Injury, Int. J.

Care Injured 43 (2012) 670–675

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

The effect of ischemia reperfusion injury on skeletal muscle

Syed Gillani, Jue Cao, Takashi Suzuki, David J. Hak *
Denver Health/Univeristy of Colorado, 777 Bannock Street, MC 0188 Denver, CO 80204, USA

A R T I C L E I N F O A B S T R A C T

Article history: Ischemia reperfusion (IR) injury occurs when tissue is reperfused following a period of ischemia, and
Accepted 7 March 2011 results from acute inflammation involving various mechanisms. IR injury can occur following a range of
circumstances, ranging from a seemingly minor condition to major trauma. The intense inflammatory
Keywords: response has local as well as systemic effects because of the physiological, biochemical and
Ischemia reperfusion injury immunological changes that occur during the ischemic and reperfusion periods. The sequellae of the
Crush syndrome cellular injury of IR may lead to the loss of organ or limb function, or even death. There are many factors
Compartment syndrome
which influence the outcome of these injuries, and it is important for clinicians to understand IR injury in
order to minimize patient morbidity and mortality. In this paper, we review the pathophysiology, the
effects of IR injury in skeletal muscle, and the associated clinical conditions; compartment syndrome,
crush syndrome, and vascular injuries.
ß 2011 Published by Elsevier Ltd.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670
Pathophysiology of IR Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Azurophilic granules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Specific granules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Gelatinase or tertiary granules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Secretory granules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Immunological aspect of the IR injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Role of complement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Role of cytokines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Factors affecting the outcome of the IR injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Critical ischemic time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Type of muscle fibres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Clinical situations associated with skeletal muscle IR injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Compartment syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Crush syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Vascular injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674

Introduction of circumstances, ranging from a seemingly minor condition to

Ischemia reperfusion (IR) injury occurs when tissue is reperfused
following a period of ischemia, and results from acute inflammation
involving various mechanisms. IR injury can occur following a range
* Corresponding author. Tel.: +1 303 436 6403; fax: +1 303 436 6572.
E-mail address: David.Hak@dhha.org (D.J. Hak).
major trauma. The intense inflammatory response has local as well
as systemic effects because of the physiological, biochemical and
immunological changes that occur during the ischemic and
reperfusion periods.16,19,21 The sequellae of the cellular injury of
IR may lead to the loss of organ or limb function, or even death. There
are many factors which influence the outcome of these injuries, and
it is important for clinicians to understand IR injury in order to
minimize patient morbidity and mortality.

0020–1383/$ – see front matter ß 2011 Published by Elsevier Ltd.

doi:10.1016/j.injury.2011.03.008
 S. Gillani et al. / Injury, Int. J. Care Injured 43 (2012) 670–675 671

IR injury is a common and important clinical problem which

affects many different organ systems including the brain (stroke
and head injury), heart (myocardial infarction), and skeletal
muscle. IR injury affects donor organ transplants.38 IR injury is
also thought to play a role in the formation and healing failure of
chronic wounds such as diabetic foot wounds and pressure
ulcers.48 IR injury plays an important role in extremity injuries
sustained in military conflicts. High energy blast injuries are
associated with both extensive bone and soft tissue damage,
tourniquets may be applied to the limb during evacuation,
and finally associated vascular injury may lead to IR injury. In
this paper, we review the pathophysiology, the effects of IR
injury in skeletal muscle, and the associated clinical conditions;
compartment syndrome, crush syndrome, and vascular inju-
ries.30,40–42,46,50,61,64
Fig. 1. Diagram showing how cell injury can lead to free radical reactions in the
Pathophysiology of IR Injury surrounding area.
Adapted from: Halliwell B. Reactive oxygen species in living systems: source,
biochemistry, and role in human disease. Am J Med 1991; 9: 14S–22S.
Reactive oxygen species (ROS) and activated neutrophils are the
main factors responsible for local and systemic damage caused by
IR. ROS are oxygen derived radicals like radical the superoxide radical (OH). Hydroxyl radicals are extremely reactive, destroying
anion (O2 ), hydrogen peroxide (H2O2), hydroxyl radical (OH), tissue by modifying DNA and lipid peroxidation.1,23,33
hypochlorous acid (HOCl) and nitric oxide-derived peroxynitrite.
Whilst there are a number of sources of these ions xanthine Specific granules
oxidase (XO) and activated neutrophils are the most common
source. Specific granules are another type of intracellular granules
Xanthine oxidase plays a major role in ROS production. This released during the inflammatory process and its products my
enzyme is localized in microvascular endothelial cells of skeletal have a role in complement activation.72 Specific granules also
muscle, and normally exists as an oxidized nicotinamide-adenine contain collagenase and apolactoferrin which play significant roles
dinucleotide (NAD+)-dependent dehydrogenase (XDH) in nonis- in inflammation by adhering neutrophils to inflammatory site.51
chemic cells. During ischemia, XDH is converted to the oxidant-
producing XO. Ischemia also induces the breakdown of adenosine Gelatinase or tertiary granules
triphosphate (ATP) to hypoxanthine. Thus, ischemia-induced XO
production and the accumulation of hypoxanthine set the stage for These granules may play an important role in functional utility
oxidant production by the XO reaction. The only missing substrate of surface protein. The leakage of the neutrophils not only causes
XO-catalysed ROS formation is molecular oxygen, which is cell damage but also it is associated with severe inflammation.32
provided upon reperfusion.18,44,60
Reactive oxygen species (ROS) are potent oxidizing and Secretory granules
reducing agents which cause cell membrane damage by lipid
peroxidation, and in turn by neutrophil activation.63 Cell injury Like gelatinase or tertiary granules, these granules may play an
activates cyclooxygenase and lipoxygenase pathways along with important functional role as a surface protein.
transition metal ions which increase lipid peroxidation in the During reperfusion, the activated leukocytes adhere to the
surrounding tissues (Fig. 1). Products of the lipoxygenase pathway endothelium and create a ‘‘microenvironment’’ which results in
are responsible for neutrophil activation. endothelial disruption.67 Activated leukocytes also transmigrate
Neutrophils are formed in the bone marrow, and their rate of through the post capillary venules to the interstitial space and
turnover is approximately 1011 cells/day or 100 g/day.52,69 Neu- induce microvascular barrier disruption by releasing ROS and
trophils contain four types of intracellular granules which release cytotoxic enzymes. This causes leakage of the plasma proteins. The
their products upon activation. interstitial fluid pressure is increased because of the increased
transcapillary fluid filtration. The resultant oedema associated
Azurophilic granules with increased interstitial fluid pressure compresses the capillar-
ies, leading to the development of the no-reflow phenomenon.
These granules contain myeloperoxidase (MPO), elastase, and Thus, adhesive and transmigrated leukocytes contribute to the
neutral proteases. MPO is an enzyme that plays an important pathogenesis of skeletal muscle IR by directly attacking myocytes
role in IR injury by producing hypochlorous acid and oxidants and through the no-reflow phenomenon. Because of the no-reflow
(Fig. 2). MPO catalyses the reaction of hydrogen peroxide (H2O2) phenomenon, metabolic demands of the myocytes cannot be met
with chloride ion to form hypochlorous acid (HOCl). The
products of MPO initiate lipid peroxidation in cell mem-
branes.1,23,33
HOCl is a non-radical oxidant that causes increased membrane
permeability.23 HOCl also reacts with the other compounds to form
ROS. HOCl reacts with hydrogen peroxide forming singlet oxygen
(1O2) which is an electronically excited state of oxygen produced
by activated neutrophils that reacts with membrane lipids to
initiate lipid peroxidation. Lipid peroxidation is the reaction Fig. 2. Myeloperoxidase (MPO) catalyses the reaction of hydrogen peroxide with
through which cell membrane starts leaking. HOCl reacts with chloride ion to form hypochlorous acid (HOCl). HOCl reacts with other molecules to
superoxide (O2 ) and ferrous iron (Fe+2) to form the hydroxyl form reactive oxygen species with high potential for tissue damage.
672 S. Gillani et al. / Injury, Int. J. Care Injured 43 (2012) 670–675
during reperfusion, causing muscle necrosis. It has also been
suggested that neutrophils may directly adhere to the capillary
endothelium and cause microvascular occlusion.21
Immunological aspect of the IR injury
Role of complement
The complement system is a biological cascade whose function
includes the clearance of pathogens from the organism. Three
biological pathways (classic, alternative complement, and man-
nose-binding) activate the complement system.
Current evidence suggests that ischemia leads to expression of a
neoantigen or ischemia antigen on cellular surfaces, and this
induces the binding of circulating IgM natural antibody. This
immune complex then causes C1 binding, complement activation,
and the formation of C3a and C3b. C3b then activates the
remainder of the complement cascade leading to formation of
the membrane attack complex (MAC), which is the principal
mediator of injury. The MAC can also stimulate arachidonic acid
metabolism resulting in the release of prostaglandin E2 from
macrophages, leukotriene B4 from neutrophils, thromboxane B2,
prostanoids, interleukin-1, and ROS.24,25,43
In humans, the role of complement activation has been
demonstrated by increased serum levels of C3a and C5a after
lower extremity ischemia.19,28 The role of complement activation
in remote organ injury (e.g. lung and liver) due to IR injury of
skeletal muscle has been demonstrated through decreased level of
creatinine kinase (CK), myeloperoxidase (MPO) and alanine
aminotransferase (ALT) in C5-deficient mouse and in mice injected
by complement inhibitors.34–37,49,57,71
Role of cytokines
Cytokines are a category of signalling involved in cellular
communication. They encompass a large and diverse family of
polypeptide regulators that are produced widely throughout the
body by cells of diverse embryological origin. The term cytokine
has also been used to refer to the immunomodulating agents
(interleukins and interferons).68 In the literature, the role of
interleukin-1 (IL-1), interleukin-6 (IL-6), thromboxane A2 (TXA2)
and tissue necrosis factor (TNF) are well documented in IR injury.
These cytokines provide signals between the responding leucocyte
and the vascular endothelial barrier and are believed to be
responsible for selective adhesion and transmigration of leuko-
cytes.2,3,59,73–75
Clinical trials targeting neutrophils blockade and ROS scavenging
(through free radical scavengers) thus far have failed to be
successful.13,15 Results from clinical trials on IR injury of myocardi-
um suggests that anti-complement therapy may offer injury
protection, providing future directions for novel interventions to
lower morbidity and mortality following skeletal muscle IR injury.14
Factors affecting the outcome of the IR injury
All tissues sensitive to IR but the damage to muscle may cause
major systemic complications. The physiological changes that
occur following ischemia and reperfusion have been studied in
Table 2
Muscle fibres types.
Type of muscle fibre Properties
Type1 fibres Slow-twitch oxidative fibres
Type IIa fibres Fast-twitch oxidative glycolytic fibres
Type IIb fibres Fast twitch glycolytic fibres
Table 1
Critical ischemic time in different tissues.
Type of tissues Critical ischemia time at
normal temperature
Muscle 4h
Nerve 8h
Fat 13 h
Skin 24 h
Bone 4 days
detail. The extent and degree of damage is multifactorial, but
mainly depends on the critical ischemia time and tissue type.
Critical ischemic time
Critical ischemia time is defined as the maximum time interval
that a tissue can tolerate and still remain viable.7 The critical
ischemic time varying depending on the tissue (Table 1) and on the
temperature.11
Type of muscle fibres
Muscles are composed of different fibre types(Table 2). Several
experimental animal studies which illustrate the outcome of IR
injury differs in different types of muscle fibres.6,8,9,20,55,70 Type II
Myosin muscle fibres sustain more damage than type I muscle
fibres. The muscles with Type II fast-twitch fibres sustain more
damage to the mitochondria, sarcoplasmic reticulum, myofibrils
and have a delayed recovery after IR.70 Similarly, the muscle with
Type II muscle fibres had decreased number of fibres and more
necrosis than muscle with Type I muscle fibre after IR.6,55 Fast twist
muscle fibres are more resistant to ischemic insults than slow
twitch muscles.20
Clinical situations associated with skeletal muscle IR injury
Compartment syndrome
Acute compartment syndrome is a condition in which increased
pressure within a closed fascial space reduces capillary perfusion
below a level necessary for tissue viability.46 The initial insult may
be due to a number of reasons, such as direct or indirect trauma,
burns, and prolonged compression in a comatose patient. The
cumulative effect of the ischemia results in microcirculatory
changes due to activation of inflammatory mediators as discussed
above. The microvascular permeability increases resulting in an
increased rate of transcapillary fluid leakage, further increasing the
intracompartmental pressure (ICP).26,41,58 Research studies in
animals has suggested that the severity of skeletal muscle injury
can be decreased with the administration of the antioxidants, such
as vitamin C.5,31,56
Crush syndrome
Crush syndrome is the systemic manifestation of muscle cell
damage resulting from direct pressure or crushing. The complete
pathophysiology of the crush injury is still being investigated but
Function Examples
Contraction and posture Soleus
Locomotion Vastus lateralis
Locomotion Semi-membranous
 S. Gillani et al. / Injury, Int. J. Care Injured 43 (2012) 670–675
the systemic manifestations in crush syndrome are due to
rhabdomyolysis and IR injury. As a result of the mechanical
stress due to crush injury, muscle cells become stretched and the
sarcolemmal membranes start to leak contents out of the cells
into the circulation. These contents include myoglobin, urate,
potassium and phosphate which are systemically toxic. Water,
calcium and sodium leaks into the muscle cell from the
extracellular space because of the leakiness of the sarcolemma,
causes muscle swelling and intravascular volume depletion 61
(Fig. 3).
After muscle compression is relieved and reperfusion is re-
established, myoglobin, urate, potassium and phosphate in the
affected muscle cells are released into the circulation. Large
volumes of intravascular fluid also leaks into the involved muscles
due to the increased capillary permeability. This release of toxins
and hypovolemia leads to the systemic effects seen in crush
syndrome.40
Although the clinical signs of crush injury are the same as
compartment syndrome, the pathophysiology is different. In
compartment syndrome, the elevation of the intracompartmental
pressure causes the muscle damage and necrosis, whereas is crush
injury the compartment pressure elevation is secondary to the
muscle damage. In crush injury the muscle damage is due to
prolonged direct pressure. As a result of this damage, the muscle
cells swell, causing a secondary elevation in the compartment
pressure.42
In experimental settings several pharmacological interventions
can reduce the extent of the muscle damage from a crush injury,
but efficacy of these agents has yet to be established in clinical
settings.30,50 As the clinical signs of CS are the same as the late signs
of injury, i.
Vascular injury
Vascular injuries in orthopaedics are mainly associated with
trauma. Vascular injury causes ischemia, and depending on tissue
critical ischemia time will result in ischemic damage. Muscle is the
primary affected tissue. Restoration of perfusion may result in a
subsequent reperfusion injury, with associated adult respiratory
distress syndrome (ARDS) and multiple organ failure syndrome
(MOF). The mechanism of IR injury after vascular injury is the same
as described above.16 Vascular injuries may also cause compartment
syndrome in the extremities.64
Fig. 3. The pathogenesis of rhabdomyolysis. Adapted from Ref. [40].
673
Summary
Although IR injury can affect every organ in the body its effects
on skeletal muscles is frequently quite devastating. Whilst
ischemia causes the initial insult, paradoxically it is the reperfusion
which causes the most significant damage to the muscle. Since the
outcome of the IR injury depends on many factors, it is important
to understand the pathophysiology of IR injury. Depending on the
extent of the muscle damage, reperfusion can cause multiple organ
dysfunction syndrome (MODS) which is life threatening.16
Whilst there are few clinical strategies designed to reduce the
effects of IR injuries, none of them are completely successful in
attenuating the detrimental effects of an IR injury. These strategies
include pharmacological intervention, hyperbaric oxygen, hypo-
thermia, and pre- and post-injury conditioning.27,31,36,56
Therapeutic delivery of hydrogen sulphide has been shown to
protect muscle cells against ischemia–reperfusion injury when
administered prior to ischemia, and a recent study has shown
promising results when administered following ischemia but prior
to reperfusion.29 Copolymer surfactants have important ‘‘surface-
active’’ properties that adsorb to damaged cell membranes and can
seal cell membrane defects. The administration of poloxamer 188,
a copolymer surfactant, has been shown to decrease myocyte
injury and improve survival in a mouse hind-limb ischemia
model.47 Various complement blocking compounds are also being
explored to mitigate IR damage.27,36
Hyperbaric (HBO) treatment can increase the partial pressure of
oxygen in tissue. HBO treatment has been shown to be effective in
reducing skeletal muscle IR injury in a rat tourniquet induced limb
ischemia model.22,65 Hypothermia is commonly used to maintain
amputated tissues prior to replantation. The use of local hypother-
mia during ischemia, during reperfusion, and during both was
studied in a rat gracilis muscle flap model. Local hypothermia was
shown to be protective when applied during the early reperfusion of
skeletal muscle, suggesting a potential future clinical strategy for
minimizing reperfusion induced IR injury.45 Some promising results
have also recently been reported on the ability of low-level laser
therapy to protect skeletal muscle against IR injury.4,39
In ischemic preconditioning, brief episodes of ischemia and
reperfusion are administered. In many tissues this has been shown
to be protective against injury during a subsequent period of
sustained ischemia. Whilst useful for some clinical situations,
ischemic preconditioning is not feasible for trauma induced
674 S. Gillani et al. / Injury, Int. J. Care Injured 43 (2012) 670–675
conditions. Instead, investigators have explored potential benefits
of post-conditioning on IR injury. Following 3 h of complete
ischemia to the rat extensor digitorum longus muscle, investiga-
tors studied the effect of 6 cycles of 15 s of reperfusion followed by
15 s of re-occlusion. They found that this post-ischemic condition-
ing attenuated the acute inflammatory reaction induced by IR.53
Since skeletal muscle is not a considered a vital organ most
research in this field has focused on the heart, kidney, liver, brain
and intestine. However, there has been an increased interest in
skeletal muscle IR injury due to the significant extremity injuries
sustained by soldiers during recent conflicts in Afghanistan and
Iraq. In limb salvage procedures, the role of IR injury plays a critical
role in the patients functional outcome. The goal of future research
studies should focus on elucidating the common pathway for all
the IR injury mechanisms, which may allow a more directed
interventional strategy to minimize subsequent damage.
Conflict of interest
None of the authors report any conflict of interest in connection
with this paper.
References
1. Arnhold J. Properties, functions, and secretion of human myeloperoxidase.
Biochemistry (Moscow) 2004;69:4–9.
2. Ascer E, Gennaro M, Cupo S, Mohan C. Do cytokines play a role in skeletal muscle
ischemia and reperfusion? J Cardiovasc Surg (Torino) 1992;33:588–92.
3. Ascer E, Mohan C, Gennaro M, Cupo S. Interleukin-1 and thromboxane release
after skeletal muscle ischemia and reperfusion. Ann Vasc Surg 1992;6:69–73.
4. Avni D, Levkovitz S, Maltz L, Oron U. Protection of skeletal muscles from
ischemic injury: low-level laser therapy increases antioxidant activity. Photo-
med Laser Surg 2005;23:273–7.
5. Bushell A, Klenerman L, Davies H, et al. Ischemia–reperfusion-induced muscle
damage. Protective effect of corticosteroids and antioxidants in rabbits. Acta
Orthop Scand 1996;67:393–8.
6. Carvalho AJ, Hollett P, McKee NH. Recovery of synergistic skeletal muscle
function following ischemia. J Surg Res 1995;5:527–33.
7. Chafin B, Belmont MJ, Quraishi H, et al. Effect of clamp versus anastomotic-
induced ischemia on critical ischemic time and survival of rat epigastric
fasciocutaneous flap. Head Neck 1999;21:198–203.
8. Chan RK, Austen Jr WG, Ibrahim S, et al. Reperfusion injury to skeletal muscle
affects primarily type II muscle fibers. J Surg Res 2004;122:54–60.
9. Chan RK, Ibrahim SI, Takahashi K, et al. The differing roles of the classical and
mannose-binding lectin complement pathways in the events following skeletal
muscle ischemia–reperfusion. The Journal of Immunology 2006;177:8080–5.
11. Eckert P, Schnackerz K. Ischemic tolerance of human skeletal muscle. Ann Plast
Surg 1991;26:77–84.
13. Faxon DP, Gibbons RJ, Chronos NA, et al. The effect of blockade of the CD11/CD18
integrin receptor on infarct size in patients with acute myocardial infarction
treated with direct angioplasty: the results of the HALT-MI study. J Am Coll
Cardiol 2002;40:1199–204.
14. Fitch JC, Rollins S, Matis L, et al. Pharmacology and biological efficacy of a
recombinant, humanized, single-chain antibody C5 complement inhibitor in
patients undergoing coronary artery bypass graft surgery with cardiopulmo-
nary bypass. Circulation 1999;100:2499–506.
15. Flaherty JT, Pitt B, Gruber JW, et al. Recombinant human superoxide dismutase
(h-SOD) fails to improve recovery of ventricular function in patients undergo-
ing coronary angioplasty for acute myocardial infarction. Circulation
1994;89:1982–91.
16. Giannoudis PV. Current concepts of the inflammatory response after major
trauma: an update. Injury 2003;34:397–404.
18. Granger DN. Role of xanthine oxidase and granulocytes in ischemia–reperfu-
sion injury. Am J Physiol 1988;255(6 (Pt 2)):H1269–75.
19. Groeneveld AB, Raijmakers PG, Rauwerda JA, Hack CE. The inflammatory
response to vascular surgery-associated ischemia and reperfusion in man:
effect on postoperative pulmonary function. Eur J Vasc Endovasc Surg
1997;14:351–9.
20. Gurke L, Marx A, Sutter PM, et al. Function of fast- and slow-twitch rat skeletal
muscle following ischemia and reperfusion at different intramuscular tem-
peratures. Eur Surg Res 2000;32:135–41.
21. Gute DC, Ishida T, Yarimizu K, Korthius RJ. Inflammatory responses to ischemia,
and reperfusion in skeletal muscle. Mol Cell Biochem 1998;179:169–87.
22. Haapaniemi T, Nylander G, Sirsjö A, Larsson J. Hyperbaric oxygen reduces
ischemia-induced skeletal muscle injury. Plast Reconstr Surg 1996;97:602–7.
23. Hampton MB, Kettle AJ, Winterbourn CC. Inside the neutrophil phagosome:
oxidants, myeloperoxidase, and bacterial killing. Blood 1998;92:3007–17.
24. Hansch GM, Seitz M, Betz M. Effect of the late complement components C5b-
9 on human monocytes: release of prostanoids, oxygen radicals and of a
factor inducing cell proliferation. Int Arch Allergy Appl Immunol 1987;82:
317–20.
25. Hansch GM, Seitz M, Martinotti G, et al. Macrophages release arachidonic acid,
prostaglandin E2, and thromboxane in response to late complement compo-
nents. J Immunol 1984;133:2145–50.
26. Hargens AR, Schmidt DA, Evans KL, et al. Quantitation of skeletal-muscle
necrosis in a model compartment syndrome. J Bone Joint Surg Am
1981;63:631–6.
27. Haynes DR, Harkin DG, Bignold LP, et al. Inhibition of C5a-induced neutrophil
chemotaxis and macrophage cytokine production in vitro by a new C5a receptor
antagonist. Biochem Pharmacol 2000;60:729–33.
28. Heideman M, Norder-Hansson B, Bengtson A, Mollnes TE. Terminal comple-
ment complexes and anaphylatoxins in septic and ischemic patients. Arch Surg
1988;123:188–92.
29. Henderson PW, Jimenez N, Ruffino J, et al. Therapeutic delivery of hydrogen
sulfide for salvage of ischemic skeletal muscle after the onset of critical
ischemia. J Vasc Surg 2011;53:785–91.
30. Huerta-Alardı́n AL, Varon J, Marik PE. Bench-to-bedside review: rhabdomyoly-
sis—an overview for clinicians. Crit Care 2005;9:158–69.
31. Kearns SR, Daly AF, Sheehan K, et al. Oral vitamin C reduces the injury to
skeletal muscle caused by compartment syndrome. J Bone Joint Surg Br
2004;86:906–11.
32. Kjeldsen L, Sengelov H, Lollike K, et al. Isolation and characterization of
gelatinase granules from human neutrophils. Blood 1994;83:1640–9.
33. Klebanoff SJ. Myeloperoxidase: friend and foe. J Leukoc Biol 2005;77:598–625.
34. Kyriakides C, Austen Jr W, Wang Y, et al. Skeletal muscle reperfusion injury is
mediated by neutrophils and the complement membrane attack complex. Am J
Physiol 1999;277:C1263–8.
35. Kyriakides C, Austen Jr WG, Wang Y, et al. Neutrophil mediated remote organ
injury after lower torso ischemia and reperfusion is selectin and complement
dependent. J Trauma 2000;48:32–8.
36. Kyriakides C, Wang Y, Austen Jr WG et al. Moderation of skeletal muscle
reperfusion injury by a sLe(x)- glycosylated complement inhibitory protein.
Am J Physiol 2001;281:C224–30.
37. Lindsay TF, Hill J, Ortiz F, et al. Blockade of complement activation prevents local
and pulmonary albumin leak after lower torso ischemia–reperfusion. Ann Surg
1992;216:677–83.
38. Linfert D, Chowdhry T, Rabb H. Lymphocytes and ischemia–reperfusion injury.
Transplant Rev (Orlando) 2009;23:1–10.
39. Lakyová L, Toporcer T, Tomečková V, et al. Low-level laser therapy for protection
against skeletal muscle damage after ischemia–reperfusion injury in rat hin-
dlimbs. Lasers Surg Med 2010;42:665–72.
40. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care
Clin 2004;20:171–92.
41. Mars M, Hadley GP. Raised intracompartmental pressure and compartment
syndromes. Injury 1998;29:403–11.
42. Michaelson M. Crush injury and crush syndrome. World J Surg 1992;16:899–
903.
43. Morgan BP. Regulation of the complement membrane attack pathway. Crit Rev
Immunol 1999;19:173–98.
44. Moriwaki Y, Yamamoto T, Higashino K. Enzymes involved in purine metabo-
lism—a review of histochemical localization and functional implications. Histol
Histopathol 1999;14:1321–40.
45. Mowlavi A, Neumeister MW, Wilhelmi BJ, et al. Local hypothermia during early
reperfusion protects skeletal muscle from ischemia–reperfusion injury. Plast
Reconstr Surg 2003;111:242–50.
46. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin North Am
1983;63:539–65.
47. Murphy AD, McCormack MC, Bichara DA, et al. Poloxamer 188 protects against
ischemia–reperfusion injury in a murine hind-limb model. Plast Reconstr Surg
2010;125:1651–60.
48. Mustoe T. Understanding chronic wounds: a unifying hypothesis on their patho-
genesis and implications for therapy. Am J Surg 2004 May;187(5A):65S–70S.
49. Nielsen EW, Mollnes TE, Harlan JM, Winn RK. C1-inhibitor reduces the ische-
mia–reperfusion injury of skeletal muscles in mice after aortic cross-clamping.
Scand J Immunol 2002;56:588–92.
50. Odeh M. The role of reperfusion-induced injury in the pathogenesis of the crush
syndrome. N Engl J Med 1991;324:1417–22.
51. Oseas R, Yang HH, Baehner RL, Boxer LA. Lactoferrin: a promoter of polymor-
phonuclear leukocyte adhesiveness. Blood 1981;57:939–45.
52. Palmblad J. The role of granulocytes in inflammation. Scand J Rheumatol
1984;13:163–72.
53. Park JW, Kang JW, Jeon WJ, Na HS. Postconditioning protects skeletal muscle
from ischemia–reperfusion injury. Microsurgery 2010;30:223–9.
55. Petrasek PF, Homer-Vanniasinkam S, Walker PM. Determinants of ischemic
injury to skeletal muscle. J Vasc Surg 1994;19:623–31.
56. Rubin BB, Romaschin A, Walker PM, et al. Mechanisms of postischemic injury in
skeletal muscle: intervention strategies. J Appl Physiol 1996;80:369–87.
57. Rubin BB, Smith A, Liauw S, et al. Complement activation and white cell
sequestration in postischemia skeletal muscle. Am J Physiol 1990;259:H525–31.
58. Sadasivan KK, Carden DL, Moore MB, Korthuis RJ. Neutrophil mediated micro-
vascular injury in acute, experimental compartment syndrome. Clin Orthop
Relat Res 1997;339:206–15.
59. Seekamp A, Warren JS, Remick DG, et al. Requirements for tumor necrosis
factor-alpha and interleukin-1 in limb ischemia/reperfusion injury and associ-
ated lung injury. Am J Pathol 1993;143:453–63.
 S. Gillani et al. / Injury, Int. J. Care Injured 43 (2012) 670–675
60. Smith JK, Carden DL, Korthuis RJ. Role of xanthine oxidase in postischemic
microvascular injury in skeletal muscle. Am J Physiol 1989;257(6 Pt 2):H1782–9.
61. Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma
2003;54(Suppl. 5):S226–30.
63. Toyokuni S. Reactive oxygen species-induced molecular damage and its appli-
cation in pathology. Pathol Int 1999;49:91–102.
64. Velmahos GC, Toutouzas KG. Vascular trauma and compartment syndromes.
Surg Clin North Am 2002;82:125–41.
65. Vidigal J, José Fagundes D, De Jesus Simões M, et al. Effect of different periods of
hyperbaric oxygen on ischemia–reperfusion injury of rat skeletal muscle.
Microsurgery 2007;27:252–7.
67. Weiss SJ. Tissue destruction by neutrophils. N Engl J Med 1989;320:365–76.
68. Westlin WF, Gimbrone Jr MA. Neutrophil-mediated damage to human
vascular endothelium. Role of cytokine activation. Am J Pathol 1993;142:
117–28.
69. Witko-Sarsat V, Rieu P, Descamps-Latscha B, et al. Neutrophils: molecules.
functions and pathophysiological aspects. Lab Invest 2000;80:617–53.
675
70. Woitaske MD, McCarter RJ. Effects of fiber type on ischemia–reperfusion injury
in mouse skeletal muscle. Plast Reconstr Surg 1998;102:2052–63.
71. Woodruff TM, Arumugam TV, Shiels IA, et al. A potent C5a receptor antagonist
inhibits markers of local and remote organ injury following tourniquet-induced
limb ischemia–reperfusion in rats. J Surg Res 2004;116:81–90.
72. Wright DG, Gallin JI. A functional differentiation of human neutrophil granules:
generation of C5a by a specific (secondary) granule product and inactivation of
C5a by azurophil (primary) granule products. J Immunol 1977;119:1068–76.
73. Yi ES, Ulich TR. Endotoxin, interleukin-1, and tumor necrosis factor cause
neutrophil-dependent microvascular leakage in postcapillary venules. Am J
Pathol 1992;140:659–63.
74. Zhang F, Hu EC, Gerzenshtein J, et al. The expression of proinflammatory
cytokines in the rat muscle flap with ischemia–reperfusion injury. Ann Plast
Surg 2005;54:313–7.
75. Zhang F, Hu EC, Topp S, et al. Proinflammatory cytokines gene expression in skin
flaps with arterial and venous ischemia in rats. J Reconstr Microsurg 2006;
22:641–7.