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Pfeifer R, Klingebiel FKL, Balogh ZJ, Beeres FJP, Coimbra R, Fang C, Giannoudis PV, Hietbrink F, Hildebrand F, Kurihara H, Lustenberger T, Marzi I, Oertel MF, Peralta R, Rajasekaran S, Schemitsch EH, Vallier HA, Zelle BA, Kalbas Y, Pape HC. Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review. J Trauma Acute Care Surg 2024:01586154-990000000-00776. [PMID: 39085995 DOI: 10.1097/ta.0000000000004428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
BACKGROUND The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE Delphi-Consensus/Systematic Review; Level IV.
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Affiliation(s)
- Roman Pfeifer
- From the Department of Trauma Surgery (R.Pf., F.K.-L.K., Y.K., H.-C.P.), Harald-Tscherne Laboratory for Orthopaedic and Trauma Research (R.Pf., F.K.-L.K., Y.K., H.-C.P.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia; Department of Orthopaedic and Trauma Surgery (F.J.P.B.), Lucerne Cantonal Hospital, Lucerne, Switzerland; Riverside University Health System Medical Center and Loma Linda University School of Medicine (R.C.), Loma Linda, California; Department of Orthopaedics and Traumatology (C.F.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong; Academic Department of Trauma and Orthopaedics (P.V.G.), School of Medicine, University of Leeds; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom; Department of Trauma Surgery (F.Hie.), University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Orthopaedics (F.Hil.), Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany; Emergency Surgery Unit (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Trauma Surgery (T.L.), Aarau Cantonal Hospital, Aarau, Switzerland; Department of Trauma (I.M.), Hand, and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Department of Neurosurgery (M.F.O.), Clinical Neuroscience Center (M.F.O.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery (R.Pe.), Trauma Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Surgery (R.Pe.), Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic; Department of Orthopedics and Spine Surgery (S.R.), Ganga Hospital, Coimbatore, India; Department of Surgery, Division of Orthopaedic Surgery (E.H.S.), University of Western Ontario, London, Ontario, Canada; Department of Orthopaedic Surgery (H.A.V.), Case Western Reserve University, Cleveland, Ohio; and Department of Orthopaedics (B.A.Z.), UT Health San Antonio, San Antonio, Texas
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Pape HC, Starr AJ, Gueorguiev B, Wanner GA. The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review. Patient Saf Surg 2024; 18:22. [PMID: 38902828 PMCID: PMC11191186 DOI: 10.1186/s13037-024-00404-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024] Open
Abstract
Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.
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Affiliation(s)
- Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital of Zurich, Raemistr. 100, Zurich, 8091, Switzerland.
| | - Adam J Starr
- Department of Orthopaedic Surgery, Parkland Memorial Hospital, University of Texas Southwestern, 4900 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstr. 8, Davos, 7270, Switzerland
| | - Guido A Wanner
- Department of Spine & Trauma Surgery, Bethanien Hospital, Toberlstr. 51, Zurich, 8044, Switzerland
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Hörauf JA, Woschek M, Schindler CR, Verboket RD, Lustenberger T, Marzi I, Störmann P. Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course. J Clin Med 2024; 13:3333. [PMID: 38893044 PMCID: PMC11173217 DOI: 10.3390/jcm13113333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.
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Affiliation(s)
- Jason-Alexander Hörauf
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Mathias Woschek
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Cora Rebecca Schindler
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Rene Danilo Verboket
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas Lustenberger
- Department of Orthopedic Surgery and Traumatology, Inselspital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Ingo Marzi
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Philipp Störmann
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Kalbas Y, Klingebiel FKL, Halvachizadeh S, Kumabe Y, Scherer J, Teuben M, Pfeifer R, Pape HC. Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES. Eur J Trauma Emerg Surg 2024; 50:657-669. [PMID: 36820896 PMCID: PMC11249440 DOI: 10.1007/s00068-023-02245-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology. METHODS A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades. RESULTS 4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000. CONCLUSION Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland.
| | - Felix Karl-Ludwig Klingebiel
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Yohei Kumabe
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Julian Scherer
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
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Scherer J, Coimbra R, Mariani D, Leenen L, Komadina R, Peralta R, Fattori L, Marzi I, Wendt K, Gaarder C, Pape HC, Pfeifer R. Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section. Eur J Trauma Emerg Surg 2024; 50:671-678. [PMID: 36227354 PMCID: PMC11249422 DOI: 10.1007/s00068-022-02126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/01/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fixation of major fractures plays a pivotal role in the surgical treatment of polytrauma patients. In addition to ongoing discussions regarding the optimal timing in level I trauma centers, it appears that the respective trauma systems impact the implementation of both, damage control and safe definitive surgery strategies. This study aimed to assess current standards of polytrauma treatment in a Europe-wide survey. METHODS A survey, developed by members of the polytrauma section of ESTES, was sent online via SurveyMonkey®, between July and November 2020, to 450 members of ESTES (European Society of Trauma and Emergency Surgery). Participation was voluntary and anonymity was granted. The questionnaire consisted of demographic data and included questions about the definition of "polytrauma" and the local standards for the timing of fracture fixation. RESULTS In total, questionnaires of 87 participants (19.3% response rate) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years, and on average, 17 multiple-injured patients were treated monthly. Most of the participants stated that a polytrauma patient is defined by ISS ≥ 16 (44.16%), followed by the "Berlin Definition" (25.97%). Systolic blood pressure < 90 mmHg, tachycardia or vasopressor administration (86.84%), pH deviation, base excess shift (48.68%), and lactate > 4 mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three most often stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytrauma patients. Normal coagulation (79.69%), missing administration of vasopressors (62.50%), and missing clinical signs of "SIRS" (67.19%) were stated as criteria for safe definite secondary surgery. CONCLUSION Different definitions of polytrauma are used in the clinical setting. Indication for and the extent of secondary (definitive) surgery are mainly dependent on the polytrauma patient`s physiology. The «Window of Opportunity» plays a less important role in decision making.
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Affiliation(s)
- Julian Scherer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland.
| | - Raul Coimbra
- Riverside University Health System and Loma Linda University, Riverside, CA, USA
| | - Diego Mariani
- Department of Emergency General Surgery, Legnano Hospital, ASST Ovest Milanese, Legnano, MI, Italy
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, 3000, Celje, Slovenia
| | - Ruben Peralta
- Surgical Department (Hamad General Hospital), Hamad Medical Corporation, HMC, Doha, Qatar
| | - Luka Fattori
- Department of Surgery, San Gerardo Hospital, University of Milan Bicocca, G.B. Pergolesi 33, Monza, Italy
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Klaus Wendt
- Department of Trauma Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevål, Kirkeveien 166, 0450, Oslo, Norway
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland
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Halvachizadeh S, Pfeifer R, Duncan J, Klingebiel FKL, Kalbas Y, Berk T, Neuhaus V, Pape HC. Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures? J Trauma Acute Care Surg 2024; 96:931-937. [PMID: 38196119 DOI: 10.1097/ta.0000000000004252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sascha Halvachizadeh
- From the Department of Trauma, University Hospital Zurich, University of Zurich, Zurich, Switzerland; and Department of Trauma and Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Martínez-Hernández A, Jara-Benedetti G, Roig-Martí C, Ordóñez-Urgiles C, Laguna-Sastre JM. Approach and management of patients injured by bullfighting trauma. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00085-7. [PMID: 38782359 DOI: 10.1016/j.recot.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Bullfighting festivals are attributed to the cultural idiosyncrasies of the Ibero-American people, posing an extreme risk to the physical integrity of the participants. Spain is considered the country with the highest number of bull-related celebrations worldwide and, therefore, with the highest number of patients injured by bullfighting trauma treated, thus justifying a public health problem. The generalities associated with this type of trauma define the people injured as polytraumatised patients. In addition, it is important to know the kinematics of the injuries and their specific characteristics, in order to implement quality medical-surgical care. METHODS scientific review of the literature to promote a comprehensive guide for the medical-surgical management of patients injured by bullfighting trauma. RESULTS We described the guidelines to standardise protocols for in-hospital approach of patients injured by bullfighting trauma. CONCLUSIONS Bullfighting trauma is considered a real health problem in the emergency departments of the ibero-Americans countries, especially in Spain, where bullfighting is part of the national culture. The inherent characteristics of these animals cause injuries with special aspects, so it is important to know the generalities of bullfighting trauma. Because of the multidisciplinary approach, this guidelines are adressed to all healthcare providers involved in the management of these patients. It is essential to establish particular initial care for this type of injury, specific therapeutic action and follow-up based on the medical-surgical management of the trauma patient in order to reduce the associated morbidity and mortality.
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Affiliation(s)
- A Martínez-Hernández
- Departamento de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castelló de la Plana, España; Departamento de Medicina y Cirugía, Universidad Jaime I, Castellón, España.
| | - G Jara-Benedetti
- Departamento de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castelló de la Plana, España
| | - C Roig-Martí
- Departamento de Medicina Interna, Hospital General Universitario de Castellón, Castelló de la Plana, España
| | - C Ordóñez-Urgiles
- Departamento de Traumatología y Cirugía Ortopédica, Hospital Universitario de Terrasa, Barcelona, España
| | - J M Laguna-Sastre
- Departamento de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castelló de la Plana, España; Departamento de Medicina y Cirugía, Universidad Jaime I, Castellón, España
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Wähnert D, Miersbach M, Colcuc C, Brianza S, Vordemvenne T, Plecko M, Schwarz A. Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation. Front Surg 2024; 11:1376441. [PMID: 38756355 PMCID: PMC11096559 DOI: 10.3389/fsurg.2024.1376441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.
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Affiliation(s)
- Dirk Wähnert
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Marco Miersbach
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Christian Colcuc
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | | | - Thomas Vordemvenne
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Michael Plecko
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
| | - Angelika Schwarz
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
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Kalbas Y, Heining SM, Kaiser A, Klingebiel FKL, Pfeifer R, Wanner GA, Pape HC. Fracture fixation in polytraumatized patients-From an interdisciplinary early total/appropriate care to the safe definitive surgery concept. Front Med (Lausanne) 2024; 11:1362986. [PMID: 38707191 PMCID: PMC11069308 DOI: 10.3389/fmed.2024.1362986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024] Open
Abstract
The strategies for the timing of fracture fixation in polytrauma patients have changed with improvements in resuscitation and patient assessment. Specifically, the criteria for damage control have been formulated, and more precise parameters have been found to determine those patients who can safely undergo primary definitive fixation of major fractures. Our current recommendations are supported by objective and data-based criteria and development groups. Those were validated and compared to existing scores. This review article introduces the concept of "safe definitive surgery" and provides an update on the parameters used to clear patients for timely fixation of major fractures.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandro-Michael Heining
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anne Kaiser
- Department of Anesthesia, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Roman Pfeifer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Guido A. Wanner
- Department of Spine and Trauma Surgery, Bethanien Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Kumabe Y, Kalbas Y, Halvachizadeh S, Teuben M, Cesarovic N, Weisskopf M, Hülsmeier A, Hornemann T, Cinelli P, Pape HC, Pfeifer R. Occult hypoperfusion and changes of systemic lipid levels after severe trauma: an analysis in a standardized porcine polytrauma model. Eur J Trauma Emerg Surg 2024; 50:107-114. [PMID: 35819473 PMCID: PMC10924008 DOI: 10.1007/s00068-022-02039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Occult hypoperfusion describes the absence of sufficient microcirculation despite normal vital signs. It is known to be associated with prolonged elevation of serum lactate and later complications in severely injured patients. We hypothesized that changes in circulating lipids are related to responsiveness to resuscitation. The purpose of this study is investigating the relation between responsiveness to resuscitation and lipidomic course after poly trauma. METHODS Twenty-five male pigs were exposed a combined injury of blunt chest trauma, liver laceration, controlled haemorrhagic shock, and femoral shaft fracture. After 1 h, animals received resuscitation and fracture stabilization. Venous blood was taken regularly and 233 specific lipids were analysed. Animals were divided into two groups based on serum lactate level at the end point as an indicator of responsiveness to resuscitation (<2 mmol/L: responder group (R group), ≧2 mmol/L: occult hypoperfusion group (OH group)). RESULTS Eighteen animals met criteria for the R group, four animals for the OH group, and three animals died. Acylcarnitines showed a significant increase at 1 h compared to baseline in both groups. Six lipid subgroups showed a significant increase only in R group at 2 h. There was no significant change at other time points. CONCLUSIONS Six lipid groups increased significantly only in the R group at 2 h, which may support the idea that they could serve as potential biomarkers to help us to detect the presence of occult hypoperfusion and insufficient resuscitation. We feel that further study is required to confirm the role and mechanism of lipid changes after trauma.
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Affiliation(s)
- Yohei Kumabe
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Miriam Weisskopf
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Andreas Hülsmeier
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Thorsten Hornemann
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland.
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland.
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11
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Chung CY, Scalea TM. Damage control surgery: old concepts and new indications. Curr Opin Crit Care 2023; 29:666-673. [PMID: 37861194 DOI: 10.1097/mcc.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW While the principles of damage control surgery - rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction - have remained consistent, forms of damage control intervention have evolved and proliferated dramatically. This review aims to provide a historic perspective of the early trends of damage control surgery as well as an updated understanding of its current state and future trends. RECENT FINDINGS Physiologically depleted patients in shock due to both traumatic and nontraumatic causes are often treated with damage control laparotomy and surgical principles. Damage control surgery has also been shown to be safe and effective in thoracic and orthopedic injuries. Damage control resuscitation is used in conjunction with surgical source control to restore patient physiology and prevent further collapse. The overuse of damage control laparotomy, however, is associated with increased morbidity and complications. With advancing technology, catheter- and stent-based endovascular modalities are playing a larger role in the resuscitation and definitive care of patients. SUMMARY Optimal outcome in the care of the most severely injured patients requires judicious use of damage control surgery supplemented by advancements in resuscitation and surgical adjuncts.
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Affiliation(s)
- C Yvonne Chung
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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12
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von Lübken F, Prause S, Lang P, Friemert BD, Lefering R, Achatz G. Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU ®). Eur J Trauma Emerg Surg 2023; 49:1933-1946. [PMID: 36662169 PMCID: PMC10449664 DOI: 10.1007/s00068-022-02215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/26/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated. METHODS We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score. RESULTS We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected. CONCLUSION We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.
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Affiliation(s)
- Falk von Lübken
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Sascha Prause
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Patricia Lang
- Centre for Integrated Rehabilitation, Rehabilitation Hospital of Ulm, Ulm, Germany
| | - Benedikt Dieter Friemert
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Gerhard Achatz
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
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13
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Klingebiel FKL, Hasegawa M, Strähle O, Kalbas Y, Teuben M, Halvachizadeh S, Kumabe Y, Pape HC, Pfeifer R. Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05828-4. [PMID: 37195466 PMCID: PMC10267260 DOI: 10.1007/s00264-023-05828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions. METHODS A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region. RESULTS This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load. CONCLUSION This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.
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Affiliation(s)
- Felix Karl-Ludwig Klingebiel
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland.
| | - Morgan Hasegawa
- Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Oliver Strähle
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yohei Kumabe
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
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14
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Pfeifer R, Klingebiel FKL, Halvachizadeh S, Kalbas Y, Pape HC. How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature. Injury 2023; 54:292-317. [PMID: 36404162 DOI: 10.1016/j.injury.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. METHODS Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. RESULTS The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma. CONCLUSION In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.
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Affiliation(s)
- Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | | | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
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15
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Halvachizadeh S, Leibovitz D, Held L, Jensen KO, Pape HC, Muller D, Neuhaus V. The number of beds occupied is an independent risk factor for discharge of trauma patients. Medicine (Baltimore) 2022; 101:e31024. [PMID: 36221382 PMCID: PMC9542835 DOI: 10.1097/md.0000000000031024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Reducing the burden of limited capacity on medical practitioners and public health systems requires a time-dependent characterization of hospitalization rates, such that inferences can be drawn about the underlying causes for hospitalization and patient discharge. The aim of this study was to analyze non-medical risk factors that lead to the discharge of trauma patients. This retrospective cohort study includes trauma patients who were treated in Switzerland between 2011 and 2018. The national Swiss database for quality assurance in surgery (AQC) was reviewed for trauma diagnoses according to the ICD-10 code. Non-medical risk factors include seasonal changes, daily changes, holidays, and number of beds occupied by trauma patients across Switzerland. Individual patient information was aggregated into counts per day of total patients, as well as counts per day of levels of each categorical variable of interest. The ARIMA-modeling was utilized to model the number of discharges per day as a function of auto aggressive function of all previously mentioned risk factors. This study includes 226,708 patients, 118,059 male (age 48.18, standard deviation (SD) 22.34 years) and 108,649 female (age 62.57, SD 22.89 years) trauma patients. The mean length of stay was 7.16 (SD 14.84) days and most patients were discharged home (n = 168,582, 74.8%). A weekly and yearly seasonality trend can be observed in admission trends. The mean number of occupied trauma beds ranges from 3700 to 4000 per day. The number of occupied beds increases on weekdays and decreases on holidays. The number of occupied beds is a positive, independent risk factor for discharge in trauma patients; as the number of occupied beds increases at any given time, so does the risk for discharge. The number of beds occupied represents an independent non-medical risk factor for discharge. Capacity determines triage of hospitalized patients and therefore might increase the risk of premature discharge.
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Affiliation(s)
- Sascha Halvachizadeh
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
- * Correspondence: Sascha Halvachizadeh, University Hospital Zurich, Department of Trauma, Raemistrasse 100, Zurich 8091, Switzerland (e-mail: )
| | - Daniel Leibovitz
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Leonhard Held
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Kai Oliver Jensen
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
| | - Hans-Christoph Pape
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
| | - Dominik Muller
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Valentin Neuhaus
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
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Hafner T, Horst K, Hildebrand F. [Fracture management in polytrauma]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:559-567. [PMID: 35790541 DOI: 10.1007/s00113-022-01192-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
The management of polytrauma patients is a complex multidisciplinary and dynamic task. The early and comprehensive assessment of the clinical condition is of great importance with respect to the timing and the individual decision-making on surgical fracture treatment. Stable patients benefit from early definitive fracture treatment, whereas for unstable patients, the concept of multistage fracture treatment with temporary minimally invasive stabilization has gained wide acceptance. These concepts, known as early total care (ETC) and damage control orthopedics (DCO), have been extended in recent decades by dynamic and injury-adapted treatment protocols, such as early appropriate care (EAC) or safe definitive orthopedic surgery (SDS): Therefore, patients in an initially unclear condition (borderline patients) can now also be treated with an individually adapted care concept as soon as possible.
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Affiliation(s)
- Tobias Hafner
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum RWTH Aachen, AöR, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Klemens Horst
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum RWTH Aachen, AöR, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Frank Hildebrand
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum RWTH Aachen, AöR, Pauwelsstr. 30, 52074, Aachen, Deutschland
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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18
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Halvachizadeh S, Kalbas Y, Teuben MPJ, Teuber H, Cesarovic N, Weisskopf M, Cinelli P, Pape HC, Pfeifer R. Effects of Occult Hypoperfusion on Local Circulation and Inflammation - An Analysis in a Standardized Polytrauma Model. Front Immunol 2022; 13:894270. [PMID: 35799796 PMCID: PMC9254728 DOI: 10.3389/fimmu.2022.894270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionOccult hypoperfusion (OH) is defined as persistent lactic acidosis despite normalization of vital parameters following trauma. The aim of this study was to analyze the association of occult hypoperfusion with local circulation and inflammation of injured soft tissue in a porcine polytrauma model.MethodsThis experimental study was performed with male landrace pigs who suffered a standardized polytrauma, including a femoral fracture, blunt chest trauma, liver laceration and a mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after induction of trauma, the animals were resuscitated with retrograde femoral nailing, liver packing and volume replacement. Animals were stratified into Group Norm (normalizing lactate levels after resuscitation) and Group occult hypoperfusion (OH) (persistent lactate levels above 2 mmol/l with normalizing vital parameters after resuscitation). Local circulation (oxygen saturation, hemoglobin amount, blood flow) was measured with optical sensors at the subcutaneous soft tissue at the fractured extremity as well as at the stomach and colon. Local inflammatory parameters [interleukin (IL) 6, 8, 10, and heat shock protein (HSP)] were analyzed in the subcutaneous tissue of the fractured extremity.ResultsGroup Norm (n = 19) and Group OH (n = 5) were comparable in baseline vital and laboratory parameters. The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH had significantly lower local relative hemoglobin amount at the injured soft tissue of the fractured extremity when compared with Group Norm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). The local oxygenation was significantly lower in Group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in the fatty tissue was significantly higher in Group OH (318.3, SD 326.6 [pg/ml]) when compared with Group Norm (73.9,SD 96.3[pg/ml], p = 0.03). The local circulation at the abdominal organs was comparable in both groups.ConclusionOH is associated with decreased local circulation and increased local inflammation at the injured soft tissue of the extremity in polytrauma. OH might reflect the severity of local soft tissue injuries, and guide treatment strategies.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
- *Correspondence: Sascha Halvachizadeh,
| | - Yannik Kalbas
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | | | - Henrik Teuber
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Health Sciences and Technology, Eidgenössische Technische Hochschule (ETH) Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
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Halvachizadeh S, Klingebiel FKL, Pfeifer R, Gosteli M, Schuerle S, Cinelli P, Zelle BA, Pape HC. The local soft tissue status and the prediction of local complications following fractures of the ankle region. Injury 2022; 53:1789-1795. [PMID: 35382943 DOI: 10.1016/j.injury.2022.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/10/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region. METHODS This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region. INCLUSION CRITERIA Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF. RESULTS Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26). CONCLUSION Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland.
| | - Felix Karl Ludwig Klingebiel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Martina Gosteli
- Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Simone Schuerle
- Institute for translational medicine, Department of Health Science & Technology, ETH Zurich, Rämistrasse 101, Zürich 8092, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Boris A Zelle
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas TX 78229, United States
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; Harald Tscherne laboratory for orthopaedic and trauma research, University of Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
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Driessen MLS, de Jongh MAC, Sturms LM, Bloemers FW, Ten Duis HJ, Edwards MJR, Hartog DD, Leenhouts PA, Poeze M, Schipper IB, Spanjersberg RW, Wendt KW, de Wit RJ, van Zutphen SWAM, Leenen LPH. Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study. Eur J Trauma Emerg Surg 2022; 48:4267-4276. [PMID: 35445813 DOI: 10.1007/s00068-022-01972-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD. METHODS Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs. RESULTS A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII. CONCLUSION A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.
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Affiliation(s)
- Mitchell L S Driessen
- Dutch Network Emergency Care ((LNAZ)), Newtonlaan 115, 3584 BH, Utrecht, The Netherlands.
| | - Mariska A C de Jongh
- Network Emergency Care Brabant, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Leontien M Sturms
- Dutch Network Emergency Care ((LNAZ)), Newtonlaan 115, 3584 BH, Utrecht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Location VU, P.O. Box 1081 HV, Amsterdam, The Netherlands
| | | | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, 618., P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, Rotterdam, P.O. Box 3000 CA, Rotterdam, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, P.O Box 9600, 2300 RC, Leiden, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Center Groningen, P.O Box 30.001, 9700 RB, Groningen,, The Netherlands
| | - Ralph J de Wit
- Department of Trauma Surgery, Medical Spectrum Twente, P.O. Box 50000, 7500 KA, Enschede, The Netherlands
| | - Stefan W A M van Zutphen
- Department of Surgery, Elisabeth Two Cities Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients. J Clin Med 2021; 10:jcm10194335. [PMID: 34640353 PMCID: PMC8509393 DOI: 10.3390/jcm10194335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
There has been an ongoing discussion as to which interventions should be carried out by an “organ specialist” (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.
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22
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Tan JH, Wu TY, Tan JYH, Sharon Tan SH, Hong CC, Shen L, Loo LMA, Iau P, Murphy DP, O'Neill GK. Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation. J Orthop Trauma 2021; 35:e234-e240. [PMID: 33252447 DOI: 10.1097/bot.0000000000001999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5. INTERVENTION These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days). MAIN OUTCOME MEASURES Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications. RESULTS Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications. CONCLUSIONS Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jiong Hao Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Tian Yi Wu
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Joel Yong Hao Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Si Heng Sharon Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Choon Chiet Hong
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore ; and
| | - Lynette Mee-Ann Loo
- Division of General Surgery, University Surgical Cluster, National University Health System (NUHS), Singapore
| | - Philip Iau
- Division of General Surgery, University Surgical Cluster, National University Health System (NUHS), Singapore
| | - Diarmuid P Murphy
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Gavin Kane O'Neill
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
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Buxbaum RE, Shani A, Mulla H, Rod A, Rahamimov N. Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures. J Orthop Surg Res 2021; 16:317. [PMID: 34001172 PMCID: PMC8127240 DOI: 10.1186/s13018-021-02420-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Fractures in the ankylotic spine may have an insidious presentation but are prone to displace with devastating consequences. The long lever arm of ankylosed spine fragments may lead to pulmonary and great vessel injury and is difficult to adequately immobilize. Conservative treatment will produce in many cases poor outcomes with high morbidity and mortality. Open surgical treatment is also fraught with technical difficulties and can lead to major blood loss and prolonged operative times. In recent years, percutaneous instrumentation of non-ankylotic spine fractures has gained popularity, producing similar outcomes to open surgery with shorter operative times and reduced blood loss and hospital length of stay. We describe our experience implementing these techniques in ankylotic spine patients. Methods We retrospectively retrieved from our hospital’s electronic health records all patients treated for thoracolumbar spine fractures between 2008 and 2015 with a diagnosis of ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). Operative and postoperative data, results, and complications were tabulated, and radiographic parameters were evaluated. Results Twenty-four patients with ankylotic spine disease underwent percutaneous augmented instrumentation between 2008 and 2015. The mean age was 76. All patients had at least one comorbidity. The mean number of ankylosed levels was 14. Mean operative time was 131 min. The average postoperative hemoglobin decrease was 1.21 gr/%, with only 4 patients requiring blood transfusion. 45.8% of the patients had postoperative medical complications. One patient (4.2%) had a superficial postoperative infection, and one patient died in hospital. The average hospital length of stay was 14.55 days. All patients retained their preoperative ASIA grades, and 3 improved one grade. All patients united their fractures without losing reduction. Conclusions PMMA-augmented percutaneous instrumentation is an attractive surgical option for this difficult patient subset, especially when compared to other available current alternatives.
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Affiliation(s)
| | - Adi Shani
- Department of Orthopedics B and Spine Surgery, Galilee Medical Center, Nahariya, Israel
| | - Hani Mulla
- Department of Orthopedics, Bnei-Zion Medical center, Haifa, Israel
| | - Alon Rod
- Department of Orthopedics B and Spine Surgery, Galilee Medical Center, Nahariya, Israel
| | - Nimrod Rahamimov
- Medical faculty, Bar-Ilan University, Safed, Israel. .,Department of Orthopedics B and Spine Surgery, Galilee Medical Center, Nahariya, Israel.
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Cheng CT, Wang Y, Chen HW, Hsiao PM, Yeh CN, Hsieh CH, Miao S, Xiao J, Liao CH, Lu L. A scalable physician-level deep learning algorithm detects universal trauma on pelvic radiographs. Nat Commun 2021; 12:1066. [PMID: 33594071 PMCID: PMC7887334 DOI: 10.1038/s41467-021-21311-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
Pelvic radiograph (PXR) is essential for detecting proximal femur and pelvis injuries in trauma patients, which is also the key component for trauma survey. None of the currently available algorithms can accurately detect all kinds of trauma-related radiographic findings on PXRs. Here, we show a universal algorithm can detect most types of trauma-related radiographic findings on PXRs. We develop a multiscale deep learning algorithm called PelviXNet trained with 5204 PXRs with weakly supervised point annotation. PelviXNet yields an area under the receiver operating characteristic curve (AUROC) of 0.973 (95% CI, 0.960-0.983) and an area under the precision-recall curve (AUPRC) of 0.963 (95% CI, 0.948-0.974) in the clinical population test set of 1888 PXRs. The accuracy, sensitivity, and specificity at the cutoff value are 0.924 (95% CI, 0.912-0.936), 0.908 (95% CI, 0.885-0.908), and 0.932 (95% CI, 0.919-0.946), respectively. PelviXNet demonstrates comparable performance with radiologists and orthopedics in detecting pelvic and hip fractures.
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Affiliation(s)
- Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | | | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Meng Hsiao
- New Taipei Municipal TuCheng Hospital, New Taipei city, Taiwan
| | - Chun-Nan Yeh
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | | | | | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan.
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial hospital, Linkou, Taoyuan, Taiwan.
| | - Le Lu
- PAII Inc, Bethesda, MD, USA
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[External fixator-Temporary joint-bridging fixation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:385-386. [PMID: 32968819 DOI: 10.1007/s00064-020-00678-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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