Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure

INTRODUCTION

To determine whether obese surgical patients are at a significant disadvantage in terms of outcomes after extracorporeal device (ECD) support, such as veno-venous extracorporeal membrane oxygenation (VV ECMO) or pumpless extracorporeal lung assist (pECLA), for respiratory failure, the relationship between body mass index (BMI) and hospital outcomes was analyzed.

METHODS

This retrospective study included data on patients who were supported with an ECD between January 1, 2008 and December 31, 2014. The analysis included 89 patients (74 male).

RESULTS

The median BMI was 30 kg/m2 (19-88.5). The median duration of the ECD support was 9.0 days, with a maximum of 37.1 days. The median LOS (length of stay) in the intensive care unit (ICU) was 21 days (range 0.06-197.6). The median hospital LOS was 34.9 days (range 0.1-213.8). VV ECMO was performed 72 times, and pECLA was performed 18 times. The number of patients successfully weaned off the ECD was 54 (60.6%). Survival at the discharge from the hospital was 48.3%.

CONCLUSIONS

54 (60.6%) patients were successfully weaned off the ECD; 43 (48.3%) patients survived and were discharged from the hospital. The analysis of correlations between BMI and outcomes of surgical patients treated with ECD showed no association between BMI and mortality. Complications (especially oxygenator clotting) were not more frequent in obese and extremely obese patients. We hypothesized that patients with higher or morbid BMIs would have increased mortality after ECD support. A BMI of 30.66 kg/m2 corresponded to the desired sensitivity and specificity to predict mortality. This finding applied only to the study group. Treatment with ECD in obese patients presents unique challenges, including percutaneous cannulation and increased staff requirements. However, based on these data, obesity should not be an exclusion criterion for ECD therapy.

Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases

Elastic stable intramedullary nailing (ESIN) has been established as state of the art treatment for forearm fractures in children, if operative stabilization is required. Their use has been expanded to single bone shaft fractures, and also more complex injuries such as Monteggia fractures or Monteggia-like lesions. A wide range of complications has been reported in the literature, up to 70% in certain investigations. The purpose of this study was to assess the complication rate after ESIN treatment of forearm fractures in children and adolescents in a representative cohort of patients from a level 1 trauma center in Germany.Between 2000 and 2015, we retrospectively analyzed all patients, up to the age of 16 years, with forearm fractures, who were operatively treated using ESIN in our department of general and trauma surgery. The main outcome measurements were the rates of postoperative complications after ESIN such as re-fracture, malunion, nonunion, tendon lesion, wound infection, and limited range of motion.In all, 201 consecutive patients with 202 forearm fractures were included in this study. Age averaged 9.7 years (range 3-16 years). Fifteen (7.4%) fractures were open. Fractures were 82.2% diaphyseal both-bone forearm fractures. Follow-up averaged 10.2 months (range 0.7-176.3 months). Complications were 10 re-fractures, 2 malunions, 3 extensor pollicis longus tendon ruptures, 1 superficial wound infection, and 2 limited range of motions. Fourteen (6.9%) children required a secondary operative intervention for their complication. Time to implant removal averaged 3.8 months (range 0.4-16.3 months).Elastic stable intramedullary nailing is a minimally invasive and reliable technique with a low complication rate. Both-bone forearm fractures and single bone fractures, and also Monteggia and Monteggia-equivalent fractures can be successfully treated with this method. As a major complication, re-fractures are frequently seen, even with ESIN in situ.

48 h cessation of mechanical ventilation during venovenous extracorporeal membrane oxygenation in severe trauma: a case report

A 32-year-old motorcyclist who was hit by a tram subsequently presented with blunt force thoracic trauma, a pelvic fracture and a penetrating injury to the left lower extremity. Coagulopathy persisted following surgery of the leg and pelvic vascular intervention. Bedside thoracotomy was performed to treat pneumothorax and pneumopericardium. Severe hypoxemia secondary to lung failure ensued, which required venovenous extracorporeal membrane oxygenation (VV ECMO) support. On the third day after the trauma, ultra-protective mechanical ventilation was not possible due to non-existent lung compliance; thus, the ventilator was disconnected, and the T-piece was connected to the blocked tracheal tube left in the airway. Gas exchange occurred via VV ECMO separately. After 48 h of cessation of ventilator support, the patient was weaned from sedation. At this time, respiratory effort was observed, and assisted ventilation was initiated. The patient ultimately recovered and experienced an excellent outcome. The clinical significance of zero end-expiratory pressure (ZEEP) and the complete cessation of open lung strategy during ECMO remains controversial. In cases of reduced lung compliance, if VV ECMO can facilitate adequate gas exchange, the discontinuation of ventilation is an option that can be used to prevent ventilator-induced lung damage and to allow the lungs to rest. VV ECMO is feasible as lung support with no mechanical ventilation in case of severe lung failure after major trauma.

Extracorporeal lung support in patients with spinal cord injury: Single center experience

OBJECTIVE

Trauma-related spinal cord injury (SCI) leads to a loss of motor, sensory and vegetative functions and is disproportionately associated with respiratory complications. SCI has a significant impact on respiratory muscle function and can lead to respiratory dysfunction or severe lung failure.

PARTICIPANTS

Between 2008 and 2014, 7 patients with severe lung failure following SCI received veno-venous extracorporeal membrane oxygenation (ECMO) n = 5 and interventional lung assist (iLA) n = 2.

RESULTS

The median duration of extracorporeal lung support was 8 (5.7-17.6) days. All 5 of the ECMO-supported patients were successfully weaned, and one of the two patients treated with iLA was weaned from the device. The median intensive care unit (ICU) stay was 35 (8.5-44.5) days. The mean hospital stay was 81 (8.5-120.7) days, and the average ventilation time was 817 (206-1,225) hours. Five (71.4%) of the 7 patients were discharged from the ICU and hospital.

CONCLUSIONS

In patients with SCI, serious complications include microatelectasis, infection, ventilation-perfusion mismatching and aspiration (special case: salt-water aspiration after jumping into shallow water). In patients with SCI with post-traumatic lung failure, ECMO is a feasible and life-saving procedure. After surviving spinal shock, a long rehabilitation period with intensive follow-up in specialized centers is required.

[Neurological diseases after lightning strike : Lightning strikes twice]

Lightning strikes rarely occur but 85 % of patients have lightning-related neurological complications. This report provides an overview about different modes of energy transfer and neurological conditions related to lightning strikes. Moreover, two case reports demonstrate the importance of interdisciplinary treatment and the spectrum of neurological complications after lightning strikes.

Results of non-operative treatment of fractures of the glenoid fossa

AIMS

Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively.

PATIENTS AND METHODS

We reviewed 24 patients with a mean age of 52 years (19 to 81) at a mean of 5.6 years (11 months to 18 years) after the injury.

RESULTS

At final follow-up, the mean Constant and Murley score was 79 points (18 to 98); the mean Western Ontario Shoulder Instability Index score (WOSI) was 77% (12 to 100) and the mean Rowe score was 93 points (50 to 100). Fractures with little intra-articular displacement (≤ 3 mm) had an uneventful outcome. Those with intra-articular displacement of ≤ 3 mm had a significant better mean Constant and Murley score than those with displacement of ≥ 5 mm and/or a fracture gap of ≥ 5 mm. Poor clinical results such as nonunion and post-traumatic osteoarthritis were associated with displaced or angulated glenoid fragments and significant intra-articular displacement.

CONCLUSION

Glenoid fossa fractures with displacement of ≥ 5 mm should be treated surgically if the patient's condition allows. Displacement and angulation can lead to nonunion and a poor outcome if the degree of displacement results in a persistent fracture gap in the glenoid fossa or if the angulation of fragments leads to malunion. Cite this article: Bone Joint J 2016;98-B:1074-9.

Heterotopic ossification mimicking infection in patients with traumatic spinal cord injury

BACKGROUND

Heterotopic ossification (HO) is a common concominant condition in patients with traumatic spinal cord injury (SCI). In this context, we report on patients with heterotopic ossification causing infection like symptoms as a first manifestation of HO subsequent to traumatic SCI.

OBJECTIVE

The objective of the study was to analyse possible ``early-indicator symptoms'' in patients suffering from heterotopic ossification following SCI with special focus on elevated serum CRP, serum CK and body temperature.

METHODS

All eligible patients treated between January 2004 and December 2013 because of a SCI and heterotopic ossification have been enrolled in this retrospective study. An age below 18 years and the absence of the combination of elevated serum CRP, CK and elevated body temperature (> 38.5 °C) were defined as exclusion criteria. The presence of another infection, led to exclusion. Fifteen out of 235 patients (6.4%) met the inclusion criteria and were included in the final data analysis.

RESULTS

The patient cohort consists of 13 male and two female patients with a mean age of 30.6 years (range from 18 to 56 years; SD = 13.5). The mean time interval between HO development and the injury was 49.4 days (range from 16 to 131 days; SD = 34.3). Focussing on laboratory parameters, mean serum CRP level was 10.2 mg/dl (range from 1.3 to 24.4 mg/dl; SD = 9.6). Mean serum CK was 1365 U/l (range from 255 to 4729 U/l; SD = 1491). Worth mentioning, in 9 cases (60%) serum CK was higher than 500 U/l. Mean body temperature was 38.7 °C (range from 38.0 to 39.4; SD = 0.4). CT scans of the thorax, abdomen and pelvis revealed no further pathologies besides the heterotopic ossification. Urinary tract infections were ruled out, using urine tests as a standard procedure in all cases.

CONCLUSIONS

Elevated levels of serum CRP, serum CK and high body temperature in acute SCI may be considered as indicators for a concominant HO diagnosis.

The Effectiveness and Safety of Exoskeletons as Assistive and Rehabilitation Devices in the Treatment of Neurologic Gait Disorders in Patients with Spinal Cord Injury: A Systematic Review

Study Design Systematic review. Clinical Questions (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury? Methods PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or complete spinal cord injury. Results No comparison studies were found evaluating exoskeletons as an assistive device. Nine comparison studies (11 publications) evaluated the use of exoskeletons as a rehabilitative device. The 10-meter walk test velocity and Spinal Cord Independence Measure scores showed no difference in change from baseline among patients undergoing exoskeleton training compared with various comparator therapies. The remaining primary outcome measures of 6-minute walk test distance and Walking Index for Spinal Cord Injury I and II and Functional Independence Measure-Locomotor scores showed mixed results, with some studies indicating no difference in change from baseline between exoskeleton training and comparator therapies, some indicating benefit of exoskeleton over comparator therapies, and some indicating benefit of comparator therapies over exoskeleton. Conclusion There is no data to compare locomotion assistance with exoskeleton versus conventional KAFOs. There is no consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in patients with chronic spinal cord injury. Trials comparing later-generation exoskeletons are needed.

Percutaneous Dilatational Tracheostomy in Ankylosing Spondylitis (Bechterew Disease) Is Feasible and Not Associated With Higher Complication Rates

BACKGROUND

Ankylosing spondylitis (AS) is a common disease with an incidence of approximately 0.5% in Europe, causing severe limitations of axial spine mobility and cervical kyphosis. Deformities of the cervical spine and the temporomandibular joints could increase the risk of complications while performing an intubation or tracheostomy. The percutaneous dilatational tracheostomy (PDT) is a standard procedure in intensive care medicine. However, the combination of cervical kyphosis and osteoporosis makes patient positioning challenging. Therefore, one could conclude that patients with AS are not candidates for PDT, but neither studies nor case reports yet reported about feasibility of this procedure in AS.

METHODS

Retrospective analysis at a level 1 trauma center of patient records from 2002 to 2016, assessing all patients with AS and PDT.

RESULTS

A total of 31 patients with AS have been subjected to PDT. All PDTs were performed using the modified Ciaglia single-step dilatational technique. Neither cardiopulmonary nor surgical complications occurred during the procedure. One patient received a change of the existing airway prior to the procedure; a small nasal tube was changed for a laryngeal mask.

CONCLUSION

Although head positioning may be challenging, PDT should be taken into consideration for patients with AS. In the hands of an experienced doctor, it is safe and feasible.

Ankylosing spondylitis does not increase the risk of neurogenic heterotopic ossification in patients with a spinal cord injury: a retrospective cohort study

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

The present study was performed to analyze the impact of ankylosing spondylitis (AS) in developing heterotopic ossification (HO) in patients following spinal cord injury.

SETTING

Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany.

MATERIALS AND METHODS

Between January 2003 and December 2015, 67 patients with AS and SCI were included in the study. The control group consisted of 141 patients with SCI and without AS. The definitive diagnosis of HO was made via magnetic resonance imaging or computed tomography. Primary outcome measure was to analyze the impact of AS on the development of HO.

RESULTS

Fifteen out of 67 AS patients (22.4%) had a diagnosed HO. In the control group, 28 of 141 patients (19.9%) suffered from HO. Patients with AS had no significant higher risk for HO development compared with patients without AS (RR=1.16; 95% CI=0.65-2.09). However, patients with a complete neurological deficit had a twofold higher risk for HO development (RR=2.55; 95% CI=1.26-5.16).

CONCLUSIONS

AS does not increase the risk for HO development in patients with spinal cord injury.

Pediatric pelvic ring injuries: How benign are they?

INTRODUCTION

With an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.

PATIENTS AND METHODS

This Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4-16) and an average follow up of 28.6 months (range 6-101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.

RESULTS

For Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5mm. Group 1 had more pelvic asymmetry (12.3mm vs. 6.6mm) and ring width difference (6.9mm vs. 3.9mm) on final X-rays as compared to Group 2. Children with 5-10mm posterior sacral displacement had significantly more pain than children with 0-4mm displacement (p=0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p=0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5mm to 15mm occurred.

DISCUSSION AND CONCLUSION

In pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.

[The acetabulum nonunion: reconstruction and reosteosynthesis : A long-term outcome]

Acetabular nonunions are rare, especially after operative treatment of an acetabular fracture. There are only single reports of the reconstruction and therapy of acetabular nonunion. Furthermore, there are fewer reports for treatment of acetabular nonunion with a long follow-up. We report a successful revision of an acetabular nonunion after transversal fracture and previous operative intervention, as well as the long-term follow-up after revision surgery.

The sensitivity of ultrasound screening examination in detecting heterotopic ossification following spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To analyze the role of sonography in detecting heterotopic ossification (HO) following spinal cord injury (SCI).

SETTING

Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Germany.

METHODS

Between January 2003 and December 2013, 217 patients with HO of the hips met the inclusion criteria and were included in the final analyses. The diagnosis of HO was carried out in all cases using our hospital protocol. Primary outcome measure was to calculate the sensitivity of ultrasound screening examination in detecting HO following SCI.

RESULTS

The diagnosis of HO was confirmed in 217 patients after a mean interval of 64.8 days (range from 8 to 295; s.d.=40.4) via computerized tomography or magnetic resonance imaging scan. In 193 out of 217 patients, suspicious HO signs were noted in the ultrasound screening examination (sensitivity=88.9%).

CONCLUSIONS

The use of ultrasound for screening for HO in SCI patients is reliable and has a high sensitivity.

Treatment of Chronic Acromioclavicular Joint Dislocation in a Paraplegic Patient with the Weaver-Dunn Procedure and a Hook-Plate

In case of patients with spinal cord injury and concomitant acromioclavicular (AC) joint-dislocation the treatment is challenging, as in this special patient group the function of the shoulder joint is critical because patients depend on the upper limb for mobilization and wheelchair-locomotion. Therefore the goal of this study was to examine, if the treatment of chronic AC-joint dislocation using the Weaver-Dunn procedure augmented with a hook-plate in patients with a spinal cord injury makes early postoperative wheelchair mobilization and the wheelchair transfer with full weight-bearing possible. In this case the Weaver-Dunn procedure with an additive hook-plate was performed in a 34-year-old male patient with a complete paraplegia and a posttraumatic chronic AC-joint dislocation. The patient was allowed to perform his wheelchair transfers with full weight bearing on the first post-operative day. The removal of the hook-plate was performed four months after implantation. At the time of follow-up the patient could use his operated shoulder with full range of motion without restrictions in his activities of daily living or his wheel-chair transfers.

A 23-year-old patient with secondary tumoral calcinosis: Regression after subtotal parathyroidectomy: A case report

•

Tumoral calcinosis needs to be diagnosed correctly.

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Subtotal parathyroidectomy leads to rapid regression.

•

Potential mutilations may be avoid by early subtotal parathyroidectomy.

Introduction

Tumoral calcinosis (TC) is a rare disorder defined by hyperphosphatemia and ectopic calcifications in various locations. The most common form of TC is associated with disorders such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The primary (hereditary) TC is caused by inactivating mutations in either the fibroblast growth factor 23 (FGF23), the GalNAc transferase 3 (GALNT3) or the KLOTHO (KL) gene.

Presentation of case

We report here a case of secondary TC in end-stage renal disease. The patient was on regular hemodialysis and presented with severe painful soft-tissue calcifications around her left hip and shoulder that had been increasing over the last two years. Initially, she was treated with dietary phosphate restriction and phosphate binders. Because of high phosphate blood levels, which were not yet managed with dialysis and medical therapy, a subtotal parathyroidectomy (sP) was performed. This approach demonstrated significant response. Three months after surgery a rapid regression of the tumors was observed.

Disscusion

Regardless of the etiology, the two types of TC do not differ in their radiologic or histopathologic presentations but need to be diagnosed correctly to initiate targeted and effective treatment. Considering the primary TC, primary treatment is early and complete surgical excision. In case of secondary TC surgical excision of the tumoral masses should be avoid because of extensive complications. These patients benefit from sP.

Conclusion

After initial conservative therapy chronic kidney disease patients with TC might benefit from sP to avoid prolonged suffering and potential mutilations.

Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates

INTRODUCTION

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures in the increasing older population. According to the AAOS, approximately 19,200 Americans are actually living with ipsilateral prosthetic hip and knee leading to 240 interprosthetic fractures annually. Few reviews and case reports give an idea of the obvious problem to achieve consolidation in interprosthetic fractures. Preconfigured plates have been shown to be superior compared with other treatments in patients with stable components. Utilization of internal fixators for interprosthetic fractures might be advantageous. The purpose of this study was to evaluate interprosthetic femoral fractures with polyaxial locking plate treatment in regard to surgical procedure, complications, and clinical outcome.

METHODS

Between 2005 and 2012, 143 patients underwent surgical treatment for periprosthetic femur fractures. Thirty-two fractures were identified as interprosthetic fractures. Five patients were excluded. Fractures were classified according to OTA/AO system, Vancouver, Rorabeck, Soenen and Pires. Trauma fellowship trained orthopaedic surgeons performed the surgeries using a NCB-construct (Zimmer Inc., Warshaw, IN). Plate choice was determined according to radiographic classification. Submuscular plate insertion was performed if possible. Complications were recorded concerning infection, union, fixation failure, and revision surgery.

RESULTS

Twenty-seven patients were identified. There were 92.6% females. Follow-up by regular outpatient clinic visits was 24 months. Surface replacements were found in 18 TKA. Nine patients had a stemmed femur component of their TKA. 89% healed after the index procedure. Three patients developed a nonunion with 1 construct leading to hardware failure. Previous revision THA or Pires/modified Vancouver classification did not influence nonunion formation, but all patients with nonunion formation were classified as AO/OTA type B (p=0.001). These fractures were treated with longer plates (p=0.015), but with similar working length (p=0.400). Plate design, additional cerclages, or submuscular insertion did not influence nonunion formation.

CONCLUSION

Interprosthetic fracture treatment remains challenging. NCB-locked plating can achieve satisfactory results. Additional soft tissue damage can be prevented by submuscular plate insertion. Treatment of type B fractures resulted in significantly greater nonunion rate. Therefore, consideration of the individual fracture type is essential to determine plate length, plate type, and additional bone grafting or BMP supplementation.

Fibrin glue as a protective tool for microanastomoses in limb reconstructive surgery

Aim: Fibrin glue becomes a more and more routinely used tool for stabilization of microanastomoses and nerve repair. This paper summarizes the technical properties and advantages of its use in a wide variety of microsurgical contexts, and includes an exemplary limb reconstructive case.

Patients and methods: A total of 131 patients who had undergone elective and emergency microsurgery mainly of the limbs were retrospectively analyzed, as was the use of free flaps.

Results: The use of fibrin glue allows for proper positioning of anastomoses and repaired nerves. No torsion of the pedicle could be seen. The flap survival rated >94%. The fibrin glue could stay in place in >99%. In the rare case of revision, the fibrin glue could easily be removed without damaging the region of the microanastomosis.

Conclusion: Fibrin glue should not be used to repair insufficient, i.e., leaking anastomoses, but it does protect the site of anastomosis from tissue and fluid pressure. It prevents the pedickle from torsion and its use facilitates relocation of the microanastomoses in cases of revision surgery.

Haemophilia A in a major trauma patient

Haemophilia A is a coagulopathy with an absence or functional deficiency of coagulation factor VIII. The disease can be subdivided into a congenital form (incidence 1:10,000-1:20,000) and an acquired form (incidence 1:1,000,000). Both forms present an increased risk of bleeding even in low-impact trauma in severe cases of haemophilia A. The course of a man with haemorrhagic shock after a fall from a height of more than 3 m is described. After the secondary survey in the intensive care unit, several interventions (laparotomy, mass transfusion) were performed to stop the bleeding. A history of haemophilia was belatedly reported by relatives. The activity of factor VIII was determined, and substitution was initiated. No recurrent signs of bleeding occurred. The patient survived in good condition and presented for follow-up 3 years later with no disabilities.

The roles of serum alkaline and bone alkaline phosphatase levels in predicting heterotopic ossification following spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To analyze the usefulness of serum alkaline phosphatase (AP) and bone alkaline phosphatase (BAP), as well as C-reactive protein (CRP) levels in predicting heterotopic ossification (HO).

SETTING

Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Germany.

METHODS

Between January 2003 and December 2013, 87 patients with HO around the hips met the inclusion criteria and were included in the study. Alkaline phosphatase, CRP and BAP were assessed and interpreted at the time of HO diagnosis and after radiation therapy in all patients.

RESULTS

At the time of HO diagnosis, 49 out of 87 patients (49.4%) had elevated alkaline phosphatase levels and 39 out of 87 patients (44.8%) had elevated BAP levels. Elevated CRP values were found in 67 patients (77.0%). Within 3 days after single-dose radiation therapy, elevated AP levels persisted in 38 patients (43.7%) and elevated BAP levels in 28 patients (32.2%).

CONCLUSIONS

The results obtained show that the determination of CRP, AP and BAP levels may not be considered a reliable screening method for early HO detection, subsequent to spinal cord injury.

Use of extracorporeal membrane oxygenation in an awake patient after a major trauma with an incidental finding of tuberculosis

We report the use of extracorporeal membrane oxygenation (ECMO) in a trauma patient with an incidental finding of open tuberculosis (TB). Sedation was reduced during extracorporeal support and awake veno-venous ECMO was successfully performed. Subsequently, accidental cannula removal caused major blood loss which required the administration of cardiopulmonary resuscitation (CPR). Our case report demonstrates that the incidental finding of open TB is an important hint for differential diagnosis and that it should still be considered in high-income countries. In addition, awake ECMO appears to be a feasible therapeutic option in non-transplant patients, although the described case demonstrates that patient compliance and nursing care are important for therapeutic success to avoid complications, for example, inadvertent decannulation.

Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients

PURPOSE

Isolated pediatric radial head and neck fractures are rare. In recent literature, their incidence is estimated to be around 1% of all fractures. High rates of complications are reported. Beside non-operative treatment, head fractures are treated with k-wires, mini-screws or polypins, whereas neck fractures are treated more and more with elastic stable intramedullary nailing (ESIN). Purpose of the study was to evaluate the operative management, complications and clinical outcomes of these injuries.

METHODS

Retrospective analysis between 2002 and 2014. 19 children with isolated radial head and neck fractures were treated in our institution. Age averaged 11 years (range 6-16). Operative treatment with elastic stable intramedullary nailing (ESIN) was performed in 13 patients, in one patient with an additional k-wire; two screw, two k-wire and one polypin fixation was performed in the others. One child was treated non-operatively.

RESULTS

Follow up averaged 19 months (2-89). Initial complications occurred in nine children such as fracture dislocation (1), nonunion (1), malunion (1), elbow ankylosis (1), infection (1), crossunion (2), intraarticular screw penetration (1) and radial nerve irritation (1). ESIN lead a complication rate of 36%, mini-screw fixation and k-wire fixation showed a complication rate of 100%. All children (100%) with an open reduction maneuver and 36% children with closed or percutaneous reduction developed a complication. Secondary surgeries included ESIN removal and k-wire fixation (1), open arthrolysis (1), debridement (1), removal of crossunion (1), radial head removal plus arthrolysis (3) and screw removal (1). Subsequently 74% (14) children showed a free or <20° limited range of motion on final follow up. Implant removal was performed after an average of 8 weeks (5-12). Three patients were transferred to our surgical department after a complication following initial treatment. Excluding these, an overall complication rate of 37.5% was noted.

CONCLUSIONS

Radial head injuries in children are rare. In this population, neck fractures occur more frequently. If conservative treatment is not possible, ESIN seems to be a simple and protective procedure for neck fractures; polypins or screws can be used for complicated radial head fractures. Complications occur frequently after open reduction. If closed reduction and internal fixation is possible, range of motion can be completely restored.

Fulminant Necrotizing Fasciitis of the Thigh, Following an Infection of the Sacro-iliac Joint in an Immunosuppressed, Young Woman

Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient's history revealed intravenous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.

HAL® exoskeleton training improves walking parameters and normalizes cortical excitability in primary somatosensory cortex in spinal cord injury patients

BACKGROUND

Reorganization in the sensorimotor cortex accompanied by increased excitability and enlarged body representations is a consequence of spinal cord injury (SCI). Robotic-assisted bodyweight supported treadmill training (BWSTT) was hypothesized to induce reorganization and improve walking function.

OBJECTIVE

To assess whether BWSTT with hybrid assistive limb® (HAL®) exoskeleton affects cortical excitability in the primary somatosensory cortex (S1) in SCI patients, as measured by paired-pulse somatosensory evoked potentials (ppSEP) stimulated above the level of injury.

METHODS

Eleven SCI patients took part in HAL® assisted BWSTT for 3 months. PpSEP were conducted before and after this training period, where the amplitude ratios (SEP amplitude following double pulses - SEP amplitude following single pulses) were assessed and compared to eleven healthy control subjects. To assess improvement in walking function, we used the 10-m walk test, timed-up-and-go test, the 6-min walk test, and the lower extremity motor score.

RESULTS

PpSEPs were significantly increased in SCI patients as compared to controls at baseline. Following training, ppSEPs were increased from baseline and no longer significantly differed from controls. Walking parameters also showed significant improvements, yet there was no significant correlation between ppSEP measures and walking parameters.

CONCLUSIONS

The findings suggest that robotic-assisted BWSTT with HAL® in SCI patients is capable of inducing cortical plasticity following highly repetitive, active locomotive use of paretic legs. While there was no significant correlation of excitability with walking parameters, brain areas other than S1 might reflect improvement of walking functions. EEG and neuroimaging studies may provide further information about supraspinal plastic processes and foci in SCI rehabilitation.

Results and complications of operative and non-operative navicular fracture treatment

BACKGROUND

Navicular fractures (NF) are uncommon. The purpose of this study was to compare results of operative (ORIF) and non-operative (NOT) treatment in NF.

METHODS

A retrospective analysis was undertaken on patients diagnosed with NF between March 2002 and June 2007 at a Level I teaching trauma centre. Clinical outcome consisted of functional ability and complications.

RESULTS

Eighty-eight patients with 90 fractures were identified including 56 males and 32 females with a mean age of 38 (range 17-72) and body mass index of 28.2 (range 18.7-48.9). Twenty-one of 90 (23.3%) injuries were isolated. Ten of 90 (11.1%) injuries were open. Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting. Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (χ(2)=0.000). Secondary surgery was 25 hardware removals (16 for irritation, five for prominent or broken plates), nine arthrodeses/-plasties, two debridements for infection, and one tarsal tunnel release. Pain was present at final follow up in 39/90 (43.3%) feet. Work status was 64 without restrictions, 17 with restrictions, and 5 did not return to work. Sixty-two of 88 (69%) patients were able to wear normal shoes, which were related to return to work without restrictions (ρ=-0.508, p=0.000). Inability to return to previous work was related to pain (ρ=-0.394), SOA (ρ=-0.280), and poor reduction quality (ρ=-0.384) with significance at p<0.01. Increased BMI (>35) related to pain (ρ=0.250) and poor reduction quality (ρ=0.326) at a σ<0.05.

CONCLUSIONS

Despite modern surgical techniques, operative treatment of displaced fractures is at high risk for complications. Obesity, pain, and secondary osteoarthrosis determine shoe wear, return to function, and employment status.

LEVEL OF EVIDENCE

Level III.