Major trauma due to suicide attempt: increased workload but not mortality

INTRODUCTION

Suicide attempt is a common cause for major trauma. Due to the underlying psychiatric disease, patients` compliance or even prognosis may be reduced. Modalities of discharge after surgical acute care might differ.

METHODS

Retrospective study including trauma patients of two urban level 1 trauma centers between 2013 and 2017. Data originally collected for quality management using the German trauma registry were supplemented after review of medical charts with details on psychiatric disease and discharge modalities.

RESULTS

We included 2118 consecutive patients of which 108 (5%) attempted suicide. Most common psychiatric diagnosis were depression (38%) and schizophrenia (25.9%). Comparing patients after suicide attempt with others, suicide attempt was associated with a younger age (42.3 vs. 49.0 years), a higher injury severity (mean ISS 24.7 vs. 16.8) and consecutively, a higher expected mortality (risk-adjusted prognosis for mortality 18.0 vs. 8.1%), while observed mortality was lower than expected in both groups (16.7 vs. 6.4%). Survivors after suicide attempt had a longer stay on ICU (mean days on ICU 17 vs. 7). 56% were transferred to psychiatric facilities and only 4% could be discharged home after acute surgical care.

CONCLUSION

Incidence of suicide attempts among major trauma patients is high. Mean injury severity is higher than in unintended trauma and associated with a prolonged stay on intensive care unit even after adjustment for injury severity and age. Risk-adjusted mortality is not increased. Proportion of patients discharged home or to out-patient rehabilitation is very low. Specialized institutions who offer both, musculoskeletal rehabilitation and psychiatric care are required for rehabilitative treatment after the acute surgical care.

Poor outcome of octogenarians admitted to ICU due to periprosthetic joint infections: a retrospective cohort study

Background

Even though surgical techniques and implants have evolved, periprosthetic joint infection (PJI) remains a serious complication leading to poor postoperative outcome and a high mortality. The literature is lacking in studies reporting the mortality of very elderly patients with periprosthetic joint infections, especially in cases when an intensive care unit (ICU) treatment was necessary. We therefore present the first study analyzing patients with an age 80 and higher suffering from a periprosthetic joint infection who had to be admitted to the ICU.

Methods

All patients aged 80 and higher who suffered from a PJI (acute and chronic) after THR or TKR and who have been admitted to the ICU have been included in this retrospective, observational, single-center study.

Results

A total of 57 patients met the inclusion criteria. The cohort consisted of 24 males and 33 females with a mean age of 84.49 (± 4.0) years. The mean SAPS II score was 27.05 (± 15.7), the mean CCI was 3.35 (± 2.28) and the most patient had an ASA score of 3 or higher. The PJI was located at the hip in 71.9% or at the knee in 24.6%. Two patients (3.5%) suffered from a PJI at both locations. Sixteen patients did not survive the ICU stay. Non-survivors showed significantly higher CCI (4.94 vs. 2.73; p = 0.02), higher SAPS II score (34.06 vs. 24.32; p = 0.03), significant more patients who underwent an invasive ventilation (132.7 vs. 28.1; p = 0.006) and significantly more patients who needed RRT (4.9% vs. 50%; p < 0.001). In multivariate analysis, RRT (odds ratio (OR) 15.4, CI 1.69–140.85; p = 0.015), invasive ventilation (OR 9.6, CI 1.28–71.9; p = 0.028) and CCI (OR 1.5, CI 1.004–2.12; p = 0.048) were independent risk factors for mortality.

Conclusion

Very elderly patients with PJI who needs to be admitted to the ICU are at risk to suffer from a poor outcome. Several risk factors including a chronic infection, high SAPS II Score, high CCI, invasive ventilation and RRT might be associated with a poor outcome.

Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls

BACKGROUND

Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality.

AIMS

The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy.

METHODS

Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively.

RESULTS

Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed.

CONCLUSION

Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.

Persistent Fistula for Treatment of a Failed Periprosthetic Joint Infection: Relic From the Past or a Viable Salvage Procedure?

BACKGROUND

New treatment algorithms for periprosthetic joint infections (PJIs) show high success rates in achieving permanent infection eradication with some degree of failure. Different salvage procedures are described, but there is no evidence for persistent fistula (PF). The purpose of this study was to analyze PF as a salvage procedure in patients with therapy-resistant PJIs.

METHODS

This retrospective analysis included all patients treated with PF (2005-2018) in a maximum care center with PJI (knee or hip). The baseline parameters (age, sex, BMI) and other data (number of surgeries, pathogen spectrum, American Society of Anesthesiologists classification) were recorded. The function was documented using the Harris Hip Score, the Knee Society Score, and the quality of life using the SF-36 Health Survey.

RESULTS

A total of 159 patients were included (80 ± 12 years) and subdivided into four groups: hip (n = 66), knee (n = 13), Girdlestone resection arthroplasty (n = 50), knee arthrodesis (n = 27). Patients stayed 111 ± 87 days in the hospital, underwent six operations and three revisions after establishing PF. The mean American Society of Anesthesiologists score was 2.7. The BMI was 31 ± 3 kg/m² (P = .1). The follow-up was 2.8 ± 0.5 years including 27 patients. The Harris Hip Score and Knee Society Score were 38 and 34, respectively. SF-36 showed no significant difference.

CONCLUSION

The study showed poor outcomes regarding quality of life and the function of the infected joint. Therefore, the indication for establishing a PF in the treatment of PJI must be assessed very critically. PF is only an option for multimorbid patients with a limited life expectancy.

Enhanced dissolution of silver nanoparticles in a physical mixture with platinum nanoparticles based on the sacrificial anode effect

A strategy to reduce implant-related infections is the inhibition of the initial bacterial implant colonization by biomaterials containing silver (Ag). The antimicrobial efficacy of such biomaterials can be increased by surface enhancement (nanosilver) or by creating a sacrificial anode system for Ag. Such a system will lead to an electrochemically driven enhanced Ag ion release due to the presence of a more noble metal. Here we combined the enlarged surface of nanoparticles (NP) with a possible sacrificial anode effect for Ag induced by the presence of the electrochemically more noble platinum (Pt) in physical mixtures of Ag NP and Pt NP dispersions. These Ag NP/Pt NP mixtures were compared to the same amounts of pure Ag NP in terms of cell biological responses, i.e. the antimicrobial activity against Staphylococcus aureus and Escherichia coli as well as the viability of human mesenchymal stem cells (hMSC). In addition, Ag NP was analyzed by ultraviolet-visible (UV-vis) spectroscopy, cyclic voltammetry, and atomic absorption spectroscopy. It was found that the dissolution rate of Ag NP was enhanced in the presence of Pt NP within the physical mixture compared to a dispersion of pure Ag NP. Dissolution experiments revealed a fourfold increased Ag ion release from physical mixtures due to enhanced electrochemical activity, which resulted in a significantly increased toxicity towards both bacteria and hMSC. Thus, our results provide evidence for an underlying sacrificial anode mechanism induced by the presence of Pt NP within physical mixtures with Ag NP. Such physical mixtures have a high potential for various applications, for example as antimicrobial implant coatings in the biomedicine or as bactericidal systems for water and surface purification in the technical area.

Secondary purulent infections of the elbow joint: a retrospective, single-center study

Background

Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections.

Methods

Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included.

Results

Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured.

Conclusions

Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.

Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection

BACKGROUND

Sonication is a valuable tool in the diagnosis of periprosthetic joint infections (PJI). However, conditions and definition criteria for PJI vary among studies. The aim of this study was to determine the diagnostic performance (i.e., specificity, sensitivity) of sonicate fluid culture (SFC) against periprosthetic tissue culture (PTC), when using European Bone and Joint Infection Society (EBJIS) criteria.

METHODS

From March 2017 to April 2018, 257 implants were submitted for sonication. PJI was defined according to the EBJIS criteria as well as according to the International Consensus Meeting criteria of 2018 (ICM 2018). Only cases with at least one corresponding tissue sample were included. Samples were cultured using traditional microbiological plating techniques. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples. Subgroup analysis was performed dividing the cohort according to the site of PJI, previous antibiotic treatment, and time of manifestation. Prevalence of pathogens was determined for all patients as well as for specific subgroups.

RESULTS

Among the 257 cases, 145 and 112 were defined as PJI and aseptic failure, respectively. When using the EBJIS criteria, the sensitivity of SFC and PTC was 69.0 and 62.8%, respectively (p = .04). Meanwhile, the specificity was 90.2 and 92.9%, respectively (p = .65). When adopting ICM 2018 criteria, the sensitivity of SFC and PTC was 87.5 and 84.4% (p = .63) respectively, while the specificity was 85.1 and 92.5% (p = .05), respectively. The most commonly identified pathogens were coagulase-negative staphylococci (26% overall), while 31% of PJI were culture-negative and 9% polymicrobial.

CONCLUSIONS

SFC exhibited significantly greater sensitivity versus PTC when using the EBJIS criteria. Nevertheless, the diagnosis of PJI remains a difficult challenge and different diagnostic tools are necessary to optimize the outcome.

Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties

BACKGROUND

Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility.

METHODS

We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS.

RESULTS

Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41).

CONCLUSIONS

IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Arthrodesis of the Infected Knee Joint with the Ilizarov External Fixator: an Analysis of 13 Cases

BACKGROUND

Knee joint infections with pronounced joint destruction, soft tissue and bone involvement are serious diseases in which not only the joint but also the entire extremity are directly endangered. What results can be achieved with the Ilizarov external fixator for septic knee arthrodesis?

PATIENTS AND METHODS

Between 2005 and 2017, 13 patients (4 women and 9 men, mean age 46 years) with acute joint and concomitant bone and soft-tissue infections were treated with Ilizarov knee joint arthrodesis. In addition to demographic data, the time spent in the fixator, major and minor complications were retrospectively evaluated.

RESULTS

The average time spent in the Ilizarov external fixator was 27 weeks (min. 13, max. 68). Arthrodesis and infection repair were primarily achieved in 12 out of 13 patients. In one patient, a delayed healing of the arthrodesis zone could be cured by iliac crest bone grafting, so that eventually a bony knee arthrodesis was achieved in all patients. Pin infects as a minor complication during the time spent in the fixator were common and could be treated by stab incision and antibiotics. Major complications occurred in 3 cases (2 femoral fractures peri-implant, 1 nonunion in the arthrodesis area), which were treated by dilatation of the Ilizarov external fixator and finally plate osteosynthesis or by resection of the pseudarthrosis and iliac crest bone grafting.

CONCLUSION

The knee joint arthrodesis with the Ilizarov external fixator is a salvage procedure for limb preservation in fulminant knee joint and concomitant soft tissue infections. The advantages lie in the possibility of osteosynthesis in the acute infection and/or chronic osteomyelitis and the direct full load capacity. Disadvantages are long and complicated treatment times in the fixator with limited patient comfort.

[Temporary arthrodesis of the knee in two-stage septic prosthesis exchange : In vitro analysis of adhesion of Staphylococcus aureus on steel and carbon fiber rods]

BACKGROUND

In two-stage septic revision arthroplasty of the knee, a temporary intramedullary fixation with an antibiotic-containing polymethyl methacrylate (PMMA) spacer is often performed in cases of extensive bone defects after endoprosthesis explantation. A common method is the use of conventional steel or carbon fiber rods, which are connected via a tube-to-tube connector and finally reinforced near the joint with bone cement.

OBJECTIVE

As the surface of foreign materials plays a critical role in the colonization and biofilm formation in the treatment of periprosthetic joint infections (PJI), the steel and carbon fiber rods were examined and compared with respect to bacterial surface adhesions.

MATERIAL AND METHODS

Carbon fiber and steel rods of external fixator systems were used for this experimental study. The sample material was placed in a substrate enriched with S. aureus. The adherent bacteria were examined both by fluorescence microscopy and quantitatively after ultrasonic detachment (sonication) in a smear preparation. In addition, scanning electron micrograph (SEM) images were taken to analyze the topography of bacterial adhesions.

RESULTS

The fluorescence microscopy revealed a uniform surface distribution for both materials. The observation of the SEM images showed that for carbon fiber rods the growth of bacteria ran in unison with the direction of the fiber, while for the steel rods an arbitrary arrangement was found. With the help of sonication a significant difference in the number of adherent micro-organisms between the two materials could not be determined using the Wilcoxon test (significance level p < 0.05).

CONCLUSION

Both materials can be used to perform PMMA-reinforced intramedullary fixation without fear of sacrificing therapeutic success. From an economic point of view, the use of steel rods seems reasonable as the material costs are significantly lower.

[Shoulder prosthesis replacement options : New implants, treatment algorithms and clinical results]

BACKGROUND

Bony defect situations are a common problem in revision arthroplasty of the shoulder and are the cause of the complexity of the procedure. Aseptic and septic loosening as well as difficult implant removal can result in humeral and/or glenoid bone loss.

PLANNING

A careful preoperative imaging is needed to estimate the extent of the bony defect and to enable precise planning of the bone reconstruction and the required implants. However, the size of the defect needs to be re-evaluated intraoperatively after removal of the implant components and any larger defects have to be addressed appropriately.

PROSTHESIS DESIGN

While in the glenoid autologous bone grafts and, to a lesser extent, allogenic bone grafts are preferred, metallic augmented implants have recently become available to fill the glenoid bone defect. However, humeral defects are normally addressed with longer revision stems, possibly with allograft augmentation. The soft tissue loss in proximal humeral defects can be addressed with fixation techniques to improve function and reduce the risk of dislocation. Modern modular prosthesis designs allow prosthesis conversion while leaving bony, tightly integrated component parts on the glenoid or shaft. This review describes the preoperative diagnostic steps as well as techniques for revision surgery of the shoulder in the case of bone loss.

Outpatient Parenteral Antibiotic Therapy (OPAT) with Peripherally Inserted Central Catheter in Patients with Periprosthetic Joint Infection

BACKGROUND

A key factor in the successful treatment of periprosthetic joint infection is the consistent antimicrobial therapy. Depending on the pathogen antimicrobial susceptibility, intravenous (i. v.) antibiotics may not be switched to oral medication at patient discharge, without risking a treatment failure. The implementation of an outpatient i. v. therapy using peripherally inserted central catheters (PICCs) allows for early discharge with continuation of adequate antimicrobial therapy.

METHODS

We prospectively evaluated the systematic use of PICC in 11 patients with periprosthetic joint infection. Inclusion criterion was the detection of a pathogen that cannot be optimally treated with oral antibiotics according to the current treatment concept (Trampuz et al.).

RESULTS

A total of 12 PICCs in 11 patients were analysed. An error or mechanical nerve irritation was not observed. The occurrence of a catheter-related bloodstream infection (CRBSI) was not recorded. None of our patients had PICC-associated infections, thrombophlebitis or thrombosis. One patient stopped therapy due to a lack of compliance. Ten patients successfully completed their treatment. At a mean follow-up of 29 months, successful infection eradication as measured by the Delphi criteria was achieved in 100%.

CONCLUSION

Although the number of patients included in the study was small, our short-term results suggest a good applicability of PICCs in the outpatient i. v. antimicrobial therapy for treatment of periprosthetic joint infection. Catheter-associated complications could not be observed in our collective. The successful infection control in all cases despite proven difficult-to-treat infection is promising.

Bimetallic silver-platinum nanoparticles with combined osteo-promotive and antimicrobial activity

Bimetallic alloyed silver-platinum nanoparticles (AgPt NP) with different metal composition from Ag₁₀Pt₉₀ to Ag₉₀Pt₁₀ in steps of 20 mol% were synthesized. The biological effects of AgPt NP, including cellular uptake, cell viability, osteogenic differentiation and osteoclastogenesis as well as the antimicrobial activity towards Staphylococcus aureus and Escherichia coli were analyzed in comparison to pure Ag NP and pure Pt NP. The uptake of NP into human mesenchymal stem cells was confirmed by cross-sectional focused-ion beam preparation and observation by scanning and transmission electron microscopy in combination with energy-dispersive x-ray analysis. Lower cytotoxicity and antimicrobial activity were observed for AgPt NP compared to pure Ag NP. Thus, an enhanced Ag ion release due to a possible sacrificial anode effect was not achieved. Nevertheless, a Ag content of at least 50 mol% was sufficient to induce bactericidal effects against both Staphylococcus aureus and Escherichia coli. In addition, a Pt-related (≥50 mol% Pt) osteo-promotive activity on human mesenchymal stem cells was observed by enhanced cell calcification and alkaline phosphatase activity. In contrast, the osteoclastogenesis of rat primary precursor osteoclasts was inhibited. In summary, these results demonstrate a combinatory osteo-promotive and antimicrobial activity of bimetallic Ag₅₀Pt₅₀ NP.

Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

METHODS

All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

RESULTS

A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

CONCLUSIONS

We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

[Unplanned admission or readmission to the intensive care unit : Avoidable or fateful?]

BACKGROUND

Unplanned admissions or readmissions to the intensive care unit lead to a poorer outcome and present medical, logistic and economic challenges for a clinic. How often and what are the reasons for readmission to the intensive care unit? Which strategies and guidelines to avoid readmission are recommended.

MATERIAL AND METHODS

Analysis and discussion of available studies and recommendations of national and international societies.

RESULTS

Many studies show that unplanned admissions and readmissions to the intensive care unit represent an independent risk factor for a poor outcome for patients. Different factors that increase the probability of readmission can be identified. Structural changes concerning the normal wards, intensive care unit or the clinic internal emergency service could positively effect readmission rates and/or patient outcome while other studies failed to show any effect of these arrangements.

CONCLUSION

Patient transition from the intensive care unit to a lower level of care is a critical point of time and has to be accompanied by a high quality handover. Unstable patients on normal wards have to be identified and treated as soon as possible but effects of standardized medical emergency teams are controversial.

[Benefits of medical emergency teams : Mortality on normal wards and readmission to intensive care wards]

Medical emergency teams (MET) were implemented in many hospitals worldwide in order to identify patients at risk on normal wards and to initiate diagnostics and therapy without delay. Ideally, the implementation leads to prevention of cardiac arrests and unexpected deaths on normal wards, reduced rates of admissions to intensive care units and hospital mortality. Various track and trigger systems are available to identify such patients and for them to be assessed and treated within 30-45 min by the MET. The ideal personnel composition of METs has not yet been established. Whether the implementation of an MET generally leads to an improvement of treatment on normal wards or to a reduction in mortality in hospitals has not been finally clarified. Mortality and morbitidy (M&M) conferences can help to analyze if an individual clinic is likely to profit from the introduction of a MET.

Necrotizing fasciitis and the midterm outcomes after survival

Background and Aims:

Radical surgical intervention is necessary to save patients’ lives in cases of necrotizing fasciitis. This leads to persistent disabilities and most likely to a deteriorated quality of life. The purpose of this study was to evaluate the midterm outcomes after survival of necrotizing fasciitis.

Materials and Methods:

A retrospective analysis of 69 patients, treated for necrotizing fasciitis between 2003 and 2012. The patients were identified using the International Classification of Diseases (10th Revision) code M 72.6. Of the 50 survivors, 22 patients completed the Short Form 36 and Short Musculoskeletal Function Assessment questionnaires as a postal survey. The follow-up averaged 59 months (range: 6–128 months).

Results:

The average age at the time of necrotizing fasciitis was 60.0 years. The body mass index average was 29.7. The patients had a significantly decreased physical component summary score of 33.3 compared to a normative group (p < 0.001) (Short Form 36). They further showed a significantly decreased dysfunction and bother indices (Short Musculoskeletal Function Assessment) (p < 0.001). An increased age (⩾70 years) was associated with an inferior role emotional (p = 0.048) and physical functioning (p = 0.011) as well as social functioning (p = 0.038) (Short Form 36). The majority of patients (16, 72.7%) complained of pain at the final follow-up and 50% of patients required an assistive device on a regular basis.

Conclusion:

Patients who survived necrotizing fasciitis suffer from functional impairment and changed body appearance. Assistive devices or pain medication are often required, and the patients present with significantly decreased physical, social, and emotional functioning at the midterm follow-up. The patient’s age is a critical factor regarding functional or mental outcome parameters. Further research on the post-hospital course and long-term multidisciplinary care is required to improve the outcomes of these patients.

Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems

BACKGROUND

Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room.

METHODS

We screened six open access and German language-based CIRS-platforms on the internet.

RESULTS

We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents.

CONCLUSIONS

Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.

A Randomized and Controlled Crossover Study Investigating the Improvement of Walking and Posture Functions in Chronic Stroke Patients Using HAL Exoskeleton - The HALESTRO Study (HAL-Exoskeleton STROke Study)

Background: The exoskeleton HAL (hybrid assistive limb) has proven to improve walking functions in spinal cord injury and chronic stroke patients when using it for body-weight supported treadmill training (BWSTT). Compared with other robotic devices, it offers the possibility to initiate movements actively. Previous studies on stroke patients did not compare HAL-BWSTT with conventional physiotherapy (CPT). Therefore, we performed a crossover clinical trial comparing CPT and HAL-BWSTT in chronic stroke patients with hemiparesis, the HALESTRO study. Our hypothesis was that HAL-training would have greater effects on walking and posture functions compared to a mixed-approach CPT.

Methods: A total of 18 chronic stroke patients participated in this study. Treatment consisted of 30 CPT sessions and of 30 sessions of BWSTT with a double leg type HAL exoskeleton successively in a randomized, crossover study design. Primary outcome parameters were walking time and speed in 10-meter walk test (10MWT), time in timed-up-and-go test (TUG) and distance in 6-min walk test (6MWT). Secondary outcome parameters were the functional ambulatory categories (FAC) and the Berg-Balance Scale (BBS). Data were assessed at baseline, at crossover and at the end of the study, all without using and wearing HAL.

Results: Our study demonstrate neither a significant difference in walking parameters nor in functional and balance parameters. When HAL-BWSTT was applied to naïve patients, it led to an improvement in walking parameters and in balance abilities. Pooling all data, we could show a significant effect in 10MWT, 6MWT, FAC and BBS, both therapies sequentially applied over 12 weeks. Thereby, FAC improve from dependent to independent category (3 to 4). One patient dropped out of the study due to intensive fatigue after each training session.

Conclusion: HAL-BWSTT and mixed-approach CPT were effective therapies in chronic stroke patients. However, compared with CPT, HAL training with 30 sessions over 6 weeks was not more effective. The combination of both therapies led to an improvement of walking and balance functions. Robotic rehabilitation of walking disorders alone still lacks the proof of superiority in chronic stroke. Robotic treatment therapies and classical CPT rehabilitation concepts should be applied in an individualized therapy program.

[Periprosthetic humeral fractures: from osteosynthesis to prosthetic replacement]

OBJECTIVE

Stabilization of the humeral shaft and the restoration of shoulder function dependent on the osseous integrity of the prosthetic stem component.

INDICATIONS

In cases of a stable prosthesis stem, an isolated plate osteosynthesis is possible. Prosthesis stem replacement is indicated in cases of a loose stem. With sufficient bone stock of the proximal humeral segment, a change to a shorter humeral shaft component with subsequent plate fixation of the fracture is possible. If the bone stock is poor, conversion to a long revision stem is necessary.

CONTRAINDICATIONS

Inoperability of the patient due to serious comorbidities. Advanced age and low demands on shoulder function are relative contraindications for complex prosthesis replacements.

SURGICAL TECHNIQUE

Plate osteosynthesis can be done through an anterior or posterior approach, stem replacement only from anterior deltopectoral approach. When changing humeral shaft components, the loose shaft and all cement residues are removed, the fracture is reduced and, if possible, a shorter shaft is implanted with subsequent plate osteosynthesis of the fracture. When changing to a long revision stem, additional osteosynthesis with cerclages wires is usually sufficient. In case of poor bone stock, an additive autologous or allogenic bone grafting can be performed. An instable anatomical prosthesis with poor shoulder function may require conversion to an inverse prosthesis.

POSTOPERATIVE MANAGEMENT

In cases of an isolated plate osteosynthesis with an otherwise stable prosthesis, immediate active rehabilitation of the upper limb is advocated. When a prosthesis replacement and conversion to an inverse prosthesis is performed the shoulder is immobilized in 30° abduction for 6 weeks. Passive and after 3 weeks active-assistive shoulder movement up to 90° abduction and flexion is allowed.

RESULTS

In 40 patients with a periprosthetic humeral fracture, an isolated plate osteosynthesis was performed in 30 cases and a prosthesis replacement in 10 cases. Complications included 3 infections and 3 temporary radial nerve palsies. Revisions due to pseudarthrosis were necessary in 2 cases.

Glancing-Angle Deposition of Nanostructures on an Implant Material Surface

Cell-compatible and antibacterial surfaces are needed for implants, which frequently have complex and rough surfaces. Bio-inspired columnar nanostructures can be grown on flat substrates; however, the application of these nanostructures on clinically relevant, complex, and rough surfaces was pending. Therefore, a titanium plasma spray (TPS) implant surface was coated with titanium nano-spikes via glancing angle magnetron sputter deposition (GLAD) at room temperature. Using GLAD, it was possible to cover the three-dimensional, highly structured macroscopic surface (including cavities, niches, clefts, and curved areas) of the TPS homogeneously with nano-spikes (TPS+), creating a cell-compatible and antibacterial surface. The adherence and spreading of mesenchymal stem cells (MSC) were similar for TPS and TPS+ surfaces. However, MSC adherent to TPS+ expressed less and shorter pseudopodia. The induced osteogenic response of MSC was significantly increased in cells cultivated on TPS+ compared with TPS. In addition, Gram-negative bacteria (E. coli) adherent to the nano-spikes were partly destructed by a physico-mechanical mechanism; however, Gram-positive bacteria (S. aureus) were not significantly damaged.

Is the Midterm Progress of Pediatric and Adolescent Talus Fractures Stratified by Age?

The outcomes of pediatric talus fractures have been minimally reported in published studies. The purpose of the present retrospective study was to determine the clinical and radiographic outcomes after talus fractures in pediatric and adolescent patients and to define the differences among the different age groups in this population. A total of 52 children and adolescents (54 fractures) with 24 type 1 (44.44%), 13 type 2 (24.07%), 8 type 3 (14.81%), and 9 type 4 (16.67%) Marti-Weber fractures were considered. Of the 52 patients, 19 (35.19%; 21 talus fractures) with follow-up data available for >12 months were included in the final study population. Of the 21 fractures, 9 (42.86 %) were type 1, 4 (19.05%) were type 2, 1 (4.76%) was type 3, and 7 (33.33%) were type 4. The mean patient age was 14.7 (range 4 to 18) years. The patients were divided into 3 age groups: group 1, age ≤11.9 years; group 2, age 12.0 to 15.8 years; and group 3, age 16.1 to 18.0 years. Of the 21 fractures, 3 (14.29%) were treated nonoperatively and 18 (85.71%) operatively. The overall mean follow-up duration was 40.3 (range 14 to 95) months. The outcomes of interest included fracture nonunion, talar avascular necrosis, ankle range of motion, pain, arthrosis, and arthrodesis. After treatment, the mean ankle range of motion was 20° (range 0° to 35°) of dorsiflexion and 40° (range 0° to 45°) of plantarflexion. Complications included persistent pain in 10 fractures (47.62%), 3 cases of nonunion (14.29%), 3 cases of avascular necrosis (14.29%; of which, 1 [4.76%] required ankle and subtalar fusion), and arthrosis developing in ≥1 surrounding joint in 12 fractures (57.14%). Of the 12 fractures in group 3, 9 (75.00%) developed arthrosis and 2 (16.67%) subsequently required arthrodesis. Our observations suggest that the incidence of displaced talus fractures, as well as complications, increases with patient age.