Incidence and severity of electric scooter related injuries after introduction of an urban rental programme in Vienna: a retrospective multicentre study

PURPOSE

Electric scooters (e-scooters) are an emerging way of mobility in cities around the world. Despite quickly rising numbers of e-scooters, limited studies report on incidence and severity of e-scooter-associated injuries. The aim of our study was to report on these injuries and identify potential protective measures to ultimately decrease e-scooter-associated morbidity.

METHODS

We performed a retrospective multicentre study including all patients, who were admitted to three major trauma departments in Vienna from May 2018 to September 2019. We analysed patients' data, including demographics, injury pattern, types of injury and subsequent treatment.

RESULTS

A total number of 175 patients (115 males, 60 females) sustained e-scooter-associated injuries. Patients' mean age was 34.4 years [4-74]. While the mean Injury Severity Score (ISS) was 3.4, 11 patients presented with an ISS ≥ 9 and 2 patients with an ISS ≥ 16. ISS increased with age. Older patients (≥ 40 years) presented a significantly higher ISS than younger patients (< 40 years) (P = 0.011). Seventy-one patients (40.6%) sustained major injuries affecting head (35.2%) and upper extremities (36.6%). Twenty-three patients (13.1%) required surgery leading to hospitalization of 11 days on average [1-115]. E-scooter-associated injuries increased during late afternoon plateauing at 8.00 pm. However, the largest share of patients (39.2%) sustained their injuries during early night (8.00 pm to 1.59 am) with especially young adults (19-39 years) being at risk.

CONCLUSION

The popularity of rideshare e-scooters across cities worldwide seems to be on the rise, so are e-scooter-associated injuries. These injuries should be considered high-energy trauma affecting primarily head and upper extremity; indeed, 17.7% sustained major head injuries. Therefore, the mandatory use of a helmet seems to be adequate to decrease head injury-associated morbidity. Ultimately, given the remarkably high rates of nighttime injuries, an e-scooter ban during night could further cut injury numbers in half.

Combined APRI/ALBI score to predict mortality after hepatic resection

Background

Aspartate aminotransferase/platelet ratio index (APRI) and albumin–bilirubin grade (ALBI) are validated prognostic indices implicated as predictors of postoperative liver dysfunction after hepatic resection. The aim of this study was to evaluate the relevance of the combined APRI/ALBI score for postoperative clinically meaningful outcomes.

Methods

Patients undergoing hepatectomy were included from the American College of Surgeons National Surgical Quality Improvement Program database. The association between APRI/ALBI score and postoperative grade C liver dysfunction, liver dysfunction-associated and overall 30-day mortality was assessed.

Results

A total of 12 055 patients undergoing hepatic resection from 2014 to 2017 with preoperative blood values and detailed 30-day postoperative outcomes were included (exploration cohort: January 2014 to December 2016; validation cohort: 2017). In the exploration cohort (8538 patients), the combination of both scores (APRI/ALBI) was significantly associated with postoperative grade C liver dysfunction, 30-day mortality, and liver dysfunction-associated 30-day mortality, and was superior to either score alone. The association with postoperative 30-day mortality was confirmed in multivariable analysis. A predictive model was generated using the exploration cohort. The predicted incidence of events closely followed the observed incidence in the validation cohort (3517 patients). Subgroup analyses of tumour types were used to generate disease-specific risk models to assess risk in different clinical scenarios. These findings informed development of a smartphone application (https://tellaprialbi.37binary.com).

Conclusion

The predictive potential of the combined APRI/ALBI score for clinically relevant outcomes such as mortality was demonstrated. An evidence-based smartphone application will allow clinical translation and facilitation of risk assessment before hepatic resection using routine laboratory parameters.

Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score

INTRODUCTION

Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb.

MATERIAL AND METHODS

A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014.

RESULTS

Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7.

DISCUSSION

It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs.

LEVEL OF EVIDENCE

IV: retrospective or historical series.

The impact of nonosteogenic factors on the expression of osteoprotegerin and RANKL during human fracture healing

Objectives

The osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-B ligand (RANKL) balance is of the utmost importance in fracture healing. The aim of this study was therefore to investigate the impact of nonosteogenic factors on OPG and RANKL levels.

Methods

Serum obtained from 51 patients with long bone fractures was collected over 48 weeks. The OPG and serum sRANKL (soluble RANKL) concentrations were measured using enzyme-linked immunosorbent assay (ELISA). Smoking habit, diabetes, and alcohol consumption were recorded.

Results

Age and sex greatly influenced preoperative serum levels of OPG and sRANKL but differences were even more pronounced during fracture healing. Statistical significance was observed for overall serum levels of OPG (p = 0.001) and sRANKL (p < 0.001) in older men and women (age greater than 50 years). Interestingly, OPG levels increased over time in older women but decreased over time in older men.

Conclusion

These data suggest that nonosteogenic factors, most significantly age and sex, have a major impact on sRANKL and OPG levels. Given the established association of OPG and sRANKL levels and nonunion, these findings seem to be of clinical relevance.

Cite this article: J. Starlinger, G. Kaiser, A. Thomas, K. Sarahrudi. The impact of nonosteogenic factors on the expression of osteoprotegerin and RANKL during human fracture healing. Bone Joint Res 2019;8:349–356. DOI: 10.1302/2046-3758.87.BJR-2018-0116.R3.

Deep Learning Estimation of Median Nerve Volume Using Ultrasound Imaging in a Human Cadaver Model

Median nerve swelling is one of the features of carpal tunnel syndrome (CTS), and ultrasound measurement of maximum median nerve cross-sectional area is commonly used to diagnose CTS. We hypothesized that volume might be a more sensitive measure than cross-sectional area for CTS diagnosis. We therefore assessed the accuracy and reliability of 3-D volume measurements of the median nerve in human cadavers, comparing direct measurements with ultrasound images interpreted using deep learning algorithms. Ultrasound images of a 10-cm segment of the median nerve were used to train the U-Net model, which achieved an average volume similarity of 0.89 and area under the curve of 0.90 from the threefold cross-validation. Correlation coefficients were calculated using the areas measured by each method. The intraclass correlation coefficient was 0.86. Pearson's correlation coefficient R between the estimated volume from the manually measured cross-sectional area and the estimated volume of deep learning was 0.85. In this study using deep learning to segment the median nerve longitudinally, estimated volume had high reliability. We plan to assess its clinical usefulness in future clinical studies. The volume of the median nerve may provide useful additional information on disease severity, beyond maximum cross-sectional area.

Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility

OBJECTIVES

The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity.

METHODS

A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion.

RESULTS

For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline.

CONCLUSIONS

This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.

Carpal tunnel syndrome treatment and the subsequent alterations in tendon and connective tissue dynamics

BACKGROUND

Carpal tunnel syndrome patients demonstrate diminished motion of the median nerve and fibrotic changes in the subsynovial connective tissue within the carpal tunnel. Currently, there are few prognostic factors to help predict the outcome of commonly performed treatments including surgical carpal tunnel release and corticosteroid injections. This study aimed to non-invasively assess the changes in the dynamic response of the subsynovial tissue relative to tendon motion after the intervention and to correlate this with disease severity.

METHODS

A total of 145 patients with carpal tunnel syndrome were recruited into this study. Clinical and demographic data, electrophysiological severity and dynamic ultrasound images were collected before and after treatment, either by injection or surgery. The relative motion of the subsynovial tissue with the underlying middle finger flexor digitorum superficialis tendon was measured using a speckle tracking algorithm and was expressed as a shear index (SI). Baseline and follow-up data, the association between change in SI and severity, and the role of treatment modality were analyzed and statistically compared.

FINDINGS

Overall, there was a significant increase (more relative motion) after treatment in the mean shear index from 79.9% (±15.4% SD) to 82.9% (±14.8% SD) (p = 0.03). Secondary analyses showed that this change was mostly present in those with mild disease severity undergoing surgery (p = 0.01).

INTERPRETATION

This study shows that the relative subsynovial tissue movement increases in patients after intervention. The present study lays a foundation for future studies to non-invasively assess the role of carpal tunnel dynamics in response to treatment.

Surgical glove perforation during intramedullary nailing of intertrochanteric fractures

Intramedullary nail fixation is a routine procedure for treatment of intertrochanteric fractures. Aseptic technique is vital for reducing postoperative complications, as intraoperative glove perforations increase the risk of surgical site infections. The aim of this study was to determine the incidence of surgical glove perforation during intramedullary nailing of intertrochanteric fractures and to identify surgery-specific steps at risk. A prospective series of 148 short intramedullary nail implantations was analysed. Intraoperative glove perforations and causative events were recorded. All gloves from the scrubbed surgical team were collected and examined for micro- and macroperforations. 1771 gloves were tested. A total of 341 perforations in 309 gloves were detected, resulting in an overall glove perforation rate of 17%. Surgeon experience had no influence on the overall incidence of glove perforations. Usage of the awl and insertion of the proximal locking screw resulted in 33.9% of all detected glove perforations. Perforation rate significantly increased with operative time (p = 0.003). Regular glove changing after surgery-specific risk-steps and during longer surgeries could decrease the rate of glove perforations during intramedullary nailing of intertrochanteric fractures and reduce the risk of potential septic contamination or even disease transmission for both, the surgeon, and the patient.

Risk of de novo severe carpal tunnel syndrome after bilateral oophorectomy: a population-based cohort study

OBJECTIVE

The incidence of carpal tunnel syndrome (CTS) is higher in women, and peaks around the age of menopause. Therefore, we investigated whether bilateral oophorectomy is associated with an increased risk of severe CTS.

METHODS

We included all of the 1,653 premenopausal women who underwent bilateral oophorectomy for a nonmalignant indication between 1988 and 2007, and a random sample of 1,653 age-matched referent women who did not undergo bilateral oophorectomy in Olmsted County, MN. Diagnoses of CTS assigned to women over their entire lifetime were identified in these two cohorts. The risk of de novo severe CTS after bilateral oophorectomy (or index date) was evaluated using Cox proportional hazards models adjusted for potential confounders.

RESULTS

Bilateral oophorectomy was associated with an increased risk of severe CTS (adjusted hazard ratio 1.65, 95% confidence interval 1.20-2.25). The risk was suggestively greater in women with lower body mass index, nulliparity, and with a benign ovarian indication for oophorectomy (nonsignificant interactions). We did not observe a protective effect of estrogen therapy after the oophorectomy. The findings were similar in secondary analyses considering the incidence of CTS of any severity or idiopathic CTS.

CONCLUSIONS

The risk of severe CTS, common in perimenopausal women, is increased after bilateral oophorectomy. The association may be causal or due to confounding. Therefore, the precise biological mechanisms explaining the association and the absence of a mitigating effect of estrogen therapy should be further investigated.

Close negative correlation of local and circulating Dickkopf-1 and Sclerostin levels during human fracture healing

Wnt signaling is critically involved in fracture healing. Existing data predominantly relies on rodent models. Here, we explored local and circulating Dickkopf-1 (DKK1) levels in patients with respect to fracture healing and explore its association to sclerostin (SOST). 69 patients after surgical stabilization of long bone fractures of which six patients had impaired fracture healing were included in this study. Life-style and patient related factors with a known effect on DKK1 and SOST were recorded. DKK1 and SOST concentrations were measured using enzyme-linked immunosorbent assay (ELISA) at the fracture site and in circulation. DKK1 and SOST showed a close inverse correlation. In fracture hematoma and immediately after trauma DKK1 levels were significantly reduced while SOST levels were significantly increased, compared to healthy control. Postoperatively, DKK1 peaked at week 2 and SOST at week 8, again demonstrating a close negative correlation. Age and smoking status affected the balance of DKK1 and SOST, while type 2 diabetes and sex did not demonstrate a significant influence. Early postoperative elevation of SOST without compensatory DKK1 decrease was associated with fracture non-union in younger patients (< 50a). The close inverse correlation and very rapid dynamics of DKK1 and SOST locally as well as systemically suggest their critical involvement during human fracture healing. Importantly, as immediate compensatory feedback mechanism are apparent, we provide evidence that dual-blockade of DKK1 and SOST could be critical to allow for therapeutic efficiency of Wnt targeted therapies for fracture healing.

Bisegmental posterior stabilisation of thoracolumbar fractures with polyaxial pedicle screws: Does additional balloon kyphoplasty retain vertebral height?

We retrospectively evaluated single-level compression fractures (T12-L3) scheduled for a short-segment POS (posterior-only stabilization) using polyaxial screws. Patients averaged 55.7 years (range, 19–65). Patients received either POS or, concomitantly, BK (balloon kyphoplasty) of the fractured vertebrae as well. Primary endpoint was the radiological outcome at the last radiographic follow-up prior to implant removal. POS together with BK of the fractured vertebrae resulted in a significant improvement of the local kyphosis angle and vertebral body compression rates immediately post-OP. During the further course of FU, a considerable loss of correction was observed post-OP in both groups. (Local KA: pre-OP/ post-OP/ FU: 12.6±4.8/ 3.35±4.8/ 11.6±6.0; anterior vertebral body compression%: pre-OP/post-OP/ FU: 71.94±12.3/ 94.78±19.95/ 78.17±14.74). VAS was significantly improved from 7.2±1.3 pre-OP to 2.7±1.3 (P<0.001) at FU. We found a significant restoration of the vertebral body height by BK. Nevertheless, follow-up revealed a noticeable loss of reduction. Given the fact that BK used together with polyaxial screws did not maintain intra-operative reduction, our data do not support this additional maneuver when used together with bi-segmental polyaxial pedicle screw fixation.