Thoracic Injuries in Pediatric Polytraumatized Patients: Epidemiology, Treatment and Outcome

PURPOSE

The purpose of the present study was to assess the influence and contribution, epidemiology, treatment and outcome of thoracic injuries in a cohort of pediatric and adolescent polytraumatized patients.

MATERIAL AND METHODS

All pediatric and adolescent (age < 18 years) polytraumatized patients with associated thoracic injuries were included in this study. Demographic data, mechanism of injury (MOI), injury severity score (ISS), Glasgow Coma Scale (GCS), hemodynamic parameters and pupillary response at ED admission, site of major injury (SOMI), associated chest and non-chest related injuries, length of hospital stay (LOS), procedures performed at the ED as well as outcome variables including mortality and cause of death. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome.

RESULTS

The logistic regression found the following variables decreasing the odds for a "bad outcome": lack of a hemodynamically unstable condition (p = 0.009) and the absence of a pathological pupillary response (p < 0.001).

CONCLUSIONS

The present study suggests that the severity of concomitant chest injuries in polytraumatized pediatric and adolescent patients contributes substantially to morbidity and mortality. Due to the anatomic features of the immature pediatric bones, careful attention should be drawn to possible severe chest injuries even in the absence of rib fractures.

LEVEL OF EVIDENCE

A retrospective study (level - IV study).

Long-term results after primary augmented repair of proximal tears of the anterior cruciate ligament with the Kennedy-LAD - Does it work?

BACKGROUND

The purpose of this study was to objectively evaluate the clinical functionality of the knee joint 30 years after surgical augmentation of the ACL with the "Kennedy Ligament Augmentation Device ®" (Kennedy LAD®).

METHODS

The patient collective consisted of 41 patients with an average age of 59.51 years (±10.18 standard deviation). Included were all patients treated operatively with a Kennedy LAD® augmented reattachment of the ACL at the Department of Trauma Surgery between 1983 and 1985. The state of the knee joint was evaluated with the following measures: Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Short Form (36) Health Survey, International Knee Documentation Committee Score (IKDC, objective + subjective form) and Tegner Activity Scale.

RESULTS

Seven patients (17%) sustained a re-rupture of the Kennedy LAD® augmented ACL after a mean time of 16.28 years. Five of them underwent revision surgery. Another four patients (9.76%) showed an ACL insufficiency in clinical examination. The average IKDC Score was 74.14 ± 16.62, the average Lysholm Score was 86.83 ± 14.10, the average Tegner Activity Scale was 4.34 ± 1.11, and the average Knee injury and Osteoarthritis Outcome Score was 86.25 ± 11.64 at final follow-up. The mean Kellgren Lawrence Score of the operated knee was 2 ± 0.71.

CONCLUSION

An overall good outcome 30 years after primary ACL augmented repair with the Kennedy LAD® with an implant survival rate of 73% could be reached. These results therefore support the trend of ACL augmentation in selected cases.

LEVEL OF EVIDENCE

Retrospective study, Level IV.

The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction

PURPOSE

To describe the concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction.

METHODS

The PubMed/Medline database was searched using keywords pertaining to ACL reconstruction. Relevant articles were reviewed in order to summarize important concepts of individualized surgery in ACL reconstruction. Surgical experiences with case examples are also highlighted.

RESULTS

Individualized ACL surgery allows for the customization of surgery to each individual patient. Accounting for graft selection and other characteristics such as anatomy, lifestyle and activity preferences may provide the patient with the best potential for a successful outcome. The surgeon should be comfortable with a variety of graft harvests and surgical techniques when practicing individualized surgery.

CONCLUSION

Individualized anatomic ACL reconstruction is founded on the objective evaluation of functional anatomy and individual characteristics, thereby restoring the ACL as closely as possible to the native anatomy and function. The adoption and subsequent use of individualized surgery may facilitate improved clinical as well as objective outcomes, particularly in the long term.

LEVEL OF EVIDENCE

V.

Avulsion fracture and complete rupture of the thumb radial collateral ligament

PURPOSE

Acute grade III tears of the radial collateral ligament (RCL) of the thumb as well as certain bony avulsion fractures receive early surgical repair at our institution. The aim of this study was to evaluate if patients would benefit from this treatment algorithm at long-term.

METHODS

47 patients with RCL bony avulsion fracture or grade III RCL tear were evaluated at a median follow-up of 4.5 years (range 1-17.3 years). Grade III RCL tears were treated operatively when presenting >30° angulation in stress X-ray together with palmar subluxation of ≥3 mm. Further, avulsed bony fragments with diastasis >2 mm or fragment rotation >30°-45° in conventional X-ray underwent surgery. 6 patients with grade III RCL tear as well as 9 patients with bony avulsion underwent surgical repair.

RESULTS

At follow-up, metacarpophalangeal joint stability and pain free ROM did not differ significantly between the groups. Subjective satisfaction based on the Catalano grading system revealed excellent results in operatively and conservatively treated patients.

CONCLUSIONS

This retrospective analysis indicates that early surgical repair in severe RCL injuries is associated with unrestricted ROM, persistent joint stability, and subjective patient satisfaction. This data suggest that surgical treatment in certain RCL injuries might be a feasible therapeutic option in order to avoid chronic instability.

Successful limb salvage using the two-staged technique with internal fixation after osteodistraction in an effort to treat large segmental bone defects in the lower extremity

BACKGROUND

The reconstruction of large segmental bone defects exceeding 8 cm remains a major therapeutic challenge. Strategies to avoid amputation and thereby provide satisfactory functional outcomes have not been sufficiently evaluated. Therefore, the present study reviews the clinical and functional outcomes after limb salvage.

METHODS

From 1994 to 2011, a consecutive series of 12 patients with lower-limb segmental bone loss exceeding 8 cm were reviewed. Eight patients had suffered from a third-degree open fracture, whereas four patients had undergone bone resection after osteomyelitis. All patients underwent initial skeletal fixation with a simple, external frame. In six patients, the bone healed with no further stabilization after osteodistraction, while internal fixation by intramedullary nailing or plating was necessary in six patients.

RESULTS

In reference to the clinical outcome, ten patients returned to their pre-injury activity level despite sustaining a total of 25 complications. Overall, patients with external fixator alone were at higher risk of sequelae (P = 0.014). In comparing the two groups, axis deviation at the lengthening site occurred in three patients without additional internal fixation; the only refracture occurred in this group. Generally, the size of the bone defect after debridement averaged 12.5 cm (range 8-26 cm). The mean distraction period until frame removal was 11 months (range 3.2-16.2 months). The EFI averaged 33.4 days/cm, whereas no significant differences in EFI were found between the groups.

CONCLUSION

We observed a reduced incidence of axial deviation and refracture in patients with large segmental bone defects who underwent an additional internal stabilization after fixation with an external frame. The two-stage technique caused no increase in infectious complications and might therefore be a preferable approach for successful limb salvage in patients suffering from large segmental bone defects exceeding 8 cm with insufficient bone formation during external fixation.

PNP PIN bipolar phototransistors for high-speed applications built in a 180 nm CMOS process

This work reports on three speed optimized pnp bipolar phototransistors build in a standard 180 nm CMOS process using a special starting wafer. The starting wafer consists of a low doped p epitaxial layer on top of the p substrate. This low doped p epitaxial layer leads to a thick space-charge region between base and collector and thus to a high -3 dB bandwidth at low collector-emitter voltages. For a further increase of the bandwidth the presented phototransistors were designed with small emitter areas resulting in a small base-emitter capacitance. The three presented phototransistors were implemented in sizes of 40 × 40 μm² and 100 × 100 μm². Optical DC and AC measurements at 410 nm, 675 nm and 850 nm were done for phototransistor characterization. Due to the speed optimized design and the layer structure of the phototransistors, bandwidths up to 76.9 MHz and dynamic responsivities up to 2.89 A/W were achieved. Furthermore simulations of the electric field strength and space-charge regions were done.

Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction

Based on biomechanical cadaver studies, anatomic double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of reconstructed bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of the present study is to compare rotational and translational stability after computer-navigated standard single-bundle, and anatomic double-bundle ACL reconstruction. The authors investigated 55 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure with the use of autogenous hamstring tendon grafts and EndoButton fixation, and the patients had been followed for a minimum period of 24 months. Intraoperative, anteroposterior and rotational laxity was measured with the computer navigation system, and compared between groups. Both surgical procedures significantly reduced anteroposterior displacement (AP) and internal rotation (IR) of the tibia compared to the pre-operative ACL-deficient knee (P < 0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. A significantly greater reduction in internal rotation was noted in the double-bundle group (15.6 degrees) compared to the single-bundle group (7.1 degrees). The IKDC and Lysholm score were significantly higher in the double-bundle group. However, the results were excellent in both groups. The use of a computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, provide an influence in terms of avoiding osteoarthritis or meniscus degeneration, long-term results of at least 5 years are needed.

CCL19 is constitutively expressed in the CNS, up-regulated in neuroinflammation, active and also inactive multiple sclerosis lesions

CCL19 and CCL21 bind to CCR7, which is crucial for both inducing an immune response and establishing immunological tolerance. We report that in the normal human brain CCL19, but not CCL21, is transcribed, and detectable as a protein in tissue lysates and in cerebrospinal fluid. In both active and inactive multiple sclerosis (MS) lesions CCL19 transcripts were elevated. In cerebrospinal fluid from MS and OIND patients CCL19 protein was increased. In relapsing-remitting and secondary progressive MS patients CCL19 correlated with intrathecal IgG production. This study suggests that CCL19 plays a role in both the physiological immunosurveillance of the healthy CNS and the pathological maintenance of immune cells in the CNS of MS patients.

Catching audiovisual mice: Predicting the arrival time of auditory-visual motion signals

We investigated the extent to which auditory and visual motion signals are combined when observers are asked to predict the location of a virtually moving target. In Condition 1, the unimodal and bimodal signals were noisy, but the target object was continuously visible and audible; in Condition 2, the virtually moving object was hidden (invisible and inaudible) for a short period prior to its arrival at the target location. Our main finding was that the facilitation due to simultaneous visual and auditory input is very different for the two conditions. When the target is continuously visible and audible (Condition 1), the bimodal performance is twice as good as the unimodal performances, thus suggesting a very effective integration mechanism. On the other hand, if the object is hidden for a short period (Condition 2) and the task therefore requires the extrapolation of motion speed over a temporal and spatial period, the facilitation due to both sensory inputs is almost absent, and the bimodal performance is limited by the visual performance.

The integration of auditory and visual motion signals at threshold

To interpret our environment, we integrate information from all our senses. For moving objects, auditory and visual motion signals are correlated and provide information about the speed and the direction of the moving object. We investigated at what level the auditory and the visual modalities interact and whether the human brain integrates only motion signals that are ecologically valid. We found that the sensitivity for identifying motion was improved when motion signals were provided in both modalities. This improvement in sensitivity can be explained by probability summation. That is, auditory and visual stimuli are combined at a decision level, after the stimuli have been processed independently in the auditory and the visual pathways. Furthermore, this integration is direction blind and is not restricted to ecologically valid motion signals.

Modified lapidus arthrodesis for adolescent hallux abducto valgus

The Lapidus arthrodesis was originally described for the surgical correction of hallux valgus associated with metatasus primus adductus. It was popularized on the adult patient with moderate to severe hallux valgus deformity. However, the authors present a retrospective review of 23 adolescents between the ages of 13 and 20 who underwent the procedures. Characteristics of adolescent hallux valgus include a smaller dorsal medial eminence, less valgus rotation of the hallux, and certain mechanical influences. These influences may include a generalized increase in motion at the first metatarsocuneiform joint. The modified Lapidus arthrodesis eliminates motion at the first metatarsocuneiform joint and therefore directly addresses an etiology of the deformity. Both preoperative and postoperative radiographs were evaluated for reduction in the 1-2 intermetatarsal angle. Patients were evaluated through either chart review or telephone interview for present activity level, comfortable footgear, and overall satisfaction of the procedure. Twenty-seven out of 30 feet (90%) had either a good or excellent result with only three complications and two recurrences over a mean follow-up of 61 months.

[Digoxin content in blood lipids of children, athletes, sports ground attendants and residents after content with dioxin-containing surface slag (Kieselrot)]

In 1991 it was discovered, that a large number of sporting grounds and playgrounds in Germany were covered with a waste slag material from a former copper smelter located at Marsberg, Germany. This material was found to contain high levels of PCDD/F ranging up to 100,000 TE/kg. The objective of the present study was to assess whether subjects sporting on such grounds had elevated levels of PCDD/F in blood. PCDD/F in blood fat was used as an indicator of the PCDD/F body burden. Additionally, six children and seven residents of a contaminated sporting and playground were examined. Generally, the levels of PCDD/F in blood fat were in the range of background levels in all subjects. Taking into account the effect of age, slightly elevated blood levels of PCDD/F were detected in children. The results show that the bioavailability of PCDD/F in the slag material is very low. However, from the preventive point of view children who might ingest slag material by hand-to-mouth-activities, should not play on such contaminated playgrounds.

Pharmacologic and clinical effects of lonapalene (RS 43179), a 5-lipoxygenase inhibitor, in psoriasis

The pharmacologic and clinical effects of the 5-lipoxygenase inhibitor, lonapalene, have been determined in a double-blind, placebo-controlled, topical study in ten volunteers with psoriasis. A statistically significant clinical improvement was seen in lesions treated with 2% lonapalene ointment as compared with vehicle-treated sites. Although there was a statistically significant reduction in the levels of material similar or identical to the chemoattractant arachidonate 5-lipoxygenase product, leukotriene B4, in skin chamber fluid samples from lonapalene versus vehicle treated lesions, no significant reduction in arachidonic acid or 12-hydroxy-5,8,10,14-eicosatetraenoic acid was seen. The reduction in leukotriene B4 equivalents occurred before significant clinical improvement in lesions was seen. This and the selectivity of the pharmacologic response suggest that the therapeutic effect of topical lonapalene in psoriasis might be related to inhibition of leukotriene B4 synthesis. These results support the view that 5-lipoxygenase inhibitors may be useful in the treatment of psoriasis, and that leukotriene B4 is a relevant mediator of the pathology of this disease.

Evaluation of a therapeutic concentration of dithranol in the mouse-tail test

A study of dithranol ointment in the mouse-tail test showed that 0.2% dithranol ointment induced a granular layer and orthokeratosis in mouse-tail epidermis. This provides further evidence of the value of the mouse-tail test in evaluating anti-psoriatic activity of topical preparations.

[Hair growth, liver function and light sensitivity during oral retinoid therapy for psoriasis (author's transl)]

In a multicentre, cooperative study into the treatment of extensive psoriasis with a new aromatic retinoid (Ro 10--9359) trichogram, liver function tests and the light erythema threshold were investigated. In some of the patients hair loss occurred, usually in the fifth to eighth week after a total dose of 1.9 g retinoid. In all cases this improved an average of six weeks after dose reduction or cessation of treatment. The trichogram in 27 patients showed a diffuse toxic hair loss. In 70% the effluvium was telogenic, in 22% telogen-dystrophic. GPT, GOT, alkaline phosphatase and prothrombin index showed no significant alterations during retinoid treatment. However, in individual cases there was a rise in GOT and GPT up to 80 U/l. Furthermore there was a statistical tendency in rising bilirubin levels. Finally there was no evidence for an increase in light sensitivity after three weeks of retinoid treatment. Measurement of the erythema threshold showed rather more a reduction in light sensitivity under treatment.

Laboratory investigations in patients with generalized psoriasis under oral retinoid treatment. A multicenter study of computerized data

Numerous laboratory parameters were examined 235 patients with generalized psoriasis treated orally with retinoid and in 35 patients treated topically with anthralin as control. Computer evaluation of the obtained data revealed statistical trends to elevation of the total serum bilirubin level and increasing number of blood monocytes after long-term oral treatment. No other statistically significant changes of the laboratory data were found. Particularly, the liver function tests (transaminases, prothrombin and alkaline phosphatase) showed no significant alterations. Only in a few cases did the retinoid compound have an influence on the GPT and GOT levels. The reasons for this individual sensitivity to the drug remain unknown. No significant alterations were found in the control group treated topically with anthralin.

[Epidermolysis bullosa dystrophica inversa: report on 2 sisters]

Two sister cases of epidermolysis bullosa dystrophica inversa are reported. This type, first described by Gedde-Dahl (1971), is characterized by the inverse site of skin involvement, the intermittent course, frequent traumatic corneal erosions, retarded development of skin atrophy and absence of milia formation. Our present cases had all these characteristics except the corneal involvement. The pedigree of this family favors an autosomal recessive mode of inheritance; no consanguinity is demonstrable in the ancestors over four generations. Electron microscopic examination in one of the patients reveals the blistering beneath the basal lamina, which suggests that the pathogenesis may be similar to the Hallopeau-Siemens type rather than to the junctional type of epidermolysis bullosa.