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de Freitas MTB, Martins GBV, Santiago MAM, Silva IR, Leonhardt MDC, Silva JDS, Kojima KE. LOW INFECTION AND NON-UNION RATES IN POLYTRAUMA FEMORAL FRACTURES: A RETROSPECTIVE STUDY. ACTA ORTOPEDICA BRASILEIRA 2024; 32:e278586. [PMID: 38933352 PMCID: PMC11197956 DOI: 10.1590/1413-785220243202e278586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/24/2024] [Indexed: 06/28/2024]
Abstract
Objective Assess complications and risks in staged femoral shaft fracture treatment using external fixation and intramedullary nailing (DCO). Methods Analysis involved 37 patients with 40 fractures, mostly male (87.5%), average age 32.9 years. Data included ASA score, AO/OTA and Gustilo classifications, Glasgow Coma Score, Injury Severity Score, times to external fixation and conversion, ICU duration, nail type, and reaming status. Complications tracked were mortality, deep infection, and non-union. Results Predominant fracture type was AO/OTA A (45%), with 40% open (Gustilo A, 93.8%). Average ISS was 21; GCS was 12.7. Median ICU stay was 3 days; average time to conversion was 10.2 days. Retrograde nails were used in 50% of cases, with reaming in 67.5%. Complications included deep infections in 5% and non-union in 2.5%. Conclusion DCO strategy resulted in low infection and non-union rates, associated with lower GCS and longer ICU stays. Level of Evidence III; Retrospective Cohort Study.
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Affiliation(s)
- Matheus Trindade Bruxelas de Freitas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Gabriel Benevides Valiate Martins
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Matheus Augusto Maciel Santiago
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Isaac Rocha Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Marcos de Camargo Leonhardt
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Jorge dos Santos Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Kodi Edson Kojima
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HC-FMUSP), Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
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Stevens NM, Tejwani NC. Damage-control orthopedics or early total care: What you need to know. J Trauma Acute Care Surg 2024; 96:694-701. [PMID: 38227676 DOI: 10.1097/ta.0000000000004250] [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: 01/18/2024]
Abstract
ABSTRACT Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.
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Affiliation(s)
- Nicole M Stevens
- From the Department of Orthopedics, NYU Langone Health, East Meadow, New York
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陈 志, 李 强, 刘 瑞, 郭 浩, 唐 佩, 陈 华. [Research progress of pubic symphysis diastasis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:1541-1547. [PMID: 38130199 PMCID: PMC10739657 DOI: 10.7507/1002-1892.202306093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/09/2023] [Indexed: 12/23/2023]
Abstract
Objective To review the research progress of pubic symphysis diastasis and provide effective reference for orthopedic surgeons in the diagnosis and treatment of pubic symphysis diastasis. Methods The anatomy, injury mechanism, treatment, and other aspects of pubic symphysis diastasis were summarized and analyzed by reviewing the relevant research literature at domestically and internationally in recent years. Results The incidence of pubic symphysis diastasis is high in pelvic fractures, which is caused by the injury of the ligaments and fibrocartilage disc around the pubic symphysis by external force. The treatment plan should be individualized according to the pelvic stability and the needs of patients, aiming to restore the stability and integrity of the pelvis and improve the quality of life of patients after surgery. Conclusion At present, the research on pubic symphysis diastasis still needs to be improved. In the future, high-quality, multi-center, and large-sample studies are of great significance for the selection of treatment methods and the evaluation of effectiveness for patients with pubic symphysis diastasis.
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Affiliation(s)
- 志广 陈
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
| | - 强 李
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
| | - 瑞 刘
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
| | - 浩 郭
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
- 内蒙古医科大学附属医院骨科(呼和浩特 010000)Department of Orthopaedic Surgery, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
| | - 佩福 唐
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
| | - 华 陈
- 内蒙古医科大学第一临床医学院(呼和浩特 010000)First Clinical Medical College, Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
- 内蒙古医科大学附属医院骨科(呼和浩特 010000)Department of Orthopaedic Surgery, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot Inner Mongolia, 010000, P. R. China
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Groven RVM, Greven J, Mert Ü, Horst K, Zhao Q, Blokhuis TJ, Huber-Lang M, Hildebrand F, van Griensven M. Circulating miRNA expression in extracellular vesicles is associated with specific injuries after multiple trauma and surgical invasiveness. Front Immunol 2023; 14:1273612. [PMID: 37936707 PMCID: PMC10626999 DOI: 10.3389/fimmu.2023.1273612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/04/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction Two trauma treatment principles are Early Total Care (ETC), and Damage Control Orthopedics (DCO). Cellular mechanisms that underlie the connection between treatment type, its systemic effects, and tissue regeneration are not fully known. Therefore, this study aimed to: 1) profile microRNA (miRNA) expression in plasma derived Extracellular Vesicles (EVs) from a porcine multiple trauma model at different timepoints, comparing two surgical treatments; and 2) determine and validate the miRNA's messengerRNA (mRNA) targets. Methods The porcine multiple trauma model consisted of blunt chest trauma, liver laceration, bilateral femur fractures, and controlled haemorrhagic shock. Two treatment groups were defined, ETC (n=8), and DCO (n=8). Animals were monitored under Intensive Care Unit-standards, blood was sampled at 1.5, 2.5, 24, and 72 hours after trauma, and EVs were harvested from plasma. MiRNAs were analysed using quantitative Polymerase Chain Reaction arrays. MRNA targets were identified in silico and validated in vivo in lung and liver tissue. Results The arrays showed distinct treatment specific miRNA expression patterns throughout all timepoints, and miRNAs related to the multiple trauma and its individual injuries. EV-packed miRNA expression in the ETC group was more pro-inflammatory, indicating potentially decreased tissue regenerative capacities in the acute post-traumatic phase. In silico target prediction revealed several overlapping mRNA targets among the identified miRNAs, related to inflammation, (pulmonary) fibrosis, and Wnt-signalling. These were, among others, A Disintegrin and Metalloproteinase domain-containing protein 10, Collagen Type 1 Alpha 1 Chain, Catenin Beta Interacting Protein 1, and Signal Transducers and Activators of Transcription 3. Validation of these mRNA targets in the lung showed significant, treatment specific deregulations which matched the expression of their upstream miRNAs. No significant mRNA deregulations were observed in the liver. Discussion This study showed treatment specific, EV-packed miRNA expression patterns after trauma that correlated with mRNA expressions in the lungs, target organs over distance. A systemic response to the increased surgical trauma in the ETC group was identified, with various miRNAs associated with injuries from the trauma model, and involved in (systemic) inflammation, tissue regeneration. EV-transported miRNAs demonstrated a clear role in multiple trauma, warranting further research into tissue-tissue talk and therapeutic applications of EVs after trauma.
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Affiliation(s)
- Rald Victor Maria Groven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Johannes Greven
- Experimental Orthopaedics and Trauma Surgery, Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Ümit Mert
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Qun Zhao
- Experimental Orthopaedics and Trauma Surgery, Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Taco Johan Blokhuis
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Martijn van Griensven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
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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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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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Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13061147. [PMID: 36980455 PMCID: PMC10047428 DOI: 10.3390/diagnostics13061147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. Methods: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12–24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). Results: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). Conclusion: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.
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Radetzki F, Massarwa H, Wienke A, Delank KS, Zagrodnick J. Treatment management and outcome of polytraumatized patients in a German certified trauma center - comparing standard versus maximum care. Acta Orthop Belg 2023; 89:7-14. [PMID: 37294979 DOI: 10.52628/89.1.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
German hospitals are classified as basic, standard and maximum care facilities within the German trauma networks. The Municipal Hospital Dessau was upgraded in 2015 as a maximum care provider. The aim of this study is to investigate whether a change in treatment management and outcome of polytraumatized patients has occurred afterwards. The study compared polytraumatized patients, treated in the Dessau Municipal Clinic as a standard care facility (DessauStandard) from 2012-2014 vs. those treated in the Dessau Municipal Clinic as a maximum care facility (DessauMax) from 2016-2017. Data of the German Trauma Register were analysed using the chi-square test, t-test and odds ratios with 95% confidence intervals.In DessauMax (238 patients; Ø 54 years, SD 22.3; ♂ 160, ♀ 78), the shock room time with 40.7 min (SD 21.4) was shorter than in DessauStandard (206 patients; Ø 56.1 years, SD 22.1; ♂ 133, ♀ 73 ) with 49 min (SD 25.1) (p=0.001). The transfer rate of 1.3% (n=3) to another hospital was lower in DessauMax (p=0.01). DessauStandard had 9 (4%) thromboembolic events and DessauMax 3 (1.3%) (p=0.7). Multiorgan failure was more common in DessauStandard, (16%) than in DessauMax (1.3%; p=0,001). DessauStandard showed a mortality of 13.1% (n=27), and DessauMax 9.2% (n=22) (p=0.22; OR=0.67, 95% CI, 0.37-1.23). The GOS in DessauMax (4.5, SD 1.2) was higher than in DessauStandard (4.1, SD 1.3) (p=0.002).The Dessau Municipal Clinic as a maximum care facility has achieved improved shock room time, fewer complications, lower mortality and an improved outcome.
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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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Pectol RW, Kavolus MW, Sneed CR, Albano AY, Landy DC, Aneja A. Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study. J Orthop Trauma 2022; 36:628-633. [PMID: 35916777 DOI: 10.1097/bot.0000000000002468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications. DESIGN Retrospective chart review. SETTING Eleven Level I trauma centers. PATIENTS From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included. INTERVENTION Reamed IMN. MAIN OUTCOME MEASURES Incidence of postoperative thromboembolic and respiratory complications. RESULTS Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days. CONCLUSION In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries. LEVELS OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Richard W Pectol
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
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11
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Mahajan RK, Srinivasan K, Jain A, Bhamre A, Narayan U, Sharma M. Management of Complex Upper Extremity Trauma with Associated Vascular Injury. Indian J Plast Surg 2022; 55:224-233. [DOI: 10.1055/s-0042-1744453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.
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Affiliation(s)
- Ravi K. Mahajan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Krishnan Srinivasan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Adish Jain
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Abhishek Bhamre
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Udit Narayan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Manish Sharma
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
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12
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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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13
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Off-Label Treatment for Severe Craniomaxillofacial Fractures in Low-Income Countries-A Novel Operation Method with the External Face Fixator. J Clin Med 2022; 11:jcm11061488. [PMID: 35329814 PMCID: PMC8956088 DOI: 10.3390/jcm11061488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: Craniomaxillofacial fractures (CMF) are common in low-income countries (LIC). Due to limited resources, treatment of these fractures usually consists of interdental wiring or immobilization with a Barton bandage to maintain the reduction by permanent occlusion. These non-surgical treatment methods often lead to unsatisfactory results, such as a disturbed dental occlusion and lockjaw. The aim of this study is to present an off-label treatment option for CMF by applying a hand fixator as external face fixator (EFF) and to demonstrate the surgical method in detail. Materials and Methods: The feasibility and postoperative outcomes of this new off-label operation technique were evaluated by analyzing patients with CMF (n = 13) treated at an NGO hospital in Sierra Leone between 2015 and 2019. Results: The application of the EFF was feasible. The biggest advantage compared to the conventional non-operative methods was, that a dynamic occlusion was still possible during the 6 weeks healing period. Hence, patients could eat and drink almost normally and perform dental hygiene with the EFF in place. We did not discover pintrack infections or other complications. Three patients developed an oronasal fistula due to traumatic a palatal bone loss of about 7–8 mm which was treated by a palatal mucoperiosteal flap 15–20 days after the first operation. Discussion and Conclusions: In LIC, where plate osteosynthesis for CMF cannot be performed due to limited resources the application of an EFF is a promising alternative for a better outcome and an improved quality of life for the patients.
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Layher F, Matziolis G, Kayhan LN, Bungartz M, Brinkmann O. Minimally Invasive Internal Fixation of Femoral Shaft Fractures-A Biomechanical Study with a Disruptive Technique. Life (Basel) 2021; 11:life11111254. [PMID: 34833130 PMCID: PMC8620013 DOI: 10.3390/life11111254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022] Open
Abstract
(1) Background: In polytrauma patients, femur fractures are usually stabilised by external fixation for damage control, later being treated with definitive plate or nail osteosynthesis. Screw/rod systems established in spinal surgery might be inserted for internal fixation, providing sufficient fracture stability that subsequent intervention is unnecessary. This was to be investigated biomechanically. (2) Methods: The unilaterally applied spinal internal fixator (IF) was subjected to load and deformation analysis on artificial femurs with 32-A3 fracture according to AO classification. Distance of screws to fracture and rod to cortical bone were analysed as parameters influenced surgically as stiffness and deformation of the treated fracture. In addition, the stability of another construct with a second screw/rod system was determined. The axial load in stance phase during walking was simulated. The results were compared against an established fixed-angle plate osteosynthesis (IP). (3) Results: There were no implant failures in the form of fractures, avulsions or deformations. All unilateral IF combinations were inferior to IP in terms of stability and stiffness. The bilateral construct with two screw/rod systems achieved biomechanical properties comparable to IP. 4) Conclusion: Biomechanically, a biplanar screw/rod system is suitable for definitive fracture stabilisation of the femur, despite a damage control approach.
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Affiliation(s)
- Frank Layher
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, 07607 Eisenberg, Germany; (F.L.); (G.M.); (M.B.)
| | - Georg Matziolis
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, 07607 Eisenberg, Germany; (F.L.); (G.M.); (M.B.)
| | - Leos N. Kayhan
- Schulthess Clinic, Lengghalde 2, 8008 Zürich, Switzerland;
| | - Matthias Bungartz
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, 07607 Eisenberg, Germany; (F.L.); (G.M.); (M.B.)
| | - Olaf Brinkmann
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, 07607 Eisenberg, Germany; (F.L.); (G.M.); (M.B.)
- Correspondence:
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Walker M, d'Arville A, Lacey J, Lancman B, Moloney J, Hendel S. Mass casualty, intentional vehicular trauma and anaesthesia. Br J Anaesth 2021; 128:e190-e199. [PMID: 34654520 DOI: 10.1016/j.bja.2021.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022] Open
Abstract
The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.
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Affiliation(s)
- Matthew Walker
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Asha d'Arville
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Jonathan Lacey
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Benn Lancman
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - John Moloney
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Field Emergency Medical Officer Program, Ambulance Victoria, Melbourne, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, Queensland, Australia
| | - Simon Hendel
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Department of Anaesthesia and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Australia; National Trauma Research Institute, Monash University and Alfred Health, Melbourne, Australia; Trauma Service, Alfred Health, Melbourne, Australia.
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