Ongoing decision-making dilemma for treatment of de novo spinal infections: a comparison of the Spinal Infection Treatment Evaluation Score with the Spinal Instability Spondylodiscitis Score and Spine Instability Neoplastic Score

OBJECTIVE

De novo spinal infections are an increasing medical problem. The decision-making for surgical or nonsurgical treatment for de novo spinal infections is often a non-evidence-based process and commonly a case-by-case decision by single physicians. A scoring system based on the latest evidence might help improve the decision-making process compared with other purely radiology-based scoring systems or the judgment of a single senior physician.

METHODS

Patients older than 18 years with an infection of the spine who underwent nonsurgical or surgical treatment between 2019 and 2021 were identified. Clinical data for neurological status, pain, and existing comorbidities were gathered and transferred to an anonymous spreadsheet. Patients without an MR image and a CT scan of the affected spine region were excluded from the investigation. A multidisciplinary expert panel used the Spine Instability Neoplastic Score (SINS), Spinal Instability Spondylodiscitis Score (SISS), and Spinal Infection Treatment Evaluation Score (SITE Score), previously developed by the authors' group, on every clinical case. Each physician of the expert panel gave an individual treatment recommendation for surgical or nonsurgical treatment for each patient. Treatment recommendations formed the expert panel opinion, which was used to calculate predictive validities for each score.

RESULTS

A total of 263 patients with spinal infections were identified. After the exclusion of doubled patients, patients without de novo infections, or those without CT and MRI scans, 123 patients remained for the investigation. Overall, 70.70% of patients were treated surgically and 29.30% were treated nonoperatively. Intraclass correlation coefficients (ICCs) for the SITE Score, SINS, and SISS were 0.94 (95% CI 0.91-0.95, p < 0.01), 0.65 (95% CI 0.91-0.83, p < 0.01), and 0.80 (95% CI 0.91-0.89, p < 0.01). In comparison with the expert panel decision, the SITE Score reached a sensitivity of 96.97% and a specificity of 81.90% for all included patients. For potentially unstable and unstable lesions, the SISS and the SINS yielded sensitivities of 84.42% and 64.07%, respectively, and specificities of 31.16% and 56.52%, respectively. The SITE Score showed higher overall sensitivity with 97.53% and a higher specificity for patients with epidural abscesses (75.00%) compared with potentially unstable and unstable lesions for the SINS and the SISS. The SITE Score showed a significantly higher agreement for the definitive treatment decision regarding the expert panel decision, compared with the decision by a single physician for patients with spondylodiscitis, discitis, or spinal osteomyelitis.

CONCLUSIONS

The SITE Score shows high sensitivity and specificity regarding the treatment recommendation by a multidisciplinary expert panel. The SITE Score shows higher predictive validity compared with radiology-based scoring systems or a single physician and demonstrates a high validity for patients with epidural abscesses.

The PAC (Post-operative Airway Compromise) score - First steps to Develop a Post-Surgery Tool for the Assessment of Upper Airway-related Complications following Anterior Cervical Spine Surgery

BACKGROUND

Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion (ACDF). This study aims to develop a score to identify patients at risk for acute postoperative airway compromise (PAC).

METHODS

Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified out of 1,466 patients who underwent elective ACDF between July 2014 - May 2019. A comparison group was created by a randomized selection process (non-PAC group). Associated factors with PAC and a p-value <.10 were entered into a logistic regression model and coefficients contributed each risk factor's overall score. Calibration of the model was evaluated by Hosmer-Lemeshow (H-L) goodness-of-fit test. Quantitative discrimination was calculated and the final model was internally validated with bootstrap sampling.

RESULTS

We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, ASA >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (>C4), and duration of surgery >179 min. The final prediction model included five predictors with very strong performance characteristics. These five factors formed the PAC-Score (PACS) which had a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%).

CONCLUSIONS

The acute Postoperative Airway Compromise Score (PACS) demonstrates strong performance characteristics. The PAC score may help identify patients at risk for upper airway compromise caused by surgical site abnormalities.

Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury

BACKGROUND

This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury.

METHODS

The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed.

RESULTS

On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs.

CONCLUSIONS

After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review

INTRODUCTION

From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems.

MATERIALS AND METHODS

A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account.

RESULTS

Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily.

CONCLUSION

SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.

The Impact of the SARS-COVID-19 Lockdowns on the Subjectively Perceived Performance Level of Amateur Athletes after Returning to the Gyms

Since December 2019, few issues have garnered as much global attention as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-19). The imposed lockdowns in 2020/21, which led to the closure of all gyms, barred people from participating in their favourite sports activities. This study explores athletes' self-evaluations of their performance levels upon return to training facilities post-reopening. Data were collected in May 2021, after the end of the second lockdown, using a national online questionnaire. The study recorded 20 demographic and training-specific parameters to discern the factors influencing self-perceived performance upon resuming gym activities after the 2020/2021 lockdown. A total of 1378 respondents participated in the study. Of the total number of participants, 27.5% (365) reported regaining 100% of their original performance level after reopening their studios, a proportion that comprised 212 males, 150 females, and 3 individuals of unspecified gender. Additionally, 35.7% (474) estimated their performance level to be up to 75%, followed by 30% (398) recording their performance level at 50%, and a minority of 6.8% (90) determining their performance level to be up to 25%. Exercise intensity prior to lockdown, training experience, sex, and concurrent practice of another sport significantly influenced the athletes' self-assessment of their current fitness levels (p > 0.001, p > 0.001, p > 0.001, and 0.006, respectively). We need to understand the factors that shape self-perception, especially in case of another lockdown, in order to provide preventive assistance concerning mental and physical well-being. Positive influences on self-perception include prior athletic experience, intensive training before the lockdown, and continued participation in sports throughout the lockdown. Younger age is also favourable, but this may not necessarily reflect the benefits of youth; rather, it could indicate the current lack of accessible online sports activities for older individuals. Women, however, might have a less favourable perception of their own athletic performance.

Water exchange technique improves colonoscopy in patients with spinal cord injury: Results of a matched cohort study

Background and study aims Colonoscopies in patients with spinal cord injury (SCI) frequently remain incomplete. This study aimed to evaluate the feasibility and impact of water exchange colonoscopy (WE) in patients with SCI. Patients and methods Three matched groups, each of 31 patients (WE in SCI patients [WE-SCI]) and in the general population (WE-GP), carbon dioxide-based colonoscopy in SCI patients (CO 2 -SCI)) were analyzed retrospectively. Results Intubation of the cecum and the terminal ileum was achieved in every case in both WE groups. The intubations among the CO 2 -SCI patients succeeded in 29 cases (93.5 %, ns) and 20 cases (64.5 %, P <0.001), respectively. The cecal insertion time (23:17 ± 10:17 min vs. 22:12 ± 16:48 min) and bowel preparation during cecal insertion did not differ between WE-SCI groups. Insertion in the general population was faster (13:38 ± 07:00 min, P <.001) and cleanliness was better. Both WE-SCI groups showed significantly better cleansing results during drawback; the improvement in cleanliness was highest in the WE-SCI (based on the five-step scale 1.4 ± 0.8 vs. 0.8 ± 0.8, P = 0.001). Conclusions The WE in SCI patients is feasible and safe and has the potential to improve the quality of colonoscopies substantially.

Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study

BACKGROUND

The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools.

METHODS

Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest.

RESULTS

Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results.

CONCLUSIONS

Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered.

TRIAL REGISTRATION

German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

Popular Gym Fitness Sport: An Analysis of 1387 Recreational Athletes Regarding Prone to Pain Exercises and the Corresponding Localisations

BACKGROUND

Recreational fitness sports are popular worldwide and rank first among organised sports. This study aims to bridge a knowledge gap by examining which exercises are most prone to causing pain symptoms, as a possible precursor for injury, and analysing the body regions that are most frequently affected.

METHODS

Using an online questionnaire, 20 demographic and training-specific items and 49 sport-specific exercises were recorded. Frequent exercises as well as the incidence and distribution of pain symptoms that the athletes experienced during or in relation to their training were evaluated.

RESULTS

The study assessed common exercises and documented the frequency and distribution of pain symptoms experienced by athletes during or in relation to their training. A total of 1387 respondents were included in this study. Of these, 732 (53.1%) experienced pain during their fitness training, with 333 (24.2%) being female and 397 (22.3%) being male. The method of creating a training plan showed a significant influence (p < 0.001): athletes who devised their own plans reported pain or instability more frequently than those in the comparison groups. Guided exercises on machines resulted in the lowest frequency of pain (11.54%), while exercises with free weights were associated with the highest pain rate among respondents (19.94%). Specifically, exercises such as the back squat, deadlift, bench press, and triceps dips were identified as the exercises most commonly associated with pain. The most frequently reported pain region was the shoulder, followed by the lower back and knees.

CONCLUSION

The findings reveal a significant number of unreported pain symptoms. The disparity between rigorous training volumes and the absence of professional care frequently leads to injuries and pain. It is incumbent upon sports medicine to investigate the root causes of these complaints (pain or instability) to implement preventive measures against potential injuries.

Pharmacological elevation of sphingosine-1-phosphate by S1P lyase inhibition accelerates bone regeneration after post-traumatic osteomyelitis

Posttraumatic osteomyelitis and the ensuing bone defects are a debilitating complication after open fractures with little therapeutic options. We have recently identified potent osteoanabolic effects of sphingosine-1-phosphate (S1P) signalling and have now tested whether it may beneficially affect bone regeneration after infection. We employed pharmacological S1P lyase inhibition by 4-deoxypyrodoxin (DOP) to raise S1P levels in vivo in an unicortical long bone defect model of posttraumatic osteomyelitis in mice. In a translational approach, human bone specimens of clinical osteomyelitis patients were treated in organ culture in vitro with DOP. Bone regeneration was assessed by μCT, histomorphometry, immunohistology and gene expression analysis. The role of S1P receptors was addressed using S1PR3 deficient mice. Here, we present data that DOP treatment markedly enhanced osteogenesis in posttraumatic osteomyelitis. This was accompanied by greatly improved osteoblastogenesis and enhanced angiogenesis in the callus accompanied by osteoclast-mediated bone remodelling. We also identified the target of increased S1P to be the S1PR3 as S1PR3-/- mice showed no improvement of bone regeneration by DOP. In the human bone explants, bone mass significantly increased along with enhanced osteoblastogenesis and angiogenesis. Our data suggest that enhancement of S1P/S1PR3 signalling may be a promising therapeutic target for bone regeneration in posttraumatic osteomyelitis.

Monteggia fractures and Monteggia-like-lesions: a systematic review

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Shoulder complaints and incidence of shoulder pathologies after contralateral major amputation in the mid and long-term

INTRODUCTION

Amputations of the upper extremity are rare but present a life-altering event that is accompanied with considerable restrictions for the affected patients. Even with functional prosthesis, tasks of the amputated limb are usually transferred to the unaffected arm which could result in complaints of the unaffected shoulder in the mid and long term. We therefore aimed to investigate musculoskeletal pain and morphological degenerative changes of the shoulder following a contralateral amputation.

MATERIALS AND METHODS

We included all patients with a major amputation treated at our institution with a minimum of three years since the amputation. All patients received an MRI of both shoulders and were investigated using validated scores for the upper extremity and physical activity (SSV, ASES, DASH, GPAQ, SF-36). Results of the MRIs were investigated for morphological changes by two blinded investigators comparing the side of the amputation and the unharmed upper extremity and results were correlated to the time since amputation and their physical activity.

RESULTS

A total of 20 patients with a mean age of 56 ± 19.9 years (range, 23-82 years) could be included in the study. The mean time since the amputation was 26.3 ± 19 years (range, 3-73 years). On the unharmed upper extremity, the mean SSV was 61.9 ± 24.6, the mean ASES-Score 54.5 ± 20.3, the Constant-score of 63.7 ± 40.4 and a DASH-score of 47.6 ± 23.8. The MRI of the unharmed shoulder showed significant more full-thickness rotator cuff tears and joint effusion compared to the side of the amputation. Significant differences in the degree of a glenohumeral arthritis, AC-joint arthritis, or partial rotator cuff tears could not be found between shoulders.

CONCLUSION

Amputations of the upper extremity are associated with a high disability of the unharmed upper extremity and more full thickness rotator cuff tears compared to the side of the amputation. However, the small number of patients and rotator cuff injuries should be kept in mind when interpreting the data.

LEVEL OF EVIDENCE

IV (retrospective case series).

A salvage procedure: Radial head excision in children and adolescents-short-to-midterm outcomes and overview of the literature

Purpose

Purpose of the study was to report the outcomes after radial head excision in children and adolescents in addition with a review of the current literature.

Methods

We report a series of five children and adolescents, who had undergone a post-traumatic radial head excision. Clinical outcomes were evaluated in terms of elbow/wrist range of motion, stability, deformity and discomforts or restrictions at two follow-up points. Radiographic changes were evaluated.

Results

Patient's age at time of the radial head excision averaged 14.6 (13-16) years. Mean time from the injury to the radial head excision was 3.6 (0-9) years. Follow-up I averaged 4.4 (1-8) years and follow-up II 8.5 (7-10) years. At follow-up I, patients showed an average elbow range of motion of 0-10-120° Ext/Flex and 90-0-80° Pro/Sup. Two patients reported discomfort or pain at the elbow. Four (80%) patients had a symptomatic wrist with pain or crepitation at the distal radio ulnar joint. In three (60%) of them, an ulna plus at the wrist was present. Two patients required ulna shortening and autograft stabilization of the interosseous membrane. At final follow-up, all patients reported full functioning with daily activities. Restrictions were present with sport activities.

Conclusion

Functional results at the elbow joint might be improved and pain syndromes lessen due to the radial head excision. Problems at the wrist are likely secondary to the procedure. A critical analysis of other options should be performed ahead of the procedure and a careless application should be avoided by all means.

Level of evidence

IV.

Minor microbial alterations after faecal diversion do not affect the healing process of anus-near pressure injuries in patients with spinal cord injury - results of a matched case-control study

STUDY DESIGN

Retrospective matched case-control study including patients with spinal cord injury who presented with an anus-near pressure injury. Two groups were formed based on the presence of a diverting stoma.

OBJECTIVES

To evaluate the primary microbial colonisation and secondary infection of anus-near pressure injuries depending on the presence of a pre-existing diverting stoma and to investigate the effect on the wound healing.

SETTING

University hospital with a spinal cord injury unit.

METHODS

A total of 120 patients who had undergone surgery of an anus-near decubitus stage 3 or 4 were included in a matched-pair cohort study. Matching was realised according to age, gender, body mass index and general condition.

RESULTS

The most common species in both groups was Staphylococcus spp.(45.0%). The only significantly different primary colonisation affected Escherichia coli, that was found in the stoma patients less often (18.3 and 43.3%, p < 0.01). A secondary microbial colonisation occurred in 15.8% and was equally distributed, except for Enterococcus spp. that was present in the stoma group only (6.7%, p < 0.05). The time to complete cure took longer in the stoma group (78.5 versus 57.0 days, p < 0.05) and was associated with a larger ulcer size (25 versus 16 cm2, p < 0.01). After correction for the ulcers' size, there was no association to outcome parameters such as overall success, healing time or adverse events.

CONCLUSIONS

The presence of a diverting stoma alters the microbial flora of an anus-near decubitus slightly without impact on the healing process.

The impact of knee arthrodesis on gait kinematics, muscle activity and patient-reported outcome

BACKGROUND

The aim of this retrospective study was to analyze gait kinematicsandoutcome parameters after knee arthrodesis.

METHODS

Fifteenpatients with a mean follow-up of 5.9 (range0.8-36) years after unilateral knee arthrodesis were included. A 3D gait analysis was performed and compared to a healthy control group of14patients. Comparative electromyography was performed bilaterally at the rectus femoris, vastuslateralis/medialisand tibialis anterior muscles. The assessment further included standardized outcome scores- Lower Extremity Functional Scale (LEFS) andShort Form Health Survey (SF-36).

RESULTS

The 3D analysis showed a significantly shortened stance phase (p = 0.000), an extended swing phase (p = 0.000), and an increased time per step (p = 0.009) for the operated side compared with thenonoperatedside. There were statistically significant differences in the extent of movement of the hips, knees and ankles among the operated andnonoperatedsides and the control group. For the mean EMG measurement, no significant difference was found between the healthy control group and the patients with arthrodesis.The average LEFSscorewas 27.5 ± 10.6out of a maximum of 80 points,and the mean physical total scale and mean emotional total scale scores for the SF-36 were 27.9 ± 8.5and 52.9 ± 9.9, respectively.

CONCLUSIONS

Arthrodesis of the knee joint causes significant kinematic changes in gait pattern,and patients achieve poor results in subjective and functional outcomes(SF- 36, LEFS).Arthrodesis ensures that the extremities are preserved and can enable walking, but it must be viewed as a severe handicap for the patient.

Improvement of vertebral body fracture reduction utilizing a posterior reduction tool: a single-center experience

BACKGROUND

Extensive research regarding instabilities and prevention of kyphotic malalignment in the thoracolumbar spine exists. Keystones of this treatment are posterior instrumentation and anterior vertebral height restoration. Anterior column reduction via a single-stage procedure seems to be advantageous regarding complication, blood loss, and OR-time. Mechanical elevation of the anterior cortex of the vertebra may prevent the necessity of additional anterior stabilization or vertebral body replacement. The purpose of this study was to examine (1) if increased bony reduction in the anterior vertebral cortex could be achieved by utilization of an additional reduction tool, (2) if postoperative loss of vertebral height could be reduced, and (3) if anterior column reduction is related to clinical outcome.

METHODS

From one level I trauma center, 173 patients underwent posterior stabilization for fractures of the thoracolumbar region between 2015 and 2020. Reduction in the vertebral body was performed via intraoperative lordotic positioning or by utilization of an additional reduction tool (Nforce, Medtronic). The reduction tool was mounted onto the pedicle screws and removed after tightening of the locking screws. To assess bony reduction, the sagittal index (SI) and vertebral kyphosis angle (VKA) were measured on X-rays and CT images at different time points ((1) preoperative, (2) postoperative, (3) ≥ 3 months postoperative). Clinical outcome was assessed utilizing the Ostwestry Disability Index (ODI).

RESULTS

Bisegmental stabilization of AO/OTA type A3/A4 vertebral fractures was performed in 77 patients. Thereof, reduction was performed in 44 patients (females 34%) via intraoperative positioning alone (control group), whereas 33 patients (females 33%) underwent additional reduction utilizing a mechanical reduction tool (instrumentation group). Mean age was 41 ± 13 years in the instrumentation group (IG) and 52 ± 12 years in the control group (CG) (p < 0.001). No differences in terms of gender and comorbidities were found between the two groups. Preoperatively, the sagittal index (SI) was 0.69 in IG compared to 0.74 in CG (p = 0.039), resulting in a vertebral kyphosis angle (VKA) of 15.0° vs. 11.7° (p = 0.004). Intraoperatively, a significantly greater correction of the kyphotic deformity was achieved in the IG (p < 0.001), resulting in a compensation of the initially more severe kyphotic malalignment. The SI was corrected by 0.20-0.88 postoperatively, resulting in an improvement of the VKA by 8.7°-6.3°. In the CG, the SI could be corrected by 0.12-0.86 and the VKA by 5.1°-6.6°. The amount of correction was influenced by the initial deformity (p < 0.001). Postoperatively, both groups showed a loss of correction, resulting in a gain of 0.08 for the SI and 4.1° in IG and 0.03 and 2.0°, respectively. The best results were observed in younger patients with initially severe kyphotic deformity. Considering various influencing factors, clinical outcome determined by the ODI showed no significant differences between both groups.

CONCLUSION

Utilization of the investigated reduction tool during posterior stabilization of vertebral body fractures in a suitable collective of young patients with good bone quality and severe fracture deformity may lead to better reduction in the ventral column of the fractured vertebral body and angle correction. Therefore, additional anterior stabilization or vertebral body replacement may be prevented.

Cage subsidence-A multifactorial matter!

STUDY DESIGN

Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates.

METHODS

This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, t‑scores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch.

RESULTS

Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (p = 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (p = 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal t‑scores (p = 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (p = 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (p < 0.01).

CONCLUSION

Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low t‑scores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.

Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients

(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.

[Resection arthroplasty and arthrodesis in revision shoulder arthroplasty]

Shoulder arthrodesis and resection arthroplasty can be used as salvage procedures to treat severe complications after shoulder prosthesis failure. for both procedures, the indication and patient selection must be very strict. Shoulder arthrodesis after prosthesis failure can be indicated in young patients in case of chronic neuromuscular dysfunction. Filling the bony defect with either autologous or allogenic material and osteosynthetic primary stability are decisive for a good functional outcome. Aftercare comprises immobilization for 12 weeks and physical load is increased thereafter, depending on the sufficiency of bony consolidation. Resection arthroplasty after shoulder prosthesis failure is mostly reserved for multimorbid patients in case of a chronic infection. Thorough debridement and adequate systemic antibiotic treatment are crucial to achieve bacterial eradication.

[New technologies and robotics]

The development of increasingly more complex computer and electromotor technologies enables the increasing use and expansion of robot-assisted systems in trauma surgery rehabilitation; however, the currently available devices are rarely comprehensively applied but are often used within pilot projects and studies. Different technological approaches, such as exoskeletal systems, functional electrical stimulation, soft robotics, neurorobotics and brain-machine interfaces are used and combined to read and process the communication between, e.g., residual musculature or brain waves, to transfer them to the executing device and to enable the desired execution.Currently, the greatest amount of evidence exists for the use of exoskeletal systems with different modes of action in the context of gait and stance rehabilitation in paraplegic patients; however, their use also plays a role in the rehabilitation of fractures close to the hip joint and endoprosthetic care. So-called single joint systems are also being tested in the rehabilitation of functionally impaired extremities, e.g., after knee prosthesis implantation. At this point, however, the current data situation is still too limited to be able to make a clear statement about the use of these technologies in the trauma surgery "core business" of rehabilitation after fractures and other joint injuries.For rehabilitation after limb amputation, in addition to the further development of myoelectric prostheses, the current development of "sentient" prostheses is of great interest. The use of 3D printing also plays a role in the production of individualized devices.Due to the current progress of artificial intelligence in all fields, ground-breaking further developments and widespread application possibilities in the rehabilitation of trauma patients are to be expected.

Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale

BACKGROUND

Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting.

METHODS

70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data.

RESULTS

The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49).

CONCLUSION

The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.

Rehabilitation during early postoperative period following total knee arthroplasty using single-joint hybrid assistive limb as new therapy device: a randomized, controlled clinical pilot study

INTRODUCTION

The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients' range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ.

MATERIALS AND METHODS

Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded.

RESULTS

OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ.

CONCLUSIONS

In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.

Comparative analysis of clinical outcome and quality of life between amputations and combined bone and flap reconstructions at the lower leg

PURPOSE

At the lower leg, soft tissue defects with exposed bones, tendons, or hardware require flap coverage. In this retrospective study, we analyzed combined bone and soft tissue reconstructions compared to amputations of the lower leg in a civilian setting.

MATERIALS AND METHODS

Patients who underwent combined bone and flap reconstruction (LR) or amputation (LA) of the lower leg were eligible for the study. Bone conditions included fractures and bony defects due to posttraumatic osteomyelitis and non-union. Besides the analysis of the medical history, the study included clinical examination including extremity functional scale (LEFS) and SF-36-questionnaire.

RESULTS

LEFS score was significantly higher in the LR group compared to the LA group. Importantly, 42% in the LR group as opposed to 80% in the LA group could not return to their occupation. Mean hospitalization was 119 in the LR and 49 days in the LA group. SF-36 body item scores were significantly higher in the LR group as compared to LA.

CONCLUSIONS

Patients undergoing complex extremity reconstructions, including flap transfer to the lower leg have better functionality and higher quality of life than amputated patients. These data emphasize the advantages of these procedures and justify reconstructive efforts for limb salvage. Level of Evidence III.Implications for RehabilitationAmputation and combined bone and flap reconstruction in severe injuries of the lower leg can imply functional disabilities even after successful treatment.Albeit longer hospitalizations, patients with complex reconstructions showed better functional outcomes and had a higher quality of life.Limb salvage showed better functional outcomes and a higher rate in reintegration to work as compared to limb amputation.These data emphasize the importance of complex bone and soft tissue reconstruction in this patient cohort.

Complication rates following stand-alone lateral interbody fusion: a single institution series after 10 years of experience

PURPOSE

This retrospective single institution study's goal was to analyze and report the complications from stand-alone lateral lumbar interbody fusions (LLIF).

METHODS

This research was approved by the institutional review board (STUDY2021000113). We retrospectively reviewed the database of patients with adult degenerative spine deformity treated via LLIF at our institution between January 2016 and December 2020.

RESULTS

Stand-alone LLIF was performed in 158 patients (145 XLIF, 13 OLIF; mean age 65 y.; 88 f., 70 m.). Mean surgical time was 85 min (± 24 min). Mean follow-up was 14 months (± 5 m). Surgical blood loss averaged 120 mL (± 187 mL) and the mean number of fused levels was 1.2 (± 0.4 levels). Overall complication rate was 19.6% (31 total; 23 approach-related, 8 secondary complications).

CONCLUSION

Lateral interbody fusion appears to be a safe surgical intervention with relatively low complication- and revision rates.

Injuries after Forklift Trucks Accidents - Injury Patterns, Therapy and Outcome in the Context of the Statutory Accident Insurance

INTRODUCTION

The use of forklift trucks during work has a high accident potential. The aim of this study is to describe injury patterns, treatment and outcome after forklift truck accidents in the context of the employers' liability insurance association.

METHODS

Retrospective data collection of all cases between 2004 and 2019. Excluded were patients < 18 years, without follow-up or with definitive external treatment. Trauma mechanism, injury patterns and distribution, treatment, complications, time of incapacity for work, return to work and impairment of earning capacity were recorded.

RESULTS

Of 109 patients with 110 injuries, 52.7% showed isolated injuries and 47.3% combined injuries, which affected the lower extremity in 95 cases. There were fractures in 85.5%, including 32.7% in open form. The mean length of stay was 29.1 days (range 1 - 129); an indication for surgery was seen in 80.9%. Surgical treatment required an average of 3 interventions, with significantly more operations for soft tissue closure than for the fractures (p ≤ 0.023). Amputations were necessary in 8 cases; complications occurred in 29.1%. Return to work was possible in 90%, after a mean period of incapacity for work of 33.6 weeks. A total of 40% showed a pensionable impairment of earning capacity.

CONCLUSION

Accidents with forklift trucks result in complex lower extremities injuries with the need of multi-stage treatment and show relatively high complication rates. A return to work is often possible after a long period of convalescence, and a pensionable impairment of earning capacity often persists.

Iliac Screw Fixation Revisited: Improved Clinical and Radiologic Outcomes Using a Modified Iliac Screw Fixation Technique

STUDY DESIGN

A retrospective study.

OBJECTIVE

To describe the modified iliac screw (mILS) technique and compare it to other spinopelvic fixation techniques in terms of wound healing complications, hardware prominence, and failure.

SUMMARY OF BACKGROUND DATA

The traditional entry point of an iliac screw often causes postoperative gluteal pain from the prominent screw head. The use of an offset connector also adds a point of weakness to the construct. By choosing a different screw entry point offset connectors can be avoided, and the screw head itself is less prominent, thereby reducing postoperative discomfort.

MATERIALS AND METHODS

A retrospective analysis was performed of adult patients undergoing lumbopelvic fixation (LPF) between January 2014 and June 2019. Patients were grouped into 1 of 3 groups based on the technique of pelvic fixation: S2 alar-iliac (S2AI) screw, traditional iliac screw (tILS), and mILS. The primary outcome parameter was the minimal distance from screw head to skin. Secondary outcome parameters were instrumentation loosening/failure, adjacent level fractures, pseudoarthrosis, and medial or lateral iliac screw perforation.

RESULTS

A total of 190 patients undergoing LPF were included in the following 3 groups: mILS group (n=113), tILS group (n=40), and S2AI group (n=37). The mean minimal distance from screw head to skin in the mILS group was 31.3 mm compared with 23.7 mm in the tILS group (P<0.00199). No statistically significant differences were found when comparing the 3 groups with respect to complications. The mILS group did not show any cases of prominent instrumentation and had the lowest rate of instrumentation failure.

CONCLUSIONS

The mILS technique is an acceptable alternative for LPF, offering the benefits of iliac screw fixation while avoiding offset connectors and screw prominence complications associated with tILS.

LEVEL OF EVIDENCE

Level III.

Tibiocalcaneal arthrodesis using the Ilizarov fixator in compromised hosts: an analysis of 19 patients

INTRODUCTION

Salvage of joint destruction of the tibiotalar and subtalar joint with necrosis or infection of the talus in compromised hosts is a challenging problem. In these cases, tibiocalcaneal arthrodesis using the Ilizarov external fixator represents a possible alternative to amputation. This retrospective study presents the results and complications of this salvage procedure.

MATERIALS AND METHODS

Between 2005 and 2015, 19 patients were treated with tibiocalcaneal arthrodesis using the Ilizarov external fixator. Ten patients received tibiocalcaneal arthrodesis due to an acute or chronic infection with joint destruction. The other nine patients presented posttraumatic necrosis of the talus or Charcot arthropathy. In addition to demographic data, the time spent in the fixator, the major and minor complications and the endpoint of the consolidation were evaluated retrospectively. Furthermore, clinical outcomes were measured using the modified American Orthopedic Foot and Ankle Society (AOFAS) score.

RESULTS

The average time spent in the fixator was 22 (range 14-34) weeks. The average follow-up in 17 patients was 116 (range 4-542) weeks. Two patients were lost to follow-up. Complete osseous consolidation was achieved in 14 out of 19 patients. One patient presented partial consolidation, and in four patients, pseudarthrosis could be detected. The mean modified AOFAS score at the final follow-up was 53 out of 86 possible points.

CONCLUSION

Tibiocalcaneal arthrodesis using the Ilizarov fixator is a possible salvage procedure even in compromised hosts. However, the healing rates are below the rates reported in the literature for tibiotalar arthrodesis in comparable clinical situations.

Femoral Neck Osteotomy: A Salvage Procedure for Unstable and Locked Acetabulum Fractures in Selected Frail Patients

INTRODUCTION

Purpose of the study is to present and discuss the femoral neck osteotomy as a salvage procedure for unstable, locked geriatric acetabular fractures in selected frail patients. When disadvantages and possible risks of other treatments exceed the benefits, this method may relieve pain and allow for early wheelchair mobilization in frail patients with limited mobility.

MATERIALS AND METHODS

We report nine patients from 2008 to 2020, which were treated with an osteotomy of the femoral neck for an unstable acetabular fracture. Indications, ASA-Score, Frailty Index, operative procedure, length of hospital stay, complications and outcomes will be discussed.

RESULTS

Patient's age averaged 86 years (range 81-92). Acetabular fractures were classified as six both column fractures, two anterior column posterior hemitransversal fractures and one destruction of the acetabulum by multiple metastases. Fracture dislocation with medialization plus locking of the femoral head and a superomedial dome impaction were present in all patients. All patients were classified as ASA III/ IV and the average value on the CSHA Frailty index was 7 (range 6-7). The operation time averaged 52 min (range 34-62). Immediate wheelchair mobilization in seven out of nine patients was started postoperatively.

CONCLUSION

The osteotomy of the femoral neck may be discussed as a salvage procedure in low functional demanding, multimorbid, frail geriatric patients with unstable acetabular fractures and impairment of mobilisation due to a locked femoral head. The procedure has the advantages of a short operation time and immediate mobilization of the patients. However, this procedure only applies as a salvage solution in selected individual cases.

Incidence, Time Course and Influence on Quality of Life of Intensive Care Unit-Acquired Weakness Symptoms in Long-Term Intensive Care Survivors

PURPOSE

Intensive care unit-acquired weakness (ICUAW) can manifest as muscle weakness or neuropathy-like symptoms, with diagnosis remaining a challenge. Uncertainties surround the long-term cause and sequelae. Therefore, the purpose was to assess incidence, time course and long-term influence on quality of life (QoL) of symptoms in ICU survivors.

METHODS

After ethical approval and registration (www.drks.de: DRKS00011593), in a single-center cohort study all patients admitted to the ICU in 2007-2017 in a German university hospital were screened. Out of 1,860 patients (≥7d ICU care including ventilation support for ≥72 h, at least 6mo-10y after ICU) 636 were deceased, 912 survivors were contacted.

RESULTS

149 former patients (age: 63.5 ± 13.1y; males: 73%; duration in ICU: 20.8 ± 15.7d; duration of ventilation: 16.5 ± 13.7 h; time post-ICU: 4.4 ± 2.7y, 5-10y: 43%) consented to be interviewed concerning occurrence, duration, recovery and consequences of ICUAW-associated muscle weakness or neuropathy-like symptoms after ICU. In 75% at least 1 persistent or previous symmetrical symptom was reported (myopathy-like muscle weakness: 43%; neuropathy-like symptoms: 13%; both: 44%) and rated as incidence of ICUAW. However, only 18% of participants had received an ICUAW diagnosis by their physicians, although 62% had persistent symptoms up to 10y after ICU (5-10y: 46%). Only 37% of participants reported a complete recovery of symptoms, significantly associated with an initially low number of symptoms after ICU (p < 0.0001), myopathy-like symptoms (p = 0.024), and younger age at the time of ICU admission (55.7 ± 13.1 vs. 62.6 ± 10.6y, p < 0.001). ICUAW still impaired the QoL at the time of the interview in 74% of affected survivors, with 30% reporting severe impairment.

CONCLUSION

ICUAW symptoms were disturbingly common in the majority of long-term survivors, indicating that symptoms persist up to 10y and frequently impair QoL. However, only a small number of patients had been diagnosed with ICUAW. Trial registry: Deutsches Register Klinischer Studien (DRKS), https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011593, registration number: DRKS00011593.

Posttraumatic Lymphedema after Open Fractures of the Lower Extremity-A Retrospective Cohort Analysis

Secondary lymphedema is a very common clinical issue with millions of patients suffering from pain, recurrent skin infections, and the constant need for a decongestive therapy. Well-established as a consequence of oncologic procedures, secondary lymphedema is also a well-known phenomenon after trauma. However, precise epidemiological data of lymphedema progress upon severe extremity injuries are still missing. In the present work, we analyzed a patient cohort of 94 individuals who suffered open fractures of the lower extremity and soft tissue injury, of 2nd and 3rd grade according to Tscherne classification, between 2013 and 2019. Typical symptoms of lymphedema have been obtained via interviews and patient medical records in a retrospective cohort analysis. Of all patients, 55% showed symptoms of secondary lymphedema and 14% reported recurrent skin infections, indicating severe lymphedema. Furthermore, comparing patients with and without lymphedema, additional parameters, such as obesity, total number of surgeries, infections, and compartment syndrome, related to lymphedema progress could be identified. According to these data, posttraumatic secondary lymphedema has a highly underestimated clinical prevalence. Further prospective studies are needed to validate this first observation and to identify high-risk groups in order to improve patient’s health care.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

Background

Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures.

Purpose

The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment.

Methods

Over a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively.

Results

Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001).

Conclusion

Bilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

Spinal Cord Injury With Tetraplegia in Young Persons After Diving Into Shallow Water: What Has Changed in the Past 10 to 15 Years?

STUDY DESIGN

Retrospective, monocentric, observational study in a tertiary health care center.

OBJECTIVES

To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water.

METHODS

Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences.

RESULTS

A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge (P ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients (P ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications.

CONCLUSIONS

People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.

Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm : a prospective study

Aims

Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI.

Methods

From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined.

Results

Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures).

Conclusion

Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results.

Cite this article: Bone Jt Open 2021;2(8):671–678.

Fixation Strength of Modified Iliac Screw Trajectory Compared to Traditional Iliac and S2 Alar-Iliac Trajectories: A Cadaveric Study

OBJECTIVE

Traditional iliac (TI) screws require extensive dissection, involve offset-connectors, and have prominent screw heads that may cause patient discomfort. S2 alar-iliac (S2AI) screws require less dissection, do not need offset connectors, and are less prominent. However, the biomechanical consequences of S2AI screws crossing the alar-iliac joint is unknown. The present study investigates the fixation strength of a modified iliac (MI) screw, which has a more medial entry point and reduced screw prominence, but does not cross the alar-iliac joint.

METHODS

Eighteen sacropelvic spines were divided into 3 groups (n = 6): TI, S2AI, and MI. Each specimen was fixed unilaterally with S1 pedicle screws and pelvic fixation according to its group. Screws were loaded at ±10 Nm at 3Hz for 1000 cycles. Motion of each screw and rod strain above and below the S1 screw was measured.

RESULTS

Toggle of the S1 screw was lowest for the TI group, followed by the MI and S2AI groups, but there were no significant differences (P = 0.421). Toggle of the iliac screw relative to the pelvis was also lowest for the TI group, followed by the MI group, and was greatest for the S2AI group, without significant differences (P = 0.179). Rod strain was similar across all groups.

CONCLUSIONS

No statistically significant differences were found between the TI, S2AI, and MI techniques with regard to screw toggle or rod strain. Advantages of the MI screw include its lower profile and a medialized starting point eliminating the need for offset-connectors.

Hierarchical Ceramic Coating Reduces Adherence of Cells, Blood, Bacteria, and Tissue on Titanium Microsurgical Instruments

BACKGROUND

 Progress in the field of microsurgery allows more detailed reconstructions of the smallest tissue structures. The applied instruments are left with biological residues after coming into contact with body fluids or tissue, leading to compromised surgical precision. Designing of residue-free innovative instruments would reduce the necessity of subsidiary practices and would improve the surgical precision.

METHODS

 We designed a ceramic coating (Lotus ceramic coating system 26-LCC-26) that exhibits self-cleaning surface properties on coated titanium specimens. A titanium surface was modified by blasting technology and electropolishing, followed by applying a high-performance ceramic and sol-gel finish layer. The physical surface characterization was performed by scanning electron microscopy and measuring the contact angle. The cell-repellent properties and cytotoxicity were investigated using live-dead staining, BrdU, and lactate dehydrogenase assay. Furthermore, bacterial and fluid-adhesion tests were performed. Finally, blood compatibility was analyzed according to DIN ISO 10993.

RESULTS

 The composite system LCC-26 increased the hydrophobic character of the titanium surface (the water contact angle of 74.9 degrees was compared with 62.7 degrees of the uncoated native titanium; p < 0.01) and led to the fluid and cell-repellent properties shown by the reduction in fibroblast adherence by ∼50.7% (p < 0.05), the reduction in Staphylococcus aureus pathogen colonization by 74.1% (p < 0.001), and the decrease in erythrocyte adherence by 62.9% (p < 0.01). Furthermore, the LCC-26 coated titanium microforceps dipped in human whole blood exhibited blood-repellent character (reduction in blood adherence by 46.1%; p < 0.05). Additionally, cyto- and hemocompatibility was guaranteed in direct and indirect tests.

CONCLUSION

 Titanium surface modification on surgical instruments exhibits cell, bacteria, and blood-repellent properties with a full guarantee of cyto- and hemocompatibility. Thus, innovatively coated instruments could contribute to increased precision during microsurgical interventions and optimized medical operation routines in the future.

Distinct Behavior of Traumatic versus Nontraumatic Intracerebral Hematomas: Different Biology or Impact of Age?

BACKGROUND AND STUDY AIMS

 Patients with large intracerebral hematomas (ICH) may demonstrate different demographics and underlying brain and systemic diseases, as well as different radiologic courses and distinct outcomes. It remains unclear whether their different behavior attributes to a different biology of the ICH or to the asymmetric characteristics of the two populations. To analyze and adjust for potential sources of selection and treatment bias, our study compared age-matched patients with traumatic and nontraumatic ICH in a single cohort diagnosed and treated in the same surgical department.

MATERIAL AND METHODS

 We analyzed 135 consecutive patients with traumatic (n = 90) or spontaneous ICH (n = 45) undergoing treatment at a surgical intensive care unit of an urban university hospital. We documented their differences before and after adjustment for age in terms of demographics, the therapies applied, their radiologic (i.e., volume and rate of ICH expansion [HE]) and clinical (patients' outcome at 30 days) course, the length of hospital and ICU stay, as well as the hospital costs.

RESULTS

 Patients with traumatic ICH demonstrated more favorable clinical and radiologic characteristics at admission, that is, higher Glasgow Coma Scale score (p < 0.001), less frequently dilated pupil (p = 0.028), lower Charlson Comorbidity Index (p < 0.001), smaller ICH volume (p < 0.001), noneloquent (p < 0.001) or nonintraventricular (p = 0.003) ICH locations, as well as underwent fewer neurosurgical interventions (p < 0.001) and showed a better outcome (p = 0.041), defined as Glasgow Outcome Scale 4 and 5. After adjustment for age, no different outcomes were observed. Of note, elderly patients on novel oral anticoagulants (NOACs) were more likely to develop an HE compared with those on vitamin K antagonists (VKAs, p = 0.05) after traumatic brain injury (TBI) but not after spontaneous ICH.

CONCLUSION

 Our data reveal a significant heterogeneity within the traumatic series. Whereas younger patients show an excellent outcome, the elderly population of the traumatic cases demonstrates a poor outcome similar to that of the nontraumatic cohort. HE under NOACs rather than under VKAs is more likely in the elderly after TBI. Larger prospective trials are warranted to elucidate the potential individual underlying molecular mechanisms for the development of an ICH and HE in these diseases.

Sonication in the diagnosis of fracture-related infections (FRI)-a retrospective study on 230 retrieved implants

BACKGROUND

In fracture-related infections (FRI), both the diagnosis of the infection and the identification of the causative pathogen are crucial to optimize treatment outcomes. Sonication has been successfully used for periprosthetic joint infections (PJI); however, its role in FRI remains unknown. Our aim was to determine the diagnostic accuracy (sensitivity, specificity) of sonicate fluid culture (SFC). The primary objective was to compare SFC with peri-implant tissue culture (PTC) overall and among subgroups using the consensus definition by Metsemakers et al. The secondary objective was to determine the yield of SFC in possible fracture-related infections (PFRI).

METHODS

From March 2017 to May 2019, 230 cases of retrieved implants were retrospectively reviewed. To perform sonication, explants were placed in sterile polypropylene jars intraoperatively. After treatment in an ultrasonic bath (Bandelin, Berlin, Germany), sonicate fluid was incubated into blood culture bottles, and conventional culturing was eventually performed. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples while Fisher's exact test was used for comparison between categorical variables.

RESULTS

Of the 230 cases, 107 were identified as FRI, whereas 123 were aseptic revision cases (ARC). Of the latter, 105 were labeled as PFRI. Sensitivity of SFC was higher in comparison with PTC, although this did not reach statistical significance (90.7% vs. 84.1%; p = .065). The specificity of SFC was significantly lower than that of PTC (73.2% vs. 88.6%; p = .003). In PFRI, SFC yielded significantly more positive results than PTC (33/105 vs. 14/105; p = .003). Overall, 142 pathogens were identified by SFC, whereas 131 pathogens were found by PTC.

CONCLUSIONS

We found that sonication of fracture fixation devices may be a useful adjunct in FRI, especially in "low-grade" infections lacking confirmatory clinical criteria. Standardized diagnostic protocols are warranted in order to further optimize the diagnostic accuracy.

Accuracy of radiographic measurement techniques for the Taylor spatial frame mounting parameters

Aim

The correction accuracy of the Taylor Spatial Frame (TSF) fixator depends considerably on the precise determination of the mounting parameters (MP). Incorrect parameters result in secondary deformities that require subsequent corrections. Different techniques have been described to improve the precision of MP measurement, although exact calculation is reportedly impossible radiologically. The aim of this study was to investigate the accuracy of intraoperative and postoperative radiographic measurement methods compared to direct MP measurement from TSF bone mounting.

Methods

A tibial Sawbone® model was established with different origins and reference ring positions. First, reference MPs for each origin were measured directly on the frame and bone using a calibrated, digital vernier calliper. In total 150 MPs measured with three different radiographic measurement techniques were compared to the reference MPs: digital radiographic measurements were performed using soft-copy PACS images without (method A) and with (method B) calibration and calibrated image intensifier images (method C).

Results

MPs measured from a non-calibrated X-ray image (method A) showed the highest variance compared to the reference MPs. A greater distance between the origin and the reference ring corresponded to less accurate MP measurements with method A. However, the MPs measured from calibrated X-ray images (method B) and calibrated image intensifier images (method C) were intercomparable (p = 0.226) and showed only minor differences compared to the reference values but significant differences to method A (p < 0,001).

Conclusion

The results demonstrate that MPs can be accurately measured with radiographic techniques when using calibration markers and a software calibration tool, thus minimizing the source of error and improving the quality of correction.

Navigated iliac screw placement may reduce radiation and OR time in lumbopelvic fixation of unstable complex sacral fractures

Purpose

Instability of the posterior pelvic ring may be stabilized by lumbopelvic fixation. The optimal osseous corridor for iliac screw placement from the posterior superior iliac spine to the anterior inferior iliac spine requires multiple ap- and lateral-views with additional obturator-outlet and -inlet views.

The purpose of this study was to determine if navigated iliac screw placement for lumbopelvic fixation influences surgical time, fluoroscopy time, radiation exposure, and complication rates.

Methods

Bilateral lumbopelvic fixation was performed in 63 patients. Implants were inserted as previously described by Schildhauer. A passive optoelectronic navigation system with surface matching on L4 was utilized for navigated iliac screw placement. To compare groups, demographics were assessed. Operative time, fluoroscopic time, and radiation were delineated.

Results

Conventional fluoroscopic imaging for lumbopelvic fixation was performed in 32 patients and 31 patients underwent the procedure with navigated iliac screw placement. No differences were found between the groups regarding demographics, comorbidities, or additional surgical procedures.

Utilization of navigation led to fluoroscopy time reduction of more than 50% (3.2 vs. 8.6 min.; p < 0.001) resulting in reduced radiation (2004.5 vs. 5130.8 Gy*cm²; p < 0.001). Operative time was reduced in the navigation group (176.7 vs. 227.4 min; p = 0.002) despite the necessity of additional surface referencing.

Conclusion

For iliac screws, identifying the correct entry point and angle of implantation requires detailed anatomic knowledge and multiple radiographic views. In our study, additional navigation reduced operative time and fluoroscopy time resulting in a significant reduction of radiation exposure for patients and OR personnel.

Facing multidrug-resistant pathogens in periprosthetic joint infections with self-administered outpatient parenteral antimicrobial therapy-A prospective cohort study

A key factor in the successful management of periprosthetic joint infection (PJI) besides the surgical regime is a consistent antimicrobial therapy. Recently, oral versus intravenous (IV) antibiotics for bone and joint infection trial demonstrated the noninferiority of oral antimicrobial therapy compared to IV, implying that an early transition to oral administration is reasonable. It is likely that the international consensus meeting of musculoskeletal Infections and the European Bone and Joint Infection Society will consider these findings. However, rising levels of antimicrobial resistance are challenging and recommendations for dealing with multidrug-resistant (MDR) pathogens resistant to oral antibiotics are lacking. This study focuses on establishing guidance towards their management in PJI. From December 2015 to June 2019, patients with MDR pathogens were included in a single-center prospective cohort study and treated with self-administered outpatient parenteral antimicrobial therapy (S-OPAT) based on a two-stage revision strategy. Demographics, pathogens, antimicrobial agents, and outcomes were recorded. A total of 1738 outpatient days in 26 patients were analyzed. The incidence of pathogens resistant to oral antibiotics in PJI was 4%, most frequently encountered were staphylococcus epidermidis. The Kaplan-Meier-estimated infection-free survival after 3 years was 90% (95% confidence interval, 84.6%-95.5%). We recorded adverse events in 6 of 54 (11%) S-OPAT episodes (3.45/1000 S-OPAT days). (i) S-OPAT in two-stage revision arthroplasty to counter increasing numbers of MDR pathogens resistant to oral agents can achieve a high infection eradication rate and (ii) should therefore be taken into account at the next society's consensus treatment updates.

Survival among patients with severe high cervical spine injuries - a TraumaRegister DGU® database study

BACKGROUND

Trauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group.

METHODS

In a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group.

RESULTS

Six hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%.

CONCLUSIONS

An AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection

A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis, the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B-loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At the 3-year follow-up, successful infection eradication as measured by the Delphi-based consensus definition was achieved with a range of motion of 0°-100°.

The use of exoskeletons in the occupational context for primary, secondary, and tertiary prevention of work-related musculoskeletal complaints

OCCUPATIONAL APPLICATIONS This guideline includes 20 recommendations and four key statements that achieved consensus or strong consensus regarding the application of exoskeletons in the workplace for the prevention of musculoskeletal complaints and diseases, the general use and implementation of exoskeletons, and recommendations for risk assessment. The guideline is intended for company physicians, occupational physicians, ergonomists, occupational safety specialists, and employers, and serves as information for all other actors in practical occupational safety. Due to the lack of evidence from the scientific literature, the recommendations and key statements are the result of expert discussions that were conducted at a consensus conference in accordance with the Regulations of the Association of the Scientific Medical Societies in Germany, moderated by an external consultant.

Osteology of the ilium revised: illuminating the clinical relevance

BACKGROUND

Several studies on anterior and posterior pelvic ring fixation have identified a fragile monocortical area located at the iliac wing. However, there are no current studies regarding this structure's dimensions and relation to known anatomic structures.

METHODS

Eleven human ilia were dissected from 6 specimens. After debulking soft tissue, photoluminescence was used to indicate the fragile area. The size and thickness of the iliac wing were determined and mapped in relation to the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS).

RESULTS

This photoluminescent unicortical area measured 15.57 cm² with a mean minimal thickness of 1.37 mm at its thinnest part. Its average diameter was 41.15 mm horizontally and 37.45 mm vertically. In all cases, it was located at the middle third of the ilium with a mean distance of 64.58 mm to the AIIS and 62.73 mm to the PSIS. Trajectory angulation above 4.5° from the PSIS lead to violation of this area.

CONCLUSION

This study provides useful anatomical information regarding a thin unicortical area at the iliac wing that is relevant to anterior and posterior pelvic ring fixation and the potential complications that can arise from iatrogenic perforation of this area.

The iliac pillar - Definition of an osseous fixation pathway for internal and external fixation

BACKGROUND

Increasing numbers of unstable pelvic ring fractures, due to the ongoing demographic change and improvements in the rescue of high-energy traumatic events, are challenging trauma and orthopedic surgeons. While initial installation of an external fixation device is often necessary, placement of iliac crest pins can be difficult due to the complex osteology of the ilium.

HYPOTHESIS

We aim to analyze (1) the length, localization and angulation of the iliac pillar and (2) to define the dimensions of the surgical corridor for a better understanding of pin entry point and trajectory, thus preventing shortcomings in anterior external fixation of pelvic ring injuries.

METHODS

Twenty hemipelvises from 10 fresh-frozen cadaveric torsos (3 female, 7 males; mean age 80.2 years) were harvested. The following measurements were taken with digital calipers: Location of the iliac pillar in relation to the anterior superior iliac spine and to the acetabulum roof, mean length and diameter of the iliac pillar, maximum diameter of the iliac pillar. In addition we measured the width of the different bone layers.

RESULTS

The mean length of the hourglass shaped iliac pillar was 107.04mm with a mean width of 17.0mm (min. 15.1; max. 19.2). The mean distance to the anterior superior iliac spine was 69.00mm (min. 64.8; max. 73.4). The mean maximum width of the iliac pillar was 12.16mm (min. 9.4; max. 13.8). Caudally the line describing the iliac pillar intercepts the cranial acetabular rim at 12 o'clock. The smallest mean diameter of the cancellous bone was 7.5mm±2.0.

CONCLUSION

The iliac pillar is part of the complex osteology of the human pelvis. A cohesive description of its location and dimensions has been lacking. Successful treatment of pelvic fracture depends on an optimal preoperative planning, accurate overall reduction, and stable fixation. We described the origin and angulation to provide a good bone stock for external fixation pin and the width of the different bone layers. This study therefore contributes by facilitating a thorough understanding of pelvic osteology and describing the location and dimensions of an optimal osseous pathway.

LEVEL OF EVIDENCE

Anatomical descriptive study.

Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI).

METHODS

Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification.

RESULTS

A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference (P = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%).

CONCLUSIONS

Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.

Major trauma due to suicide attempt: increased workload but not mortality

INTRODUCTION

Suicide attempt is a common cause for major trauma. Due to the underlying psychiatric disease, patients` compliance or even prognosis may be reduced. Modalities of discharge after surgical acute care might differ.

METHODS

Retrospective study including trauma patients of two urban level 1 trauma centers between 2013 and 2017. Data originally collected for quality management using the German trauma registry were supplemented after review of medical charts with details on psychiatric disease and discharge modalities.

RESULTS

We included 2118 consecutive patients of which 108 (5%) attempted suicide. Most common psychiatric diagnosis were depression (38%) and schizophrenia (25.9%). Comparing patients after suicide attempt with others, suicide attempt was associated with a younger age (42.3 vs. 49.0 years), a higher injury severity (mean ISS 24.7 vs. 16.8) and consecutively, a higher expected mortality (risk-adjusted prognosis for mortality 18.0 vs. 8.1%), while observed mortality was lower than expected in both groups (16.7 vs. 6.4%). Survivors after suicide attempt had a longer stay on ICU (mean days on ICU 17 vs. 7). 56% were transferred to psychiatric facilities and only 4% could be discharged home after acute surgical care.

CONCLUSION

Incidence of suicide attempts among major trauma patients is high. Mean injury severity is higher than in unintended trauma and associated with a prolonged stay on intensive care unit even after adjustment for injury severity and age. Risk-adjusted mortality is not increased. Proportion of patients discharged home or to out-patient rehabilitation is very low. Specialized institutions who offer both, musculoskeletal rehabilitation and psychiatric care are required for rehabilitative treatment after the acute surgical care.