measured within 12 hours of injury, the mean level was 10.5 mg/L (SD, rt 9.5 mg/L). Between 12 and 84 hours after injury the mean level was 33.1 mg/L (SD, t 25.8 mg/L). By the fourth day after injury, and subsequently, CRP levels were markedly lower (mean, 11.5 mg/L; SD, + 6.2 mg/L) and virtually constant, irrespective of the time that had elapsed since injury. The age and sex of the patients, location of the fracture, associated condylar fractures, and the presence or absence of a tooth at the fracture site did not affect CRP increases caused by injury. Surgical intervention resulted in significant increases in CRP values (Fig 2). The mean serum CRP level was 28.5 mg/L (SD, -+ 25.7 mg/L) preopTime 36
0
1
in hours
60
2 Time
from
64
injury
106
3
4
in days
from
132
5
156
6
160
7
injury
FIGURE 1. Preoperative CRP levels in relation to the time elapsed since injury. The bars represent standard deviations of the means for each period of time.
466
C-REACTIVE
CRP (mg/l) 120,
60 -
60 40 21.3
20 1
o!
f
. ,
Pre-op
-
I
-
2
1
1
*
I
.
1
I
4 days
3 Postoperative
5
FIGURE 2. Mean postoperative increases in CRP levels. The bars represent standard deviations of the means for each period of time.
eratively on the day of surgical treatment. Maximum postoperative CRP levels were observed in 82% of cases on the second day after the operation (mean, 73.2 mg/L; SD, + 34.9 mg/L). CRP levels began to decrease on the third day after the operation. The maximum serum CRP level (mean, 75.3 mg/L; SD, + 35.3 mg/L) exceeded 100 mg/L in only 14 patients (17.7%). The highest CRP level recorded was 157 mg/L. The increase in serum CRP level depended on the time that had elapsed between trauma and surgery. The patients were divided into three groups on this basis. Thirty-nine patients were operated within 36 hours of injury (group A), 29 patients between 36 and 84 hours after injury (group B), and 12 patients 84 hours or more after injury (group C). In groups A and B, the increases in serum CRP level were significantly higher (P < .OOl)than in group C (Fig 3). There was no significant difference between groups CRP 100 -
(mg/l)
I30 -
FRACTURES
A and B. The location of the fracture, the type of plate, the surgical approach, the use of maxillomandibular fixation, associated condylar fractures, the presence or absence of a tooth at the fracture site, and the sex and age of the patients had no effect on serum CRP levels. In groups A and B (n = 68), patients who underwent intraoral surgery were found to exhibit higher serum CRP values than those who underwent extraoral surgery (Fig 4). This difference was associated with the type of fixation, however, and not the surgical approach, because a similar difference was also observed between the two types of fixation (Fig 5). Rigid fixation resulted in fairly similar CRP curves, irrespective of the surgical approach (Fig 6). Neither did the use of maxillomandibular Iixation affect CRP increases caused by surgery in the patient group treated with A0 rigid fixation. Three patients with clinically obvious infections of their fracture sites underwent extraoral open reduction and rigid fixation. All had markedly high preoperative serum CRP values (Fig 7). Rigid fixation resulted in steady decreases in and ultimate normalization of CRP levels in two of these patients. The postoperative courses in these two patients were uneventful. In the third patient (patient 1, Fig 7) there was a delay in the normalization of the CRP level after operation. Postoperative infection of the fracture site required removal of the osteosynthesis plate after 36 days. Discussion
Determination of serum CRP levels was introduced to allow early detection of infection because it is quicker and more specific than determination of ESR. Determination of CRP levels is, however, still far from ideal because of its low specificity in patients who have sustained musculoskeletal trauma
GROUP A
e e +
A l-l
PROTEIN AND MANDIBULAR
GWPB GRCUPC
60 40 20 0.
,
Pre-op
-
1
1
*
I
-
I
3 2 Postoperative
=
I
4 days
-
1
’
5
FIGURE 3. Mean postoperative increases in CRP levels in relation to time between injury and surgery. Surgical treatment took place within 36 hours of injury in group A, between 36 and 84 hours after injury in group B, and more than 84 hours after injury in group C (* P < .05; ** P < .Ol; *** P < .OOl).
Pre-op
1
2
3
Postoperative
4
5
days
FIGURE 4. Mean postoperative increases in CRF levels in relation to surgical approach (* P < .05; ** P < .Ol).
467
IIZUKA AND LINDQVIST
CRP (ma/l)
Patient 1 Patlent 2 Patlent 3
U + +
RIGID PLATE MINIPLATE
+ + 100 -
60 80 40 -
60 40 -
20 -
o!
20 -
1 1
.
,
Pre-op
.
,
.
,
2
1
.
,
.
4
3 Postoperative
I
,
0.
5
days
or undergone surgical treatment. Shortly after operation, CRP values can be high because of both the initial trauma and the subsequent surgery. Other factors that raise CRP levels, for example pneumonia, urinary tract infection7 thrombophlebitis, acute pancreatitis3 and myocardial infarction,* can also be associated with an acute fracture. These possibilities make the interpretation of high serum CRP values in trauma patients difficult. CRP values in surgical intervention are clearly greater when the operation is undertaken within 3 days of injury than when it occurs 4 or more days after injury. This significantly high increase in serum CRP levels caused by both injury and surgical intervention has not been noted previously. Rises in serum CRP levels seemed also to be related to the type of fixation. In the patients treated with miniplates, maxillomandibular fixation was removed after surgery for safe extubation of the trachea, and the mouth was kept open until full recovery from general anesthesia, CRP (mgil) 100 7 +
EXTRA-ORAL
+
INTRA-ORAL
80 -
60 -
40 -
, Pre-op
.
, 1
.
, 2
*
, 3
Postoperative
FIGURE lation to following between
.
.
, 1
.
, 2
.
, 3
PostoperatIve
FIGURE 5. Mean postoperative increases in CRP levels in relation to type of fixation (* P < .05; ** P < .Ol).
20.
, Pre-op
, 4
.
,
,
5
days
6. Mean postoperative increases in CRP levels in resurgical approach in patients treated by rigid fixation the A0 principle. There were no significant differences the two groups.
.
, 4
.
,
1
5
days
FIGURE 7. Changes in CRP levels in three patients with infections of their fracture sites on admission.
usually for the first postoperative day. This might cause some movement in the fracture line and contribute to the more elevated CRP levels seen on the second and third postoperative days. References 1. Fisher CL, Gill C, Forrester MG, et al: Quantitation of “acute phase proteins” postoperatively. Value in detection and monitoring of complications. Am J Clin Path01 66:840, 1976 2. Pepys MB: C-reactive protein-fifty years on. Lancet 1:653, 1981 3. Mayer AD, McMahon MJ, Bowen M, et al: C-reactive protein: An aid to assessment and monitoring of acute pancreatitis. J Clin Path01 37:207, 1984 4. Stahl WM: Acute phase response to tissue injury. Critical Care Medicine 15:545, 1987 5. Aalto K, Gsterman K, Peltola H: Changes in erythmcyte sedimentation rate and C-reactive protein after total hip arthroplasty. Clin Orthop 184: 118, 1984 6. Maury CPJ, Teppo A-M, Raunio P: Control of the acute phase serum amyloid A and C-reactive protein response: Comparison of total replacement of the hip and knee. Eur J Clinical Invest 14:323, 1984 7. Mustard RA, Bohnen JMA, Haseeb S, et al: C-reactive protein values predict postoperative septic complications. Arch Surg 122:69, 1987 8. Fasching G, Kurz R, Wendler M: EinBuR von Operationen auf Entziindungsparameter. (The effect of surgical trauma on parameters of inflammation.) Z Kinderchir 43:3, 1988 9. Kock-Jensen C, Brandslund I, Sogaard I: Lumbar disc surgery and variations in C-reactive protein, erythrocyte sedimentation rate and complement split product C 3d. Acta Neurochir 90:42, 1988 10. Shih L-Y, Wu J-J, Yang D-J: Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop 255:238, 1988 Il. Vainionpti S, Wilppula E, Lalla M, et al: Cefamandole and isoxazol penicillin in antibiotic prophylaxis of patients undergoing total hip or knee-joint arthroplasty. Arch Orthop Trauma Surg 107:228, 1988 12. Shine B, deBeer FC, Pepys MB: Solid phase radioimmunoassays for human C-reactive protein. Clin Chim Acta 117:13, 1981 13. Spiessl B: Internal fixation of the mandible. Berlin Heidelberg, Springer-Verlag. 1989, p 128
