[Head injuries and their wound treatment]

Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.

[Impact of the COVID-19 pandemic on the care of major trauma patients: analysis from the TraumaRegister DGU®]

BACKGROUND

The treatment of major trauma patients requires intensive care capacity, which is a critical resource particularly during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, the aim of this study was to analyze the impact on major trauma care considering the intensive care treatment of COVID-19 positive patients.

METHODS

Demographic, prehospital, and intensive care treatment data from the TraumaRegister DGU® of the German Trauma Society (DGU) in 2019 and 2020 were analyzed. Only major trauma patients from the state of Bavaria were included. Inpatient treatment data of COVID-19 patients in Bavaria in 2020 were obtained using IVENA eHealth.

RESULTS

In total, 8307 major trauma patients were treated in the state of Bavaria in the time period investigated. The number of patients in 2020 (n = 4032) compared to 2019 (n = 4275) was not significantly decreased (p = 0.4). Regarding COVID-19 case numbers, maximum values were reached in the months of April and December with more than 800 intensive care unit (ICU) patients per day. In the critical period (> 100 patients with COVID-19 on ICU), a prolonged rescue time was evident (64.8 ± 32.5 vs. 67.4 ± 30.6 min; p = 0.003). The length of stay and ICU treatment of major trauma patients were not negatively affected by the COVID-19 pandemic.

CONCLUSION

The intensive medical care of major trauma patients could be ensured during the high-incidence phases of the COVID-19 pandemic. The prolonged prehospital rescue times show possible optimization potential of the horizontal integration of prehospital and hospital.

[Mobile C-arm-Radiation exposure and workflow killer? : Potential of an innovative assistance system for intraoperative positioning]

Despite its versatile applicability the intraoperative use of a mobile C‑arm is often problematic and potentially associated with increased radiation exposure for both the patient and the personnel. In particular, the correct positioning for adequate imaging can become a problem as the nonsterile circulating nurse has to coordinate the various maneuvers together with the surgeon without having a good view of the surgical field. The sluggishness of the equipment and the intraoperative setting (sterile borders, additional hardware, etc.) pose further challenges. A light detection and ranging (LIDAR)-based assistance system shows promise to provide accurate and intuitive repositioning support as part of an initial series of experimental trials. For this purpose, the sensors are attached to the C‑arm base unit and enable navigation of the device in the operating room to a stored target position using a simultaneous localization and mapping (SLAM) algorithm. An improvement of the workflow as well as a reduction of radiation exposure represent the possible potential of this system. The advantages over other experimental approaches are the lack of external hardware and the ease of use without isolating the operator from the rest of the operating room environment; however, the suitability for daily use in the presence of additional interfering factors should be verified in further studies.

Treatment strategies for complex ankle fractures-current developments summarized in a narrative review

Background and Objective

Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature.

Methods

We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study.

Key Contents and Findings

Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results.

Conclusions

However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

High return to sports rates after operative treatment of patella fractures

BACKGROUND

Patella fractures are relatively rare fractures and only little is known about the postoperative return to sports after patella fractures.

METHODS

This retrospective study presents information on functional outcome after operative treatment of patella fractures as well as time until return to sports and patients' complaints after open-reduction internal-fixation (ORIF) of patella fractures.

RESULTS

Overall, 39 patients after ORIF of patella fractures were evaluated at our Level-I trauma center with a mean follow-up of 42 months. The mean time until return to sports was 7 ± 3.9 months. No significant difference was found for functional outcome with respect to body mass index (BMI) or age. Fracture consolidation was accomplished after a mean of 6.9 ± 2.9 months besides a relatively low complication rate of 5.1% (n = 2).

CONCLUSION

The results demonstrate a high return to sports rate of 90.3%. However, only 51.6% were able to perform sports on their pre-injury level or above. Trial Registration The study was retrospectively registered at DRKS (No: DRKS00031146).

Functional Postoperative Outcome for 92 Cases of Radial Head Fractures: A PROM-Based Retrospective Study

Background: Fractures of the radial head are common injuries, whereas, in the case of displaced fractures, surgical treatment using screw or plate osteosynthesis, excision, or replacement of the radial head is required. However, data about patient-related outcomes (PROM) for different types of radial head fractures is limited in the current literature. Therefore, this study was conducted to evaluate the functional outcome after operatively treated radial head fractures and to further correlate these results with the initial modified Mason classification. Methods: In this retrospective study, all suitable patients with surgical treatment of a radial head fracture were identified. Only patients with Mason II-IV fractures were included. All patients completed the Elbow Self-Assessment Score (ESAS) questionnaire. Data on fracture classification, type of surgery, and revision operations (if needed) were assessed. Results: A total of 92 patients suffering from fractures of the radial head (57 Mason II, 35 Mason III-fractures) who were operatively treated at our institution were enrolled. There were 42 (47.7%) female and 50 (54.3%) male patients with an average age of 47.5 ± 14.1 years. Screw osteosynthesis was performed in 67 patients, plate osteosynthesis in 20 patients, and five patients received radial head arthroplasty. The average ESAS score accounted for 89.7 ± 16.7. Mason II fractures showed significantly better functional results with higher ESAS scores (92.3 ± 13.9 vs. 85.4 ± 20.1) as well as significantly lower rates of necessary implant removal (0 vs. 5 (14.3%) than Mason III fractures. Screw osteosynthesis showed significantly better functional ESAS scores, 91.0 ± 16.5, than plate osteosynthesis, with 85.3 ± 17.6 (p = 0.041), but was predominantly used in Mason II fractures. Conclusions: Surgical treatment using screw- and plate osteosynthesis of radial head fractures provides a good overall outcome. The postoperative function is associated with the initial Mason classification as the patients' reported outcome was worse in Mason III fractures compared to Mason type II fractures. In this context, the ESAS score can be considered a useful tool for the assessment of the patient-based functional outcome.

Surgical fixation of ipsilateral femoral neck and shaft fractures: a matter of debate?

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

Study protocol for investigating the clinical performance of an automated blood test for glial fibrillary acidic protein and ubiquitin carboxy-terminal hydrolase L1 blood concentrations in elderly patients with mild traumatic BRAIN Injury and reference values (BRAINI-2 Elderly European study): a prospective multicentre observational study

INTRODUCTION

Two blood brain-derived biomarkers, glial fibrillar acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), can rule out intracranial lesions in patients with mild traumatic brain injury (mTBI) when assessed within the first 12 hours. Most elderly patients were excluded from previous studies due to comorbidities. Biomarker use in elderly population could be affected by increased basal levels. This study will assess the performance of an automated test for measuring serum GFAP and UCH-L1 in elderly patients to predict the absence of intracranial lesions on head CT scans after mTBI, and determine both biomarkers reference values in a non-TBI elderly population.

METHODS AND ANALYSIS

This is a prospective multicentre observational study on elderly patients (≥65 years) that will be performed in Spain, France and Germany. Two patient groups will be included in two independent substudies. (1) A cohort of 2370 elderly patients (1185<80 years and 1185≥80 years; BRAINI2-ELDERLY DIAGNOSTIC AND PROGNOSTIC STUDY) with mTBI and a brain CT scan that will undergo blood sampling within 12 hours after mTBI. The primary outcome measure is the diagnostic performance of GFAP and UCH-L1 measured using an automated assay for discriminating between patients with positive and negative findings on brain CT scans. Secondary outcome measures include the performance of both biomarkers in predicting early (1 week) and midterm (3 months) neurological status and quality of life after trauma. (2) A cohort of 480 elderly reference participants (BRAINI2-ELDERLY REFERENCE STUDY) in whom reference values for GFAP and UCHL1 will be determined.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Review Boards of Hospital 12 de Octubre in Spain (Re#22/027) and Southeast VI (Clermont Ferrand Hospital) (Re# 22.01782.000095) in France. The study's results will be presented at scientific meetings and published in peer-review publications.

TRIAL REGISTRATION NUMBER

NCT05425251.

[Analysis of rising treatment cost of elevated BMI in patients with proximal femoral fracture]

Driven by the aging population, the proximal femoral fracture is a rising fracture entity, challenging trauma surgeons as well as the German healthcare system as a whole. The rising average age of the population is accompanied by a rising BMI in the German population, resulting in longer operation times, longer average length of stay (ALOS) as well as more postoperative complications.The aim of this study was to demonstrate the economic correlation between body mass index and hospital costs. The retrospective analysis of 950 patient cases suffering from a proximal femoral fracture resulted in the finding of rising treatment costs being positively associated with rising BMI due to longer operation times and longer length of hospitalization (10,452 €, 11,505 €, 12,085 € and 13,681 € for patients with BMI < 18.5 kg/m², BMI = 18.5-24.9 kg/m², BMI = 25.0-29.9 kg/m² and BMI ≥ 30.0 kg/m², respectively).

Use of Distal Tibial Cortical Bone Thickness and FRAX Score for Further Treatment Planning in Patients with Trimalleolar Ankle Fractures

Trimalleolar ankle fractures show a bimodal age distribution, affecting younger men and older women. Postmenopausal women often exhibit low bone mineral density, which contributes to a higher prevalence of osteoporotic-related fractures. The primary goal of this study was to analyse the association of patient characteristics with the cortical bone thickness of the distal tibia (CBTT) in trimalleolar ankle fractures.

METHODS

A total of 193 patients with a trimalleolar ankle fracture treated between 2011 and 2020 were included. Patient registries were reviewed regarding demographics, mechanism, and type of injury. The CBTT was assessed in radiographs and CT images. The FRAX score was calculated to estimate the probability for an osteoporotic fracture. A multivariable regression model was calculated to identify independent variables affecting the cortical bone thickness of the distal tibia.

RESULTS

Patients older than 55 years were 4.22 (95% CI: 2.12; 8.38) times more likely to be female. In the multivariable regression analysis, female sex (β -0.508, 95% CI: -0.739; -0.278, p < 0.001) and a higher age (β -0.009, 95% CI: -0.149; -0.003, p = 0.002) were independent variables associated with a lower CBTT. Patients with a CBTT < 3.5 mm had a higher 10-year probability for a major osteoporotic fracture (12% vs. 7.75%; p = 0.001).

CONCLUSIONS

The assessment of the peripheral bone quality in routine computed tomography demonstrated that higher age and female sex are significantly associated with reduced cortical bone thickness of the distal tibia. Patients with a lower CBTT showed a higher probability for a subsequent osteoporotic fracture. In female patients with reduced distal tibial bone quality and associated risk factors, an osteoporosis assessment should be evaluated.

Beneficial Perioperative Aspects Favor the Use of Percutaneous Crossed Pinning over Antegrade Nailing in Pediatric Supracondylar Fractures-A Retrospective Comparative Study

(1) Background: Displaced supracondylar humeral fractures in pediatric patients can be treated by either antegrade nailing (AN) or percutaneous crossed pinning (PCP). The aim of this study was to compare the intra- and perioperative management, complications and outcome of AN and PCP. (2) Methods: This retrospective study enrolled 271 individuals (median age 5 years, IQR 4-7 years) who underwent AN (n = 173) or PCP (n = 98). Patient history was analyzed for incidence of nerve injuries, postoperative treatment, postoperative malrotation, time of hospital stay, time to implant removal and revision rate. Operative procedures were investigated for duration and radiation exposure. (3) Results: PCP was associated with a significantly lower radiation exposure (dose area product: PCP mean 20.1 cGycm² vs. AN mean 34.7 cGycm², p < 0.001; fluoroscopy time: PCP mean 1.1 min, range 0.1-8.1 min, vs. AN mean 1.5 min, range 0.1-7.1 min, p < 0.001), duration of surgery (PCP mean 32.2 min vs. AN mean 48.3 min, p < 0.001) and time to implant removal (PCP mean 37 days vs. AN mean 113 days, p < 0.001). Cast removal was performed earlier in the AN group (PCP mean 30.2 days vs. AN mean 20.4 days, p < 0.001) and there were fewer iatrogenic nerve lesions (PCP: 24% vs. AN: 8%, p < 0.001). (4) Conclusions: In the investigated study population, the analyzed parameters seem to favor the use of PCP. The advantages of AN should be weighed against its drawbacks. For special indications, AN remains a relevant technique in supracondylar fracture treatment, and surgeons should be familiar with this procedure.

[Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]

BACKGROUND

Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice.

MATERIAL AND METHODS

In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used.

RESULTS

The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26).

DISCUSSION

RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement.

Can elderly patients regain their preoperative functional level after distal radius fracture type A? Results from a fracture register study using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, there are still ongoing debates concerning the treatment for type A fractures, especially in elderly patients. In spite of good clinical outcomes, it remains unclear whether elderly patients, especially, could regain the preoperative functional level of the wrist. Therefore, we have quantified wrist function within a retrospective study design using patient-reported outcome measures (PROM) and we have analyzed the influence of age between control and patient collective and young vs. old, respectively.

Patients and methods

The retrospective study included all patients with a surgically treated DRF type A and a control group of healthy patients, age and gender matched. The function of the wrist was examined by using a self-assessment questionnaire called the Munich Wrist Questionnaire (MWQ) according to the patient-related outcome measurements PROM.

Results

We could enroll 110 patients and controls, and the average follow-up was 66 months. Subgroup matching induced similar age group distribution: in both groups, 7 individuals &lt;30 years, 67 between 31 and 64 years, 29 between 65 and 79 years, and 7 individuals &gt;80 years, were enrolled, respectively. In the fracture group, women were significantly older than men (59 ± 15 vs. 47 ± 17 (M ± SD). There was no significant difference between the control and the patient groups (96 ± 6 vs. 95 ± 7). The function was significantly different between controls and patients &lt;30 years (100 ± 1 vs. 98 ± 2). In the control group, there was a functional difference in the age group &lt;30 compared with 65–79 and &gt;80 and in the age group 30–64 compared with 65–79 and &gt;80. In the control group, the function was found to be significantly decreasing with advancing age, whereas in the patient group, this influence was absent. A correlation analysis showed a worse function with increasing age in the control group and therefore a negative correlation. In the fracture group, a similar result could not be obtained.

Discussion

Age has a relevant influence on wrist function. Although the wrist function decreases significantly with aging, in the patient group, this influence is absent, and the functional results after surgery are excellent. Even elderly patients can regain their preoperative functional level.

Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System

Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the ‘Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries’ (UPPS) score for easier prediction of GUI in the emergency setting.

The outcome of severely injured patients following traumatic brain injury is affected by gender—A retrospective, multicenter, matched-pair analysis utilizing data of the TraumaRegister DGU®

Introduction

Traumatic brain injury (TBI) causes a major health-concern globally. Gender-dependent differences in mortality outcome after TBI have been controversially discussed.

Materials and methods

We conducted a retrospective, multicenter, matched-pair analysis using data collected by the TraumaRegister DGU® of the German Trauma Society between 2009 and 2020. All patients after severe trauma with the leading injury of TBI (AIS ≥ 3), above 18 years of age were included. Thereby, 42,034 cases were identified. We used 12 different matching criteria to ensure highly accurate matching and were able to match 11,738 pairs of one female and one male patient.

Results

Average age at injury was 67.5 ± 19.6 years in women and 66.7 ± 19.1 years in men. Mean Injury Severity Score (ISS) was 21.3 ± 8.1 in women and 21.6 ± 8.2 in men. While women were more likely to die within the first week after trauma, the mortality was significantly higher in men overall (30.8 vs. 29.2%, p &lt; 0.002). Women were less likely to suffer from multi organ failure (MOF) (27.5 vs. 33.0%) or sepsis (4.5 vs. 7.1%). When comparing younger (≤ 45-years) and older (&gt; 45 years) patients, overall mortality was lower in men (13.1% men vs. 13.4% women) in the younger age group, but in the older group mortality was lower in women (33.8% men vs. 31.8% women).

Discussion

Gender-specific differences in the clinical outcome of severely injured patients with leading TBI could be detected. While women are overall characterized by an advantage in survival, this feature is not equally reproducible in premenopausal women. Therefore, the exact pathophysiological reasons for the described survival advantages of women will have to be explored in further prospective clinical studies.

[Postoperative imaging of the musculoskeletal system : Clinical aspects]

BACKGROUND

Postoperative imaging in trauma surgery is an essential part of documenting optimal osteosynthetic care. A precise and goal-oriented analysis with a justifiable indication is essential. The clinical information has a great impact on the quality of imaging. An objective evaluation and structured reporting complete the postoperative imaging procedure.

MATERIALS AND METHODS

Conventional x‑rays in two planes is the standard of postoperative imaging in musculoskeletal surgery. In specific anatomic structures, additional images may be necessary. The postoperative x‑ray is the simplest way to visualize a successful osteosynthesis and combines the most important points of postoperative management. Computed tomography (CT) is mostly used in emergencies, but also in the postoperative management of some elective procedures, including patients with surgery of the spine, hip or to the proximal long bones of the extremities. Furthermore, CT is useful in postoperative imaging of complicated ankle fractures. Magnetic resonance imaging (MRI) plays a modest role in postoperative imaging and is mostly used in musculoskeletal cancer surgery. Ultrasound rather plays a subordinated role in postoperative management, but it is increasingly becoming established as a tool for postoperative quality control. The great advantage is dynamic visualization in real time.

CONCLUSION

Postoperative imaging remains challenging, but can detect most issues regarding osteosynthesis, which can be then be treated or monitored. Various imaging modalities are available to make reliable statements on osteosynthetic material, bone and soft tissue.

Traumatic Brain Injury Induces a Differential Immune Response in Polytrauma Patients; Prospective Analysis of CD69 Expression on T Cells and Platelet Expansion

Background: Accidents and injuries are the leading causes of mortality in young people. CD4+ regulatory T cells (CD4+ Tregs), Th17 cells and platelets could be identified as key players in post-traumatic immunological dysfunction, which is a common cause of late mortality in trauma patients. The mechanisms of activation of these cell types and their interaction remain mostly unclear. Since CD69 is not only a leukocyte marker but has also immunoregulatory functions, we postulate a role for CD69 after trauma. The present study investigates the expression of CD69 on CD4+ Tregs and Th17 cells, as well as the posttraumatic expansion of platelets and hemostatic function. Subgroup analysis was performed to assess the differences between polytrauma patients with and without severe traumatic brain injury (TBI). Methods: In this non-interventional prospective clinical trial, we analyzed sequential blood samples over a period of 10 days from 30 patients after multiple traumas with an ISS ≥ 16. Platelet function was assessed by rotational thromboelastometry (ROTEM analysis). CD4+ Tregs and Th17 cells were stained with surface markers and analyzed by flow cytometry. Results: We were able to demonstrate a significantly increased expression of CD69 on CD4+ Tregs after trauma. Subgroup analysis revealed that the absence of severe TBI is associated with a significantly higher expression of CD69 on CD4+ Tregs and on Th17 cells. Platelets expanded and showed signs of dysfunction, while an overall tendency of posttraumatic hypercoagulation was detected. Conclusions: Our results support the concept of injury-specific immune responses and add to a further understanding of the complex pathophysiology of post-traumatic immune dysfunction.

Is the Use of Segways or E-Scooters in Urban Areas a Potential Health Risk? A Comparison of Trauma Consequences

Background and objectives: Electromobility has become increasingly popular. In 2001, Segway personal transporters (Segway) were established for tourists, and e-scooters have been in use since their approval in 2019. The aim of this study was to analyze and compare the types of injuries directly related to the use of Segways and e-scooters, respectively, in a German city and to phrase potential safety advice. Materials and Methods: All patients presenting to our emergency department after Segway incidents were retrospectively analyzed and compared with the prospectively collected cohort of patients following e-scooter incidents. Presented injuries were analyzed by body region and injury severity score (ISS). Epidemiological data were collected. Results: Overall, 171 patients were enrolled. The Segway group included 56 patients (mean age 48 years), and the e-scooter group consisted of 115 patients (mean age 33.9 years). Head injuries (HI) occurred in 34% in the Segway group compared to 52% in the e-scooter group. The ISS was approximately equal for both groups (mean ISS Segway group: 6.9/e-scooter group: 5.6). Conclusions: Since the e-scooter group presented a high number of HI along with a higher likelihood and greater severity of HI, mandatory use of helmets is suggested.

Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis

OBJECTIVES

To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.

DESIGN

Retrospective.

SETTING

Two Level-1 trauma centers in Germany and United Kingdom.

METHODS

Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria.

RESULTS

A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem.

CONCLUSION

ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8–11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8–13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11–0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

The Clinical Impact of Platelets on Post-Injury Serum Creatinine Concentration in Multiple Trauma Patients: A Retrospective Cohort Study

Background and objective: Platelets contribute to the immunological response after multiple trauma. To determine the clinical impact, this study analyzes the association between platelets and creatinine concentration as an indicator of kidney function in polytraumatized patients. Methods: We investigated all patients presenting an Injury Severity Score (ISS) ≥16 for a 2-year period at our trauma center. Platelet counts and creatinine concentrations were analyzed, and correlation analysis was performed within 10 days after multiple trauma. Results: 83 patients with a median ISS of 22 were included. Platelet count was decreased on day 3 (p ≤ 0.001) and increased on day 10 (p ≤ 0.001). Platelet count was elevated on day 10 in younger patients and diminished in severely injured patients (ISS ≥35) on day 1 (p = 0.012) and day 3 (p = 0.011). Creatinine concentration was decreased on day 1 (p = 0.003) and day 10 (p ≤ 0.001) in female patients. Age (p = 0.01), male sex (p = 0.004), and injury severity (p = 0.014) were identified as factors for increased creatinine concentration on day 1, whereas platelets (p = 0.046) were associated with decreased creatinine concentrations on day 5 after multiple trauma. Conclusions: Kinetics of platelet count and creatinine concentration are influenced by age, gender, and trauma severity. There was no clear correlation between platelet counts and creatinine concentration. However, platelets seem to have a modulating effect on creatinine concentrations in the vulnerable phase after trauma.

[Decline in work and commuting injuries during the first lockdown in the SARS-CoV-2 pandemic : Comparison to the time period 2015-2019]

BACKGROUND

Measures such as restrictions on personal contact and going out were taken to reduce SARS-CoV‑2 infection numbers, ultimately resulting in the first lockdown. This was intended to create capacity in the healthcare system to manage the pandemic.

AIM OF THE WORK

To analyze whether the number of work and commuting injuries decreased during the lockdown compared to the years 2015-2019.

MATERIAL AND METHODS

All work and commuting accidents treated at the Klinikum rechts der Isar and the Berufsgenossenschaftliche Unfallklinik Murnau during the observational period 16 March-4 May 2020 were retrospectively compared with the figures from the same observation period in the years 2015-2019. The data on case numbers according to the transit physician procedure (DAV) were further broken down into cases of the injury type procedure (VAV) and severe injury type procedure (SAV) according to the injury type index of the German Social Accident Insurance (DGUV). In addition, the collected data were compared with data from the Federal Statistical Office on the numbers of traffic accidents and traffic fatalities.

RESULTS

A total of 4313 cases were considered. In 2020, the number of work and commuting accidents decreased by 31% compared to the observation period 2015-2019. VAV cases were decreased by 26% in 2020. SAV cases decreased by 5% in 2020. Road traffic accidents decreased by 17% in thre first four months in 2020 compared to the first four months in 2019. Traffic fatalities decreased by 11%.

DISCUSSION

There was a 31% decrease in work and commuting accidents. This contributed to resource reallocation in the context of the pandemic. Nevertheless, almost constant numbers of severely injured patients and accidental deaths occurred, which shows the relevance of trauma surgery structures especially in times of crisis and makes it indispensable to include them in the calculation of intensive care resources.

Dysregulation of Wnt signaling in bone of type 2 diabetes mellitus and diabetic Charcot arthropathy

Background

Type 2 diabetes mellitus (T2DM) patients show a markedly higher fracture risk and impaired fracture healing when compared to non-diabetic patients. However in contrast to type 1 diabetes mellitus, bone mineral density in T2DM is known to be normal or even regionally elevated, also known as diabetic bone disease. Charcot arthropathy is a severe and challenging complication leading to bone destruction and mutilating bone deformities. Wnt signaling is involved in increasing bone mineral density, bone homeostasis and apoptotic processes. It has been shown that type 2 diabetes mellitus is strongly associated with gene variants of the Wnt signaling pathway, specifically polymorphisms of TCF7L2 (transcription factor 7 like 2), which is an effector transcription factor of this pathway.

Methods

Bone samples of 19 T2DM patients and 7 T2DM patients with additional Charcot arthropathy were compared to 19 non-diabetic controls. qPCR analysis for selected members of the Wnt-signaling pathway (WNT3A, WNT5A, catenin beta, TCF7L2) and bone gamma-carboxyglutamate (BGLAP, Osteocalcin) was performed and analyzed using the 2-ΔΔCt- Method. Statistical analysis comprised one-way analysis of variance (ANOVA).

Results

In T2DM patients who had developed Charcot arthropathy WNT3A and WNT5A gene expression was down-regulated by 89 and 58% compared to healthy controls (p < 0.0001). TCF7L2 gene expression showed a significant reduction by 63% (p < 0.0001) and 18% (p = 0.0136) in diabetic Charcot arthropathy. In all diabetic patients BGLAP (Osteocalcin) was significantly decreased by at least 59% (p = 0.0019).

Conclusions

For the first time with this study downregulation of members of the Wnt-signaling pathway has been shown in the bone of diabetic patients with and without Charcot arthropathy. This may serve as future therapeutic target for this severe disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05314-9.

Results of a Retrospective Fracture Register of Distal Radius Fractures Built Up Using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, the best treatment for every fracture type is still debatable. However, randomized controlled trials are difficult to perform. The quality of care can be determined primarily in the context of health care research using register studies. Registers enable standardized documentation of clinical observations over time. So far, no German register studies concerning DRFs exist, and therefore, the aim of this study was to develop a register with the help of patient-reported outcome measurements (PROM).

Patients and Methods

All patients treated surgically at our hospital with a DRF between 2006 and 2016 were enrolled. Patient data such as epidemiological data, treatment, complications, insurance status, etc. were collected and the register was built up as an in-house fracture register with the help of PROM. The Munich Wrist Questionnaire (MWQ) was used as a PROM tool.

Results

Of all 1,796 patients, 339 (19%) with a complete data set could be enrolled, 96 of the patients were male (28%), 243 were female (72%). Thirty-two percent were type A (n = 110), 9% (n = 31) were type B, and 58% (n = 198) were type C fractures. The average follow-up was 66 ± 31 months. Complications occurred in 25 cases (7%). The average postoperative function measured with the MWQ was 91 ± 11%. Patients suffering from a DRF type A had the best outcome. It was significantly better than the outcome of patients with a DRF type C (95 ± 7 vs. 89 ± 13%, p < 0.05 MWUT) and significantly better compared to the results from the whole fracture register (95 ± 7 vs. 91 ± 11%, p < 0.05 MWUT). Type B fractures had a better outcome than type C fractures (92 ± 11%).

Conclusions

Retrospective register studies created with the help of PROM have numerous advantages. Data collection is fast, easy and cost-effective and a huge amount of data can be achieved from numerous patients and the observation period after surgery is quite long. The drop-out rate might be high, but patients enrolled are a representative sample compared to the current literature. This is a valuable tool for monitoring of clinical treatment quality.

Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures

Purpose

Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy.

Methods

Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data.

Results

A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss’ κ = 0.86, 95% CI 0.82–0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss’ κ = 0.78, 95% CI 0.73–0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54–0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03–5.99).

Conclusion

In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.

Treatment of vascular graft infections: gentamicin-coated ePTFE grafts reveals strong antibacterial properties in vitro

Vascular graft infections (VGI) are severe complications in prosthetic vascular surgery with an incidence ranging from 1 to 6%. In these cases, synthetic grafts are commonly used in combination with antimicrobial agents. Expanded polytetrafluoroethylene (ePTFE) is in clinical use as a synthetic graft material and shows promising results by influencing bacterial adhesion. However, the literature on antibiotic-bound ePTFE grafts is scarce. Gentamicin is a frequently used antibiotic for local treatment of surgical site infections, but has not been evaluated as antimicrobial agent on ePTFE grafts. In this study, we examine the antimicrobial efficacy and biocompatibility of novel types of gentamicin-coated ePTFE grafts in vitro. ePTFE grafts coated with gentamicin salt formulations with covalently-bound palmitate were evaluated in two drug concentrations (GP1.75% and GP3.5%). To investigate effects from types of formulations, also suspensions of gentamicin in palmitate as well as polylactide were used at comparable levels (GS + PA and GS + R203). Antibacterial efficacies were estimated by employing a zone of inhibition, growth inhibition and bacterial adhesion assay against Staphylococcus aureus (SA). Cytotoxicity was determined with murine fibroblasts according to the ISO standard 10993-5. Gentamicin-coated ePTFE grafts show low bacterial adherence and strong antibacterial properties in vitro against SA. Bactericidal inhibition lasted until day 11. Highest biocompatibility was achieved using gentamicin palmitate GP1.75% coated ePTFE grafts. ePTFE grafts with gentamicin-coating are effective in vitro against SA growth and adherence. Most promising results regarding antimicrobial properties and biocompatibility were shown with chemically bounded gentamicin palmitate GP1.75% coatings. Graphical abstract.

Correlation between Platelet Count and Lung Dysfunction in Multiple Trauma Patients-A Retrospective Cohort Analysis

(1) Background: Current findings emphasize the potential contribution of platelets to the immunological response after severe trauma. As clinical relevance remains unclear, this study aims to analyze the correlation between platelets and lung dysfunction in severely injured patients. (2) Methods: We retrospectively enrolled all multiple trauma patients presenting to our level 1 trauma center from 2015 to 2016 with an Injury-Severity Score (ISS) ≥ 16. Apart from demographic data, platelet counts and PaO₂/FiO₂ as an approximate indicator for lung physiology were analyzed and correlated on subsequent days after admission. (3) Results: 83 patients with a median ISS of 22 (IQR 18–36) were included. Compared to day 1, platelet counts were decreased on day 3 (p ≤ 0.001). Platelet counts were significantly lower on day 3 in patients with an ISS ≥ 35 (p = 0.011). There were no differences regarding PaO₂/FiO₂ index. Correlation analysis revealed a positive link between increased platelet counts and PaO₂/FiO₂ index on day 1 only in severely injured patients (p = 0.007). (4) Conclusions: This work supports the concept of platelets modulating the posttraumatic immune response by affecting lung dysfunction in the early phase after multiple trauma in dependence of injury severity. Our findings contribute to the understanding of the impact of platelets on systemic processes in multiple trauma patients.

RAY-POS: a LIDAR-based assistance system for intraoperative repositioning of mobile C-arms without external aids

PURPOSE

In current clinical practice, intraoperative repositioning of mobile C-arms is challenging due to a lack of visual cues and efficient guiding tools. This can be detrimental to the surgical workflow and lead to additional radiation burdens for both patient and personnel. To overcome this problem, we present our novel approach Lidar-based X-ray Positioning for Mobile C-arms (RAY-POS) for assisting circulating nurses during intraoperative C-arm repositioning without requiring external aids.

METHODS

RAY-POS consists of a localization module and a graphical user interface for guiding the user back to a previously recorded C-Arm position. We conducted a systematic comparison of simultaneous localization and mapping (SLAM) algorithms using different attachment positions of light detection and ranging (LIDAR) sensors to benchmark localization performance within the operating room (OR). For two promising combinations, we conducted further end-to-end repositioning tests within a realistic OR setup.

RESULTS

SLAM algorithm gmapping with a LIDAR sensor mounted 40 cm above the C-arm's horizontal unit performed best regarding localization accuracy and long-term stability. The distribution of the repositioning error yielded an effective standard deviation of 7.61 mm.

CONCLUSION

We conclude that a proof-of-concept for LIDAR-based C-arm repositioning without external aids has been achieved. In future work, we mainly aim at extending the capabilities of our system and evaluating the usability together with clinicians.

Evaluation of Acute Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Plasma Levels in Traumatic Brain Injury Patients with and without Intracranial Lesions

This pilot study aimed to evaluate the association of plasma ubiquitin C-terminal hydrolase-L1 (UCH-L1), glial fibrillary acidic protein (GFAP), and S100 calcium-binding protein B (S100B) with intracranial abnormalities visible on a computed tomography (CT) scan (CT positive) and injury severity in acute traumatic brain injury (TBI). For these purposes, a cohort of 109 adult TBI patients was recruited within 6 h from the injury event. A hyperacute subcohort of 20 patients who had their blood collected within 2 h from injury was analyzed separately for early acute biomarker levels. Levels of GFAP and UCH-L1 were analyzed using the prototype Abbott i-STAT™ TBI Plasma Test (Abbott Laboratories, Abbot Park, IL), alongside S100B measurement (Elecsys; Roche Diagnostics, Penzberg, Germany). In the hyperacute subcohort, GFAP and UCH-L1, but not S100B, levels were significantly higher in the CT-positive group compared to CT-negative patients. AUC values for differentiation between CT-positive and CT-negative patients were 0.97 for GFAP, 0.87 for UCH-L1, and 0.60 for S100B. Severity discrimination, defined by Glasgow Coma Scale (GCS) score, was then analyzed in the total patient cohort. Levels of all three biomarkers were significantly different between mild (GCS, 13-15) and moderate/severe (GCS, 3-12) injury groups. UCH-L1 showed the highest area under the curve value for severity discrimination (0.94), followed by GFAP (0.91) and S100B (0.83). These results support the clinical utility of GFAP and UCH-L1 as TBI biomarkers able to rule out CT-positive injury in acute TBI. Moreover, excellent differentiation of GFAP and UCH-L1 between mild and moderate/severe TBI groups affirms their close association with the underlying pathology.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly

INTRODUCTION

Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA).

MATERIALS AND METHODS

All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score.

RESULTS

A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal.

CONCLUSIONS

Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

Does implant removal of superior clavicle plate osteosynthesis affect the functional outcome: a prospective trial

BACKGROUND

Elective implant removal (IR) accounts for up to 30% of all orthopaedic surgeries. While there is general acceptance about the need of implant removal for obvious reasons, such as infections or implant failure, little is known about the beneficial aspects in cases of minor reasons such as patients' wish for IR. Therefore, we initiated this study to define patients' benefit of elective implant removal following plate osteosynthesis of displaced clavicle fractures.

PATIENTS AND METHODS

Prospective evaluation of patients was conducted before implant removal and 6 weeks postoperative. Subjective and objective criteria included pain rating on a visual analogue scale (VAS) and active range of motion (ROM) pre- and 6 weeks postoperative. Functional scoring included Constant-Murley Score, DASH (Disabilities of Arm, Shoulder and Hand Score), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index).

RESULTS

37 patients were prospectively enrolled in this study and implant removal was performed after 16 ± 6.1 months. No re-fractures nor other complications were detected during routine follow up. Functional outcome increased through all scores (Constant score 73.3 ± 14.6 preoperative to 87.4 ± 12.0 postoperative (p = 0.000), MSQ 85.0 ± 7.3 preoperative to 91.8 ± 9.0 postoperative (p = 0.005), DASH Score 7.4 ± 8.2 preoperative to 5.7 ± 9.5 postoperative (p = 0.414), SPADI 93.4 ± 6.6 preoperative to 94.0 ± 10.1 postoperative (p = 0.734).

CONCLUSIONS

Discomfort during daily activities or performing sports as well as limited range of motion were the main reasons for patients' wish for implant removal. We found increased functional outcome parameters and decreased irritation after implant removal. Therefore we suggest implant removal in case of patients' wish and completed fracture consolidation.

TRIAL REGISTRATION

Trial registration no: NCT04343118, Retrospective registered: www.clinicaltrials.gov .

Platelets differentially modulate CD4+ Treg activation via GPIIa/IIIb-, fibrinogen-, and PAR4-dependent pathways

CD4⁺FoxP3⁺ regulatory T cells (CD4⁺ Tregs) are known to dampen inflammation following severe trauma. Platelets were shown to augment their posttraumatic activation in burn injury, but the exact mechanisms remain unclear. We hypothesized that platelet activation mechanisms via GPIIb/IIIa, fibrinogen, and PAR4 have an immunological effect and modulate CD4⁺ Treg activation early after trauma. Therefore, C57Bl/6 N mice were injected with tirofiban (GPIIb/IIIa inhibition), ancrod (fibrinogen splitting enzyme), or tcY-NH₂ (selective PAR4 antagonist peptide) before inducing a third-degree burn injury of 25% of the total body surface area. Changes in coagulation, and local and systemic CD4⁺ Treg activity were assessed via rotational thromboelastometry (ROTEM®) and phospho-flow cytometry 1 h post intervention. The inhibition of GPIIb/IIIa and fibrinogen locally led to a higher basic activity of CD4⁺ Tregs compared to non-inhibited animals. In contrast, PAR4 disruption on platelets locally led to an increased posttraumatic activation of CD4⁺ Tregs. Fibrinogen led to complete elimination of coagulation, whereas GPIIb/IIIa or PAR4 inhibition did not. GPIIb/IIIa receptor and fibrinogen inhibition increase CD4⁺ Tregs activity independently of trauma. Both are crucial for thrombus formation. We suggest platelets trapped in thrombi are unable to interact with CD4⁺ Tregs but augment their activity when circulating freely. In contrast, PAR4 seems to reduce CD4⁺ Treg activation following trauma. In summary, GPIIb/IIIa-, PAR4-, and fibrinogen-dependent pathways in platelets modulate CD4⁺ Treg baseline activity, independently from their hemostatic functionality. PAR4-dependent pathways modulate the posttraumatic interplay of platelets and CD4⁺ Tregs.

Functional outcome of 103 fractures of the proximal fifth metatarsal bone

Background

Metatarsal fractures are common skeletal injuries of the lower extremity in adults. The majority involves the proximal fifth metatarsal bone. In the current literature, there still exists controversy regarding treatment recommendations for the different fracture entities.

Methods

All patients suffering from single fractures to the proximal fifth metatarsal bone between 2003 and 2015 were enrolled in this retrospective analysis. Only patients with a minimum follow-up of 12 months were included. The fractures were classified according to Lawrence and Botte (L&B). Data were collected via patient registry, radiographs and a standardized questionnaire (Foot and Ankle Outcome Score = FOAS). For outcome analysis, the nonparametric Mann–Whitney U test was performed and Spearman’s rank correlation coefficient calculated.

Results

In total, the functional outcomes of 103 patients suffering from fractures to the proximal fifth metatarsal bone were analyzed. L&B type I fractures (n = 13) had a FAOS score of 91 ± 23, L&B type II (n = 67) presented a score of 91 ± 15 and L&B type III (n = 23) a score of 93 ± 11. Surgically treated patients with an L&B type II fracture had no statistically significant better functional outcome in comparison to conservative management (p = 0.89). Operatively treated L&B type III fractures tended to have a better functional score (p = 0.16). The follow-up time was 58 (min: 15; max: 164) months.

Conclusions

Overall, the functional outcome following fractures to the proximal fifth metatarsal bone is satisfactory. Conservatively treated L&B type II fractures showed an equivalent functional outcome compared to surgical management. Patients with an L&B type III fracture mainly were treated surgically, but difference in FAOS score did not reach level of significance.

[Lesions of the triceps tendon : Diagnostics, management, treatment]

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Revision rate is higher in patients with periprosthetic femur fractures following revision arthroplasty in comparison with ORIF following our algorithm: a two-center 1 analysis of 129 patients

Purpose

Effective therapy of periprosthetic femur fractures of the hip (PPF) are challenging due to patients’ frailty and complexity of fracture patterns. The aim of this cohort study was to analyze the radiological and functional outcome following PPF.

Methods

A retrospective, multicenter study in the period 2009–2019 of patients with PPF at two level I trauma centers in Germany was performed. PPF were classified according to the Vancouver classification system. Demographic data, American Society of Anesthesiologists (ASA) classification, type of surgery, complications, and reoperation rate were obtained from patient records. The functional outcome was assessed by the modified Harris-Hip Score (mHHS), general health using the EQ-5D, and radiological outcome by Beals & Tower (B&T) criteria.

Results

A total of 129 patients with a mean age of 79 years (range 43–102) were included. 70% of all patients were female and 68% of the patients had an ASA score ≥ 3. 20 patients suffered from a Vancouver A, 90 from a Vancouver B and 19 from a Vancouver C fracture. 14% of the patients died within the first 2 years after surgery. The reoperation rate after open reduction and internal fixation (ORIF) (n = 60) was 8% and after revision arthroplasty (RA) (n = 47) 30% (OR 3.4, 95% CI [1.21–10.2]). Mean mHHS (n = 32) was 53 ± 19.4 and EQ-VAS was 50 ± 24.6. According to B&T criteria, 82% of patients treated with ORIF (n = 17) and 62% after RA (n = 13) showed an excellent outcome.

Conclusion

Patients with a PPF of the hip are elderly and at increased operative risk. In cases with a stable prosthesis, ORIF provides good radiological outcome with low reoperation rates. In case of RA, the risk for revision surgery is higher.

Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs

Background

In a terror attack mass casualty incident (TerrorMASCAL), compared to a “normal” MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL.

Methods

To answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta.

Results

In the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers.

Conclusion

The results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.

Medical drones: Disruptive technology makes the future happen

Trauma surgery has always been driven forward by innovative technological advancements. The recent appearance of “advanced air mobility” (AAM) represents one of the next steps in these technological developments. These innovative flying systems have major implications for all of the various healthcare stages in trauma surgery: Unmanned aircraft systems, or drones, can deliver critical supplies on demand, just in time, without physical contact, within the “last mile delivery” concept, such as AEDs, critical medication, blood for transfusion etc. Electric vertical take-off and landing (eVTOL) devices add new horizons for healthcare thanks to the smallest take-off and landing areas. These eVTOLs are not only new aircraft but, thanks to the autonomous flying options, they are flying computers with novel technological opportunities on board. With these new, flying operation systems, the whole rescue chain will be completely revolutionized by much faster response intervals, patient transportation times, telemedical applications, optimized emergency medical services, laboratory transportation etc. Hence, this article aims to provide a tentative overview of these new exciting technological developments in the field of trauma surgery for the benefit of our patients.

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures

BACKGROUND

Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures.

METHODS

Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score.

RESULTS

Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months.

CONCLUSION

Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results.

TRIAL REGISTRATION

No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

Curriculum learning for improved femur fracture classification: Scheduling data with prior knowledge and uncertainty

An adequate classification of proximal femur fractures from X-ray images is crucial for the treatment choice and the patients' clinical outcome. We rely on the commonly used AO system, which describes a hierarchical knowledge tree classifying the images into types and subtypes according to the fracture's location and complexity. In this paper, we propose a method for the automatic classification of proximal femur fractures into 3 and 7 AO classes based on a Convolutional Neural Network (CNN). As it is known, CNNs need large and representative datasets with reliable labels, which are hard to collect for the application at hand. In this paper, we design a curriculum learning (CL) approach that improves over the basic CNNs performance under such conditions. Our novel formulation reunites three curriculum strategies: individually weighting training samples, reordering the training set, and sampling subsets of data. The core of these strategies is a scoring function ranking the training samples. We define two novel scoring functions: one from domain-specific prior knowledge and an original self-paced uncertainty score. We perform experiments on a clinical dataset of proximal femur radiographs. The curriculum improves proximal femur fracture classification up to the performance of experienced trauma surgeons. The best curriculum method reorders the training set based on prior knowledge resulting into a classification improvement of 15%. Using the publicly available MNIST dataset, we further discuss and demonstrate the benefits of our unified CL formulation for three controlled and challenging digit recognition scenarios: with limited amounts of data, under class-imbalance, and in the presence of label noise. The code of our work is available at: https://github.com/ameliajimenez/curriculum-learning-prior-uncertainty.

[Operation preparation in trauma surgery]

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

[Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]

Hintergrund

Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen.

Material und Methoden

Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft.

Ergebnisse

Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war.

Schlussfolgerung

Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.

Current management of trimalleolar ankle fractures

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Patient reported outcome of 33 operatively treated talar fractures

BACKGROUND

Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures.

METHODS

A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed.

RESULTS

In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145).

CONCLUSIONS

Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.