Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) with pulmonary embolism in surgical patients – a case series

Background:

Extracorporeal life support (ECLS) devices maintain the circulation and oxygenation of organs during acute right ventricular failure and cardiogenic shock, bypassing the lungs. A pulmonary embolism can cause this life-threatening condition. ECLS is a considerably less invasive treatment than surgical embolectomy. Whether to bridge embolectomy or for a therapeutic purpose, ECLS is used almost exclusively following failure of all other therapeutic options.

Methods:

From January 1, 2008 to June 30, 2014, five patients in cardiac arrest and with diagnosed pulmonary embolism (PE) were cannulated with the ECLS system.

Results:

PE was diagnosed using computer tomography scanning or echocardiography. Cardiac arrest was witnessed in the hospital in all cases and CPR (cardiopulmonary resuscitation) was initiated immediately. Cannulation of the femoral vein and femoral artery was always performed under CPR conditions. Right heart failure regressed during the ECLS therapy, usually under a blood flow of 4-5 L/min after 48 hours. Three patients were weaned from ECLS and one patient became an organ donor. Finally, two of the five PE patients treated with ECLS were discharged from inpatient treatment without neurological dysfunction. The duration of ECLS therapy depends on the patient’s condition. Irreversible damage to the organs after hypoxemia limits ECLS treatment and leads to futile multiorgan failure. Hemorrhages after thrombolysis and cerebral dysfunction were further complications.

Conclusions:

Veno-arterial cannulation for ECLS can be feasibly achieved and should be established during active CPR for cardiac arrest. In the case of PE, the immediate diagnosis and rapid implantation of the system are decisive for therapeutic success.

[Surgical treatment of 3- and 4-part fractures of the humeral head using a polyaxial-locking plate: results and patient satisfaction]

INTRODUCTION

In recent years, new angle-stable plate implants with polyaxial screw direction were developed with the aim of an improved treatment of displaced 3- and 4-part fractures of the proximal humerus. There are only a few studies available about polyaxial implants in the treatment of 3- and 4-part proximal humerus fractures. Therefore, the aim of this study was to evaluate clinical results and complications of open reduction and internal fixation of displaced 3- and 4-part fractures using a polyaxial plate.

PATIENTS AND METHODS

Within 51 months, 105 patients with a displaced 3- or 4-part fracture of the proximal humerus were treated with a polyaxial locking plate. The complications were evaluated and the Constant & Murley score was assessed and correlated with patient satisfaction ("very satisfied" to "not satisfied"). Additionally, the results were compared with those of monoaxial plates from the literature. Furthermore, the operative experience of the surgeons at the time of surgery was correlated with the objective results of the patients.

RESULTS

65 patients (average age: 71.3 ± 11.4 years; average follow-up: 19,6 ± 9,8 month [10-44 month]) with a displaced 3- or 4-part fracture were re-examined retrospectively (female: n = 54; male: n = 11). Overall, there were 27 3-part fractures and 38 4-part fractures. The Constant and Murley Score was on average 62.1 ± 16.5 points and the complication rate was 26 %. The most frequent complication was screw perforation through the humeral head. Patient satisfaction with clinical outcome was high within the whole study group. 40 % of the patients were "very satisfied" with their shoulder function, 29 % were "satisfied" ("fair": 12 %, "not satisfied": 19 %). Additionally, the operative experience of the surgeons influenced the final clinical result.

CONCLUSION

In comparison to the literature we could not delineate better clinical outcomes or lower complication rates with polyaxial implants compared to monoaxial plates in 3- and 4-part fractures. Nevertheless, the majority of patients were satisfied with the clinical result in the context of age-related shoulder function. In addition, a close correlation could be detected between the degree of satisfaction and the objectively measured shoulder function. A high level of operative experience is required to avoid typical complications and to achieve a good clinical result.

[Trampoline-related injuries in children: an increasing problem]

INTRODUCTION

The sales of recreational trampolines have increased during the past few years. Severe injuries are associated in part with trampoline sport in the domestic setting. Therefore, this study was conducted to confirm the hypothesis of an increase in trampoline-related injuries in conjunction with the increasing sales of recreational trampolines and to find out what kind of injuries are most frequent in this context.

METHODS

Between 01/1999 and 09/2013 all trampoline-related injuries of children (0-16 years of age) were assessed retrospectively. Only those cases were evaluated which described with certainty a trampoline-associated trauma. The fractures were considered separately and assigned to specific localisations. Additionally, accidents at home were differentiated from institutional accidents.

RESULTS

Within the past 13 years and 9 months trampoline-related injuries were seen in 195 infants. Fractures were present in 83 cases (42 %). The average age was 10 ± 3.4 years (range: 2-16 years). Within first half of the observed time period (7½ years; 01/1999 to 06/2006) 73 cases were detected with a significantly increasing number of injuries up to 122 cases between 07/2006 and 09/2013 (7 years, 3 months), which corresponds to an increase of 67 % (p = 0,028). The vast majority of these injuries happened in the domestic setting (90 %, n = 175), whereas only 10 % (n = 20) of the traumas occurred in public institutions. In 102 children (52 %) the lower extremity was affected and in 51 patients (26 %) the upper extremity was involved (head/spine/pelvis: n = 42, 22 %). The upper extremity was primarily affected by fractures and dislocations (n = 38, 76 %). At the upper extremity there were more injuries requiring surgery in contrast to the lower extremity (n = 11) or cervical spine (n = 1).

CONCLUSION

The underlying data show a significant increase of trampoline-related injuries within the past years. The upper extremity is the second most affected after the lower extremity, but is more associated with fractures in contrast to other localisations and had to be operated on the most. Because of the increase of recreational trampolines within past years an increase of trampoline-associated injuries has to be expected in the future. The security guidelines should be followed exactly and the infants should be under supervision.

Surgical extraction after thrombosis around the Avalon dual lumen cannula

The use of a dual lumen cannula (DLC) for venovenous extracorporeal membrane oxygenation (ECMO) has several advantages and reports of complications are rare. We present a case of thrombosis around and inside the Avalon Elite™ bicaval DLC (Avalon Laboratories, Rancho Dominguez, CA, US), for which simple removal by retraction was impossible. A 30-year-old man had experienced an unstable C6/7 fracture with spinal contusion and haematoma in the spinal canal with incomplete neurological paraplegia and thoracic trauma. He developed acute respiratory failure due to posttraumatic systemic inflammatory response syndrome and venovenous extracorporeal membrane oxygenation (ECMO) support was indicated. The cannulation was performed with an Avalon Elite™ cannula (31Fr) in the right jugular vein under fluoroscopy. After 18 days of ECMO therapy, despite the continuous administration of heparin (400iu/h), ECMO was discontinued because of the formation of a massive thrombus in the oxygenator. At that time, the patient's haemodynamic and respiratory parameters were stable, and we were able to induce a rapid weaning from ECMO. The surgical removal of the cannula became necessary and was performed using a small neck incision without complications. We report this case to emphasise that any resistance encountered during an attempt to extract the Avalon Elite™ cannula may cause serious complications. In such cases, surgical removal must be considered.

[Lumbopelvic stabilization for bilateral lumbosacral instabilities: indications and techniques]

BACKGROUND

Bilateral lumbopelvic instabilities are rare; for the affected patients, however, they mean a severe reduction in quality of life. Optimal results can only be achieved with a well-adapted therapy algorithm that balances surgery and non-surgical procedures.

OBJECTIVES

The present article addresses the indications, strategy, and techniques of bilateral lumbopelvic fixation in the operative treatment of bilateral lumbopelvic injuries and review of the literature and personal experience.

RESULTS

The overall incidence of lumbosacral instabilities is low and mainly caused by high energy trauma, osteoporotic insuffiencies (e.g., primarily or secondary after long segment lumbar instrumentation), and tumors. Dramatic soft tissue injuries can occur in addition to hidden neurological impairments, and therefore it is important to diagnose and evaluate all concomitant comorbidities. The keys to success are gaining stability in the lumbosacral junction possibly combined with neuronal decompression and meaningful coordination of all disciplines, certainly challenged by finding the correct moment for surgery which is between 2 days and 2 weeks. Based on the superficial anatomy of the bony structures in the lumbosacral junction, the surgical approach has to match the pathology and should be tissue saving.

CONCLUSIONS

Treatment of bilateral lumbopelvic instabilities requires an accurate examination, sophisticated therapy protocol, and a multidisciplinary approach. Surgery with a bilateral lumbopelvic fixation combined with neuronal decompression is an adequate treatment that creates early bony stability, thus, promising functional weight-bearing mobilization.

Evaluation of immobilization in external rotation after primary traumatic anterior shoulder dislocation: 5-year results

BACKGROUND

It is still not clear which method is the most efficient for treating primary traumatic anterior shoulder dislocation. Immobilization in external rotation has become increasingly discussed within the last 10 years. The aim of this study was to evaluate the rate of recurrence and clinical outcome of the immobilization in external rotation after primary traumatic anterior dislocation within a midterm period of 5 years. Additionally, a summary of literature is given according to the present knowledge of this issue.

METHODS

From May 2004 to May 2006, 28 patients with primary traumatic anterior shoulder dislocations were included in a prospective MRI-controlled study. After a follow-up of 5 years, the recurrence rate and clinical outcomes of the patients were evaluated using clinical scores (Constant and Murley score, Western Ontario Shoulder Instability Index, Rowe score).

RESULTS

After 5 years, 26 patients (93 %; males, n = 25; female, n = 1; mean age, 29.3 years) were interviewed concerning re-dislocations. In the meantime, four patients (15 %) experienced a re-dislocation (ø 12.2 months) after the end of the immobilization. Overall, 21 patients (75 %) were included in a clinical follow-up (CM score: ø 92.8 points; Western Ontario Shoulder Instability Index: ø 87 %; Rowe score (in 17 patients): ø 94.2 points). Upon clinical examination, unidirectional anterior instability was found in one patient, which corresponds to an overall instability rate of 19 % within the examined patient population including the re-dislocations.

CONCLUSIONS

Immobilization in external rotation shows satisfactory results after 5 years in regard to recurrence and instability rates and clinical outcomes. The data show that with immobilization in external rotation, re-dislocations occur within the first 2 years.

[A new reduction technique for posterior locked shoulder dislocation. Case report and technique description]

The case of a 61-year-old male with posterior dislocation of the right shoulder joint is presented and a new technique for closed reduction of posterior locked shoulder dislocation is described. The technique involves four steps: in step 1 a constant traction is applied on the injured arm, in step 2 the arm is internally rotated and in steps 3 and 4 the second arm of the physician is used as a lever arm to lateralize and ventralize the shoulder. Lateralization and ventralization of the humeral head are essential to engage the humeral head and to pass it around the glenoid during reduction. Steps 3 and 4 are performed simultaneously. In the presented case the patient suffered a traumatic shoulder dislocation with a rim fracture of the glenoid. After reduction the shoulder was stable and conservative treatment was performed. A 2 year follow-up examination revealed a pain-free and stable shoulder with free range of motion and an Oxford instability score of 48 points. The described reduction technique for posterior locked shoulder dislocation is a simple and gentle technique, which can be performed easily by one person.Presentation of a reduction technique for locked posterior shoulder dislocation. Constant traction and internal rotation is performed for engaging the locked humeral head. After disengaging the humeral head the reduction is performed by using the arm of the physician as a lever arm.

[The pressure-sensitive swelling in the knee as a sign for a monoclonal gammopathy of undetermined specificity (MGUS)]

AL amyloidosis (AL-A) is seen in about 6-15 % of patients with multiple myeloma. In contrast, the sporadic occurrence of AL-A is a rarity. The presence of amyloid is often found in the respiratory tract followed by the lung, the eyelids, the skin and the lower urinary tract, while the presence in soft tissues or bone is rather uncommon. We here describe a 71-year-old woman who presented with a pressure-sensitive swelling in the left knee at our hospital. The clinical examination on admission showed a tumourous alteration of the popliteal soft tissues without any signs of neurological deficits. However, the range of motion (ROM) of the left knee was restricted with 0-0-100 degrees for extension and flexion. A dialysis-dependent renal insufficiency, heart insufficiency with the necessity of permanent anticoagulation and glaucoma were noted as pre-existing illnesses. Further diagnostic examinations including ultrasound and magnetic resonance imaging (MRI) of the left knee revealed a solid tumourous structure with a radiological suspicion of pigmented villonodular synovitis. A complete surgical extirpation of the tumourous structure was performed. The further performed diagnostic examinations including histological and immunohistochemical analyses showed evidence of an AL-A tumour. A monocloncal gammopathy of unknown specificity (MGUS) was detected as an origin for the AL-A. This case underscores the necessity of complete extirpation and histological and immunohistochemical analyses of any soft tissue tumour. Possible previously existing rare malignant diseases can be detected only in this way.

[Arteriovenous extracorporeal membrane oxygenation (ECMO). A therapeutic option for fulminant pulmonary embolism]

According to the guidelines of the European (2008) and German Societies of Cardiology (2009) thrombolysis is recommended for patients with pulmonary embolisms presenting with cardiogenic shock (recommendation level I, evidence level A). If there are contraindications or thrombolysis is not successful surgical embolectomy should be considered (recommendation level I, evidence level C). Additional options are catheter-based therapies in the proximal pulmonary artery (recommendation level IIb, evidence level C). The use of arteriovenous extracorporeal membrane oxygenation ( ECMO) was not included in these guidelines. A literature search in PubMed resulted in some case reports of the successful use of arteriovenous ECMO for resuscitation in patients with severe pulmonary embolisms following failed thrombolysis. In this article we present the case report of a patient who developed fulminant pulmonary embolism immediately after surgery. The patient was still in cardiogenic shock despite thrombolysis but the condition was stable following implementation of an arteriovenous ECMO. Acute heart failure and hypoxemia of all organs are the main symptoms of massive pulmonary embolisms. The use of arteriovenous ECMO represents a therapeutic option for life-threatening pulmonary embolism. A decisive factor for success is immediate diagnosis and rapid implementation of the system.

The biocompatibility of dense and porous Nickel-Titanium produced by selective laser melting

Nickel-Titanium shape memory alloys (NiTi-SMA) are of biomedical interest due to their unusual range of pure elastic deformability and their elastic modulus, which is closer to that of bone than any other metallic or ceramic material. Newly developed porous NiTi, produced by Selective Laser Melting (SLM), is currently under investigation as a potential carrier material for human mesenchymal stem cells (hMSC). SLM enables the production of highly complex and tailor-made implants for patients on the basis of CT data. Such implants could be used for the reconstruction of the skull, face, or pelvis. hMSC are a promising cell type for regenerative medicine and tissue engineering due to their ability to support the regeneration of critical size bone defects. Loading porous SLM-NiTi implants with autologous hMSC may enhance bone growth and healing for critical bone defects. The purpose of this study was to assess whether porous SLM-NiTi is a suitable carrier for hMSC. Specimens of varying porosity and surface structure were fabricated via SLM. hMSC were cultured for 8 days on NiTi specimens, and cell viability was analyzed using two-color fluorescence staining. Viable cells were detected on all specimens after 8 days of cell culture. Cell morphology and surface topography were analyzed by scanning electron microscopy (SEM). Cell morphology and surface topology were dependent on the orientation of the specimens during SLM production. The Nickel ion release can be reduced significantly by aligned laser processing conditions. The presented results clearly attest that both dense SLM-NiTi and porous SLM-NiTi are suitable carriers for hMSC. Nevertheless, before carrying out in vivo studies, some work on optimization of the manufacturing process and post-processing is required.

[Septic arthritis as an initial manifestation of a bacterial endocarditis]

Septic arthritis due to endocarditis is a rare and life-threatening disease. Endocarditis occurs with an incidence of 30 patients per 1 million citizens/year. Staphylococcus aureus is one of the most common causative pathogens. Methicillin-resistant Staphylococcus aureus (MRSA) can lead to a severe outcome with a high mortality rate, and embolic complications of the kidney, brain, and spleen are seen in one third of all cases. The diagnosis and treatment of endocarditis is a challenge for all health care providers. We report about a patient who was admitted to our hospital with generalized sepsis of unknown origin.

[Underdiagnosed disco-ligamentous lesion in the cervical spine of a paraglider]

INTRODUCTION

Paragliding is an increasingly popular airborne sport with numerous associated injuries. We here describe the case of an experienced paraglider who, after a fall from 15 meters, presented with an initially underdiagnosed disco-ligamentous lesion of the cervical spine.

PATIENT AND METHOD

We report on a 51-year-old male paraglider, who was referred to our hospital four days after a fall from 15 meters. Initial treatment was performed in a regional hospital. The performed clinical and radiological examinations including computerized tomography showed, besides a fracture of the radius, no further abnormalities.

RESULTS

The patient was discharged home four days after injury. Due to persistent pain in the cervical spine and parasthesia, the patient was referred to the practicing orthopaedic surgeon. The performed MRI and CT including the sagittal and coronal planes showed a disco-ligamentous lesion of the cervical spine. The patient was transferred immediately to our hospital for surgical treatment. The initial existing neurological symptoms resolved postoperatively and the patient was discharged home in a well condition.

DISCUSSION

Injuries of the cervical are extremely rare in paragliders. Nevertheless, this case underscores the importance of adequate clinical and radiological examinations. We report the case of our patient to increase awareness among physicians and training staff working in emergency rooms.

[Post-traumatic bipolar dislocation of the clavicle: is operative treatment reasonable?]

Bipolar dislocation of the clavicle ("floating clavicle") is extremely rare. It exists no standardised treatment for this trauma and the treatment is often conservative. This is mainly an anterior displacement of the sternoclavicular joint (type III according to Allman) and a posterior dislocation of the acromioclavicular joint (type IV according to Rockwood).We report on a 60 year old male who fell onto the right shoulder. He sustained a 'floating clavicle' and had a massive dislocation, impairment of range of motion and pain. Venous congestion was observable. We stabilised the dislocated acromioclavicular joint with a Balser's plate, the sternoclavicular joint was fixed with PDS cord tension band technique around the first rip and the sternum. In addition we resected the anterior part of the distal clavicle to get a better cosmetic result. Post-operatively the patient had an excellent range of motion without any further symptoms after six weeks and one year. Venous congestion was not more observable.In most of the cases dislocations of both ends of the clavicle are treated conservatively. We recommend an operative treatment especially in young and active patients to avoid re-dislocation and to archive better cosmetic results.

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?

INTRODUCTION

The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature.

PATIENTS AND METHODS

Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH).

RESULTS

The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification.

CONCLUSION

The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.

Pressure sores significantly increase the risk of developing a Fournier's gangrene in patients with spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI).

SETTING

Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany.

METHODS

All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination.

RESULTS

A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients.

CONCLUSIONS

Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

Sigmoido-gluteal fistula--a rare complication in clinically asymptomatic chronic diverticulitis

Chronic colonic diverticulitis may be associated with typical complications such as local abscesses, stenosis, bleeding, intraperitoneal bowel perforations or fistulas to other organs. Most commonly, fistulas exist between the colon and the bladder; nevertheless, they may also extend to the small intestine, other areas of the colon, ureter, uterus, salpinx, vagina, abdominal wall, portal- and mesenterial venous system, pleura, urachus, biliary system and the hip. We report on a patient with chronic colonic diverticulitis having an unusual sigmoido-gluteal fistula along the sacrum, the piriformis muscle and sciatic nerve. The patient presented with sciatic nerve symptoms and recurrent gluteal abscess formation, but no other clinical symptoms leading to an abdominal pathology. Initially, that fact caused an unsuccessful local treatment under the differential diagnosis of a local gluteal abscess for about a year. Finally, a sigmoid colon resection with end-to-end anastomosis and a proximal diverting stoma was performed. The colostomy was closed electively five months later without any complication.

[Solitary fibrous tumor of the pelvis: a rare extrathoracic manifestation]

Solitary fibrous tumors (SFT) are rare spindle cell neoplasms. To date only very few cases of pelvic SFT have been reported in the literature. SFT are characterized by unique microscopic and immunohistochemical findings. Complete local resection is the treatment of choice. Recurrence and metastasis may be related to infrequent malignant histological features, but histology is not always a reliable predictor for prognosis. Therefore long-term follow-up is necessary.We report about a male patient with a malignant pelvic SFT. After complete resection the tumor recurred after a short period of 6 months posterior to the original location in the pelvis. The differential diagnoses and the therapy options are discussed with a review of the present literature.

Activation of human leukocytes on tantalum trabecular metal in comparison to commonly used orthopedic metal implant materials

We analyzed leukocyte functions and cytokine response of human leukocytes toward porous tantalum foam biomaterial (Trabecular Metaltrade mark, TM) in comparison to equally sized solid orthopedic metal implant materials (pure titanium, titanium alloy, stainless steel, pure tantalum, and tantalum coated stainless steel). Isolated peripheral blood mononuclear cells (PBMC) and polymorphonuclear neutrophil leukocytes (PMN) were cocultured with equally sized metallic test discs for 24 h. Supernatants were analyzed for cytokine content by enzyme-linked immunosorbent assay. Compared to the other used test materials there was a significant increase in the release of IL (interleukin)-1ra and IL-8 from PMN, and of IL-1ra, IL-6, and TNF-alpha from PBMC in response to the TM material. The cytokine release correlated with surface roughness of the materials. In contrast, the release of IL-2 was not induced showing that mainly myeloid leukocytes were activated. In addition, supernatants of these leukocyte/material interaction (conditioned media, CM) were subjected to whole blood cell function assays (phagocytosis, chemotaxis, bacterial killing). There was a significant increase in the phagocytotic capacity of leukocytes in the presence of TM-conditioned media. The chemotactic response of leukocytes toward TM-conditioned media was significantly higher compared to CM obtained from other test materials. Furthermore, the bactericidal capacity of whole blood was enhanced in the presence of TM-conditioned media. These results indicate that leukocyte activation at the surface of TM material induces a microenvironment, which may enhance local host defense mechanisms.

[Pelvic stabilization in cases of septic instability. Triangular osteosynthesis in case of infection related vertical pelvic ring instability]

The combination of transiliac screws and lumbopelvic distraction osteosynthesis is usually an appropriate procedure to treat vertical pelvic ring instabilities under the condition of full weight bearing. In this case, due to the extent of septic destruction of the dorsal portion of the iliac bone, the common triangular fixation method using conventional pedicle screws was not possible. Using the transiliac dorsoventral screw position with special long screws, we achieved high mechanical triangular stability sufficient for pelvic ring fusion despite the large bony defect.

Cytokine release of mononuclear leukocytes (PBMC) after contact to a carbonated calcium phosphate bone cement

Human leukocytes (peripheral blood mononuclear cells, PBMC) were overlaid on calcium phosphate bone cement (CBC, Norian SRS) and allowed to settle for 1 h under cell culture conditions. Subsequently, the cells were either left unstimulated (i.e. sham stimulation using cell culture medium), or stimulated with toxic shock syndrome toxin-1 (TSST-1, 10 ng/mL), staphylococcal enterotoxin B (SEB, 10 ng/mL), or concanavalin A (ConA, 2 microg/mL) for further 24 h using cell culture conditions. Supernatants were then analyzed for cytokine content (interleukin-1 receptor antagonist, IL-1ra; IL-2; IL-6; IL-10; IL-12) by enzyme-linked immunosorbent assay. While the spontaneous generation of cytokines was not influenced, the IL-2 release from stimulated PBMC was significantly decreased in contrast to other analyzed cytokines after contact to the curing CBC compared to control incubations without CBC. This decrease in IL-2 release was not due to known inhibitors of IL-2 synthesis platelet factor-4 (PF-4), IL-10, TGF-beta, or elevated calcium ion concentrations.

Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing

OBJECTIVE

Presentation of a new triangular osteosynthesis technique that permits early weight-bearing in vertically unstable sacral fractures.

DESIGN

: Retrospective evaluation of a consecutive series.

SETTING

Level I trauma center.

PATIENTS

Thirty-four patients, twenty-eight of whom were poly-traumatized, all with vertically unstable sacral fractures. This group included eight women and twenty-six men, with a mean age of thirty-five years. Average time between trauma and definite operation was thirteen days (range 0 to 28 days).

INTERVENTIONS

All patients underwent triangular osteosynthesis using a combination of a vertical vertebro-pelvic distraction osteosynthesis (pedicle screw system) and a transverse fixation of the sacrum fracture with either iliosacral screws or trans-sacral plating. Immediate postoperative weight-bearing was permitted postoperatively.

RESULTS

Nineteen patients were treated with early progressive weight-bearing and advanced to full weight-bearing, on average, after twenty-three days (range 8 to 70 days). Three of the thirty-four patients (9 percent) experienced loosening of hardware, including two patients (6 percent) who required secondary intervention because of loss of the original reduction. Further complications included one pulmonary embolism (3 percent), one iatrogenic nerve lesion (3 percent), one wound necrosis (3 percent), and two local infections (6 percent).

CONCLUSIONS

Triangular osteosynthesis is a demanding procedure that can be performed on vertically unstable sacral fractures to allow early progressive weight-bearing with an acceptable complication rate.