[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]

BACKGROUND

Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed.

OBJECTIVE

A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options.

MATERIAL AND METHODS

Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed.

RESULTS AND DISCUSSION

Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

Spider prey-wrapping silk is an α-helical coiled-coil/β-sheet hybrid nanofiber

Solid-State NMR results on 13C-Ala/Ser and 13C-Val enriched Argiope argentata prey-wrapping silk show that native, freshly spun aciniform silk nanofibers are dominated by α-helical (∼50% total) and random-coil (∼35% total) secondary structures, with minor β-sheet nanocrystalline domains (∼15% total). This is the most in-depth study to date characterizing the protein structural conformation of the toughest natural biopolymer: aciniform prey-wrapping silks.

[Evidence-based trauma and orthopedic surgery : 20 years after Sackett]

The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.

Standardised effect sizes in clinical research

The Bone & Joint Journal provides the latest evidence to guide the clinical practice of orthopaedic surgeons. The benefits of one intervention compared with another are presented using outcome measures; some may be specific to a limb or joint and some are more general health-related quality of life measures. Readers will be familiar with many of these outcome measures and will be able to judge the relative benefits of different interventions when measured using the same outcome tool; for example, different treatments for pain in the knee measured using a particular knee score. But, how should readers compare outcomes between different clinical areas using different outcome measures? This article explores the use of standardised effect sizes.

Cite this article: Bone Joint J 2014;96-B:853–4.

Intention-to-treat analyses for interventional studies

The importance for observing the intention-to-treat approach in clinical studies is explained.

Cite this article: Bone Joint J 2013;95-B:1443–4.

Acetabular fractures with marginal impaction

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements.

Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients.

Cite this article: Bone Joint J 2013;95-B:230–8.

Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial

INTRODUCTION

Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Even though several prognostic factors for patellofemoral instability have been identified so far, the appropriate therapy for patients with patellar dislocation remains a controversial issue. The purpose of this study was to compare the outcome after conservative or operative treatment in patients after first-time patellar dislocation.

PATIENTS AND METHODS

This randomized controlled clinical trial was designed multicentric including patients from six German orthopaedic and trauma departments. Twenty patients with a mean age of 24.6 years with first-time traumatic patella dislocation were included and randomized into either a conservative arm or an operative arm. Plain X-ray images of the knee joint (a.p. and lateral view and tangential view of both patellae) were performed in all cases prior to therapy to exclude osteochondral fragments requiring refixation. An MRI was recommended, but not compulsory. Patients were consulted after 6, 12, and 24 months with a questionnaire including the criteria of the Kujala score, recurrent dislocation, and satisfaction.

RESULTS

The mean Kujala score of the conservative vs operative treatment group was 78.6 vs 80.3 after 6 months (p = 0.842), 79.9 vs 88.9 after 12 months (p = 0.165), and 81.3 vs 87.5 after 24 months (p = 0.339). Redislocation rate after 24 months was 37.5 % in the conservative group and 16.7 % in the operative group (p = 0.347). Due to the small number of patients that could be included, no significant difference between the groups could be detected. We see a tendency towards better results after operative treatment.

CONCLUSION

Our multicentric prospective randomized controlled trial revealed no significant difference between conservative and operative treatment for patients after first-time traumatic patellar dislocation. However, a tendency towards a better Kujala score and lower redislocation rates for patients with operative treatment was observed. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A meta-analysis including other study's level I data is desirable for the future.

[Obligation to operate splenic injuries in polytrauma patients using MS-CT criteria]

PURPOSE

The aim of this study is to evaluate the validity of multi-slice computed tomography (MS-CT) in predicting the need to operate on spleen injuries in polytrauma patients using selected grading systems; the Thompson screening test (TST) and the extended TST (ETST).

PATIENTS AND METHODS

A retrospective evaluation of 2791 patients who presented spleen injuries in polytrauma MS-CTs in the period between 12/2002 and 06/2010 was undertaken. On the basis of CT morphology, and by using the above mentioned grading systems, the probability of the need to operate on a splenic injury was defined.

RESULTS

From a sample of 2791 patients, an MS-CT polytrauma scan was used to identify 139 splenic injuries. In correlation with the actual interventions carried out on the spleen, the applied grading systems showed sensitivities of 91 % (TST) and 69 % (ETST) as well as specificities of 78 % (TST) and 93 % (ETST). Regarding interventions on a splenic injury, positive predictive values were 57 % (TST) and 76 % (ETST), and the accordant negative predictive values were 96 % (TST) and 91 % (ETST). Thereby we ascertained significantly lower results than Thompson et al.

CONCLUSION

The applied grading systems based on the findings of MS-CT do not reliably predict the need to operate on spleen injuries in polytrauma patients.

[Accidents, illness and injuries involved in road haulage : consequences for medical care and prevention]

This article reviews basic characteristics of road traffic crashes of heavy vehicles and the current health status of truck drivers. It summarises previous findings from research with a focus on orthopaedic diseases and injuries. These findings comprise a risky health behaviour and high prevalence of associated diseases which can be attributed to both the occupational framework and personal risk-taking behavioural patterns. These are of major importance given the increasing number of drivers and the consequences for acute care and prevention. On the other hand there is a substantial lack of medical care for the drivers on the road. Therefore this article presents the"DocStop Initiative" for medical care on the road, an initiative that runs an international network of care providers (http://www.docstop-online.eu).

[Limits of clinical pathways. Implant-associated infections]

There are at present no valid guidelines for multimodal treatment of implant-associated infections; however, based on many years of experience gathered by specialized septic surgeons and likewise specialized treatment centers, established principles do exist. Treatment planning should always take into consideration the individual comorbidity of the patient, the underlying injury, the implant, the spectrum of germs, and the patient's compliance. The concept for managing implant-associated infections comprises five pillars and can be summarized as follows: first priority is given to rapid and radical surgical eradication of the infection by débridement of all infected and non-vital or underperfused tissue. We cannot propose clinical pathways as such for implant-related infections, i.e., by specifying interdisciplinary activities, control parameters, and responsibilities for a typical patient with clearly defined disease, but we can proffer strategic concepts for diagnostic work-up and treatment as we have already described.

[Complex pelvic trauma in elderly patients]

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[Road traffic crashes in developing countries]

Road traffic crashes pose a major threat to individuals and national health systems. Developing countries account for 48% of motorized vehicles, but for 91% of the 1.3 million fatalities per annum. While ranked ninth among the causes of disabilities adjusted life years lost in 2004, crash injuries are projected to rise to third position by 2030. This article reviews current prognoses of deaths and disabilities, the characteristics of crashes in low and middle income countries and evidence-based road safety interventions. This article is considered a wake-up call for trauma, orthopaedic, and emergency surgeons in high-income countries to join the global community in fighting the neglected yet potentially curable epidemic named road traffic injuries.