Time trajectories and within-subject correlations of matrix metalloproteinases 3, 8, 9, 10, 12, and 13 serum levels and their ability to predict mortality in polytraumatized patients: a pilot study

BACKGROUND

Managing polytrauma victims poses a significant challenge to clinicians since applying the same therapy to patients with similar injury patterns may result in different outcomes. Using serum biomarkers hopefully allows for treating each multiple injured in the best possible individual way. Since matrix metalloproteinases (MMPs) play pivotal roles in various physiological processes, they might be a reliable tool in polytrauma care.

METHODS

We evaluated 24 blunt polytrauma survivors and 12 fatalities (mean age, 44.2 years, mean ISS, 45) who were directly admitted to our Level I trauma center and stayed at the intensive care unit for at least one night. We determined their MMP3, MMP8, MMP9, MMP10, MMP12, and MMP13 serum levels at admission (day 0) and on days 1, 3, 5, 7, and 10.

RESULTS

Median MMP8, MMP9, and MMP12 levels immediately rose after the polytrauma occurred; however, they significantly decreased from admission to day 1 and significantly increased from day 1 to day 10, showing similar time trajectories and (very) strong correlations between each two of the three enzyme levels assessed at the same measurement point. For a two-day lag, autocorrelations were significant for MMP8 (- 0.512) and MMP9 (- 0.302) and for cross-correlations between MMP8 and MMP9 (- 0.439), MMP8 and MMP12 (- 0.416), and MMP9 and MMP12 (- 0.307). Moreover, median MMP3, MMP10, and MMP13 levels significantly increased from admission to day 3 and significantly decreased from day 3 to day 10, showing similar time trajectories and an (almost) strong association between every 2 levels until day 7. Significant cross-correlations were detected between MMP3 and MMP10 (0.414) and MMP13 and MMP10 (0.362). Finally, the MMP10 day 0 level was identified as a predictor for in-hospital mortality. Any increase of the MMP10 level by 200 pg/mL decreased the odds of dying by 28.5%.

CONCLUSIONS

The time trajectories of the highly varying individual MMP levels elucidate the involvement of these enzymes in the endogenous defense response following polytrauma. Similar time courses of MMP levels might indicate similar injury causes, whereas lead-lag effects reveal causative relations between several enzyme pairs. Finally, MMP10 abundantly released into circulation after polytrauma might have a protective effect against dying.

Serum levels of matrix metalloproteinases 1, 2, and 7, and their tissue inhibitors 1, 2, 3, and 4 in polytraumatized patients: Time trajectories, correlations, and their ability to predict mortality

There has been limited research on assessing metalloproteinases (MMPs) 1, 2, and 7, as well as their tissue inhibitors (TIMPs) 1, 2, 3, and 4 in the context of polytrauma. These proteins play crucial roles in various physiological and pathological processes and could be a reliable tool in polytrauma care. We aimed to determine their clinical relevance. We assessed 24 blunt polytrauma survivors and 12 fatalities (mean age, 44.2 years, mean ISS, 45) who were directly admitted to our Level I trauma center and spent at least one night in the intensive care unit. We measured serum levels of the selected proteins on admission (day 0) and days 1, 3, 5, 7, and 10. The serum levels of the seven proteins varied considerably among individuals, resulting in similar median trend curves for TIMP1 and TIMP4 and for MMP1, MMP2, TIMP2, and TIMP3. We also found a significant interrelationship between the MMP2, TIMP2, and TIMP3 levels at the same measurement points. Furthermore, we calculated significant cross-correlations between MMP7 and MMP1, TIMP1 and MMP7, TIMP3 and MMP1, TIMP3 and MMP2, and TIMP4 and TIMP3 and an almost significant correlation between MMP7 and TIMP1 for a two-day-lag. The autocorrelation coefficient reached statistical significance for MMP1 and TIMP3. Finally, lower TIMP1 serum levels were associated with in-hospital mortality upon admission. The causal effects and interrelationships between selected proteins might provide new insights into the interactions of MMPs and TIMPs. Identifying the underlying causes might help develop personalized therapies for patients with multiple injuries. Administering recombinant TIMP1 or increasing endogenous production could improve outcomes for those with multiple injuries. However, before justifying further investigations into basic research and clinical relevance, our findings must be validated in a multicenter study using independent cohorts to account for clinical and biological variability.

The optimal window for reconstruction of the anterior cruciate ligament (ACL) with respect to quadriceps atrophies lies within 21 to 100 days

PURPOSE

The study's objective was to determine the optimal window for anterior cruciate ligament (ACL) reconstruction with respect to quadriceps atrophies and clinical outcome.

METHODS

For this retrospective, comparative study, 115 patients aged under 35 were included, who received an ACL reconstruction between 2011 and 2016. They were divided into four groups, depending on the time to surgery, to determine the optimal window for reconstruction: (group 1: ≤21 d, group 2: <21d-56d≥, group 3: >56d-100d≥, group 4: >100d). Follow-up was performed one month postoperatively, after a mean of 4.9 (±5.3) months, and after a mean of 3.5 (±1.4) years. Primary endpoints included quadriceps muscle status, range of motion (ROM), pain, swelling, the International Knee Documentation Committee Subjective Knee Form (IKDC), the Lysholm-Score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner-Activity-Scale (TAS).

RESULTS

Significantly more quadriceps atrophies were observed in group 1 and group 4, representing reconstructions earlier than 21 and later than 100 days (29% and 41% vs. 9%; p = 0.032). The measurements of knee extension (p = 0.082) and ROM (p = 0.123) were comparable in all groups. Group 1 showed the least pain (0% vs. 15%; p = 0.285) and swelling (0% vs. 23%; p = 0.077) compared to all other groups one month postoperatively. A comparison of postoperative clinical scores revealed no significant differences, with group 1 exhibiting the lowest TAS levels.

CONCLUSION

In patients who underwent ACL reconstruction within three weeks or after more than 100 days, a significantly higher incidence of quadriceps atrophy was observed, possibly attributable to the initial inflammatory phase or the delayed reconstruction affecting quadriceps function. However, this impairment may not be observable in elite athletes who undergo reconstruction within hours of the injury.

Surgical site infection after trochanteric and subtrochanteric fractures: a single centre retrospective analysis

Surgical site infection (SSI) following osteosynthesis of trochanteric or subtrochanteric fractures is a rare but serious complication with incidence rate ranging from 1 to 3%. SSIs are associated with higher mortality and increased length of hospital stay resulting in higher healthcare costs and loss of life quality. In this retrospective analysis all patients with SSI following osteosynthesis of trochanteric or subtrochanteric fractures at the Department of Trauma Surgery were identified. We included all surgical procedures performed from 1992 to 2018, using data from electronic health records and SSI-Trauma-Registry. The aim was to describe epidemiological data, as well as to identify parameters correlating with the occurrence of SSI and mortality. Of 2753 patients, 53 (1.9%) developed SSI. Longer operative time was demonstrated among patients with SSI (P = 0.008). Mortality during the first postoperative year was significantly higher in the SSI group (32.1% vs. 19.1%; P = 0.018), with detection of methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA; HR 4.13, CI 95% 1.24-13.80; P = 0.021) or Enterococcus spp. (HR 5.58, CI 95% 1.67-18.65; P = 0.005) being independent risk factors. Male sex (HR 2.25, 95% CI 1.86-2.73; P < 0.001) and higher mean age (HR 1.05, 95% CI 1.04-1.06; P < 0.001) were found to be predictors for 1-year mortality in non-infected patients. SSI rate was low with 1.9% and longer duration of surgery was associated with infection. Patients with SSI had a higher 1-year mortality, with detection of MSSA, MRSA and enterococci significantly increasing the risk of dying. Male sex and higher age were risk factors for one-year mortality in patients without SSI.

The Hidden Pandemic: Impact of the COVID-19 Pandemic on Trauma Cases Due to Domestic Violence Admitted to the Biggest Level-One Trauma Center in Austria

BACKGROUND

An alarming increase in domestic violence was reported during the COVID-19 pandemic worldwide. The aim of this study is to investigate changes in the frequency and the nature of domestic violence at the largest level-one trauma center in Austria.

METHODS

All patients admitted to our institution with domestic violence injuries 15 months before and after the beginning of the COVID-19 pandemic were included. For our analysis, we investigated the frequency of trauma patients after domestic violence in relation to all other trauma patients. Furthermore, age, sex, citizenship, injury pattern, injured body regions, injury mechanism, offender-victim relationship, and hospitalization rate were also analyzed.

RESULTS

Among all trauma patients admitted, the ratio of patients who reported domestic violence injuries increased from 0.465% to 0.548% since the start of the pandemic. In addition, out of the total count of domestic violence victims, the percentage of Austrian citizens increased significantly from 51.2% to 60.6% (p = 0.016). All other parameters showed no significant changes pre and post-pandemic.

CONCLUSION

The COVID-19 pandemic contributed to a relative increase in patients with domestic violence injuries at the largest trauma unit in Austria, along with a significant increase among Austrian citizens. The remaining study parameters did not differ significantly, indicating that the frequency changed during the pandemic but not the underlying pattern of domestic violence.

The Epidemiological Transition of Surgically Treated Proximal Hip Fractures in Austria over the Course of the Pandemic-Back to Normal or a New Normal?

BACKGROUND

The COVID-19 pandemic has had a significant impact on the treatment protocols of orthopedic and trauma departments, but its specific effect on the mortality of hip fracture patients due to possible delays in surgery remains uncertain. This study aimed to investigate whether the COVID-19 pandemic worsened the mortality of patients with hip fractures.

MATERIALS AND METHODS

This study included 246 prospectively enrolled patients who suffered from hip fractures during the Austrian State of Emergency period between 1 March and 30 June 2020 and 2021 and were admitted to a tertiary care trauma center. This cohort was compared with a retrospective control group of 494 patients admitted for hip fractures during the same timeframe in 2017, 2018, and 2019. These groups were compared to a prospective recruited "post-COVID-19 collective consisting of the years 2022 and 2023 including 313 patients.

RESULTS

This study found a 22% reduction in admissions during the COVID-19 period compared to the pre-COVID period (p = 0.018), as well as significant changes in gender (p = 0.013) and place of accident (p = 0.049). No other changes in demographic variables were observed. The 30-day mortality rate was 14.67% in the pre-COVID period, compared to 15.18% during the COVID-19 period (p = 0.381). No differences were observed in surgical complication rates or in the relationship between comorbidity burden and survival.

CONCLUSION

This study did not show a higher perioperative mortality rate due to COVID-19. However, under current circumstances, with potentially reduced surgical and hospital bed capacities, it is expected that this condition might require a high degree of resources in times when resources are potentially scarce, such as during an ongoing pandemic.

LEVEL OF EVIDENCE

Level III.

Serum Angiopoietin-2 level increase differs between polytraumatized patients with and without central nervous system injuries

Since endothelial cells rapidly release Angiopoietin-2 (Ang-2) in response to vascular injury and inflammatory stimuli, we aimed to investigate if its serum levels increase in polytraumatized patients. Our cohort study evaluated 28 blunt polytrauma survivors (mean age, 38.4 years; median ISS, 34) who were directly admitted to our level I trauma center in 2018. We assessed the serum Ang-2 level at admission and on days 1, 3, 5, 7, and 10 during hospitalization. Ang-2 was released into the circulation immediately after polytrauma. At admission (day 0), it amounted to 8286 ± 5068 pg/mL, three-and-a-half times the reference value of 2337 ± 650 pg/mL assessed in a healthy control group. Subgroup analysis provided a higher mean Ang-2 level in the CNSI group combining all patients suffering a brain or spinal cord injury compared to the non-CNSI group solely on day 0 [11083 ± 5408 pg/mL versus 3963 ± 2062 pg/mL; p < 0.001]. Whereas the mean Ang-2 level increased only in the non-CNSI group from day 0 to day 3 (p = 0.009), the respective curves showed similar continuous decreases starting with day 3. Multivariate logistic regression analysis revealed an association between the Ang-2 day 0 level and the presence of a CNSI (OR = 1.885; p = 0.048). ROC analysis provided a cutoff level of 5352 pg/mL. In our study group, serum Ang-2 levels assessed at admission differed between polytraumatized patients with and without brain or spinal cord injuries. Based on our findings, we consider serum Ang-2 levels an effective biomarker candidate for indicating CNSI in these patients at admission, worthy of further evaluation in large multicenter studies.

Red blood cell distribution width and Charlson comorbidity index help to identify frail polytraumatized patients : Experiences from a level I trauma center

INTRODUCTION

Little is known about the potential impact of the red blood cell distribution width (RDW) and pre-existing comorbidities on the late-phase survival of polytraumatized patients.

METHODS

A total of 173 polytraumatized patients were included retrospectively in this cohort study in a level I trauma center from January 2012 to December 2015. The Charlson comorbidity index (CCI) scores and RDW values were evaluated.

RESULTS

Out of all polytraumatized patients (n = 173), 72.8% (n = 126) were male, the mean ISS was 31.7 points (range 17-75) and the mean age was 45.1 years (range 18-93 years). Significantly higher RDW values (13.90 vs. 13.37; p = 0.006) and higher CCI scores (3.38 vs. 0.49; p < 0.001) were seen in elderly polytraumatized patients (age > 55 years). RDW values > 13.75% (p = 0.033) and CCI scores > 2 points (p = 0.001) were found to have a significant influence on the late-phase survival of polytraumatized patients. Age > 55 years (p = 0.009, HR 0.312; 95% confidence interval (CI) 0.130-0.749) and the presence of severe traumatic brain injury (TBI) (p = 0.007; HR 0.185; 95% CI 0.054-0.635) remained as independent prognostic factors on the late-phase survival after multivariate analysis.

CONCLUSION

Even younger elderly polytraumatized patients (> 55 years of age) showed significant higher RDW values and higher CCI scores. In addition to the presence of severe TBI and age > 55 years, RDW value > 13.75% on admission and CCI score > 2 might help to identify the "younger" frail polytraumatized patient at risk.

Predictive Validity of Mortality after Surgically Treated Proximal Femur Fractures Based on Four Nutrition Scores-A Retrospective Data Analysis

BACKGROUND

Hip fractures are becoming a growing concern due to an aging population. The high costs to the healthcare system and far-reaching consequences for those affected, including a loss of independence and increased mortality rates, make this issue important. Poor nutritional status is a common problem among geriatric patients and is associated with a worse prognosis. Nutritional screening tools can help identify high-risk patients and enable individualized care to improve survival rates.

MATERIAL AND METHODS

This retrospective study investigates four nutritional scores and laboratory parameters' predictive significance concerning postoperative mortality after surgical treatment of proximal femur fractures at 1, 3, 6, and 12 month/s for patients over 60 years using the chi-square test, Cox regression analysis, and receiver operating characteristics (ROC). The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines were used as part of the screening of the respective nutritional status of the patients, in particular to filter out malnutrition.

RESULTS

A total of 1080 patients were included in this study, whereas 8.05% suffered from malnutrition, defined as a body mass index (BMI) below 18.5 kg/m2. The Mini Nutritional Assessment (MNA) screening tool identified the highest proportion of malnourished patients at 14.54%. A total of 36.39% of patients were at risk of malnutrition according to three nutrition scores, with MNA providing the most significant proportion at 41.20%. Patients identified as malnourished had a higher mortality rate, and MNA screening was the only tool to show a significant correlation with postoperative mortality in all survey intervals. The MNA presented the best predictive significance among the screening tools, with a maximum area under the curve (AUC) of 0.7 at 12 month postoperatively.

CONCLUSIONS

MNA screening has a solid correlation and predictive significance regarding postoperative mortality-therefore routine implementation of this screening in orthopedic/traumatology wards is recommended. Moreover, nutritional substitution therapy can offer a relatively inexpensive and easy-to-implement measure. The Graz malnutrition screening (GMS) shows moderate predictive power and could be considered as an alternative for patients under 60 years of age. A higher albumin level is associated with improved survival probability, but cannot be indicative of nutritional status.

Distal locking technique affects the rate of iatrogenic radial nerve palsy in intramedullary nailing of humeral shaft fractures

BACKGROUND

Intramedullary humeral nailing is a common and reliable procedure for the treatment of humeral shaft fractures. Radial nerve palsy is a common complication encountered in the treatment of this pathology. The radial nerve runs from posterior to anterior at the lateral aspect of the distal humerus. Hence, there is reason to believe that due to the anatomic vicinity of the radial nerve in this area, lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve injury compared to anterior-posterior locking.

QUESTIONS/PURPOSE

To assess whether the choice of distal locking (lateral-medial versus anterior-posterior distal locking) in intramedullary humeral nailing of humeral shaft fractures affects the risk for iatrogenic radial nerve injury.

PATIENTS AND METHODS

Overall, 203 patients (116 females, mean age 64.3 ± 18.6 years), who underwent intramedullary nailing of the humerus between 2000 and 2020 at a single level-one trauma center, met the inclusion criteria and were analyzed in this retrospective case-control study. Patients were subdivided into two groups according to the distal locking technique.

RESULTS

Anterior-posterior locking was performed in 176 patients versus lateral-medial locking in 27 patients. We observed four patients with iatrogenic radial nerve palsy in both groups. Risk for iatrogenic radial nerve palsy was almost 7.5 times higher for lateral-medial locking (OR 7.48, p = 0.006). There was no statistically significant difference regarding intraoperative complications, union rates or revision surgeries between both groups.

CONCLUSIONS

Lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve palsy than anterior-posterior locking. Hence, we advocate for anterior-posterior locking.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Do Elevated Serum C-Reactive-Protein Levels Excuse Delayed Surgery for Femoral Neck Fractures?

In elderly patients with femoral neck fractures, preoperative serum C-reactive protein (CRP) values might be elevated due to active infections. Although there are limited data on CRP as a predictor of periprosthetic joint infection (PJI), out of concern, this could lead to delayed surgery. Therefore, we aim to investigate whether elevated serum-CRP levels justify delayed surgery for femoral neck fractures. A retrospective analysis was performed of the records of patients undergoing arthroplasty who were found to have an elevated CRP level of 5 mg/dL or more between January 2011 to December 2020. The patients were stratified to three groups, according to initial serum CRP levels at a cut off of 5 mg/dL and the time between admission and surgery (<48 vs. ≥48 h after admission). This study revealed that the patients with elevated serum CRP levels and delayed surgery showed a worse survival rate and significantly more postoperative complications than the patients on whom surgery was performed immediately. There were no significant differences in terms of PJI and prolonged wound healing in the inter-group comparison. Therefore, delays to surgery on the basis of elevated CRP values offer no benefits to patients with femoral neck fractures.

A suture anchor-based repair technique for type IV jersey finger injuries: a biomechanical investigation

The aim of this biomechanical investigation was to evaluate a repair technique for type IV FDP tendon avulsions using a suture anchor, addressing the bony and the tendinous aspect of this injury simultaneously. In 45 distal phalanges from human anatomical specimens the injury was simulated and repairs were performed with a suture anchor using an innovative technique, interosseous sutures and a combination of screws and an interosseous suture. Repetitive loading for 500 cycles simulated postoperative mobilization. Repairs were loaded to failure thereafter. Elongation of the tendon-suture complex, gap formation at the bone-bone contact line and at the bone-tendon insertion line, load at first noteworthy displacement (2 mm), load at failure and the mechanism of failure were assessed. The suture anchor technique was superior biomechanically considering load at failure (mean: 72.8 N), bony gap formation (mean: 0.1 mm) as well as tendinous gap formation (mean: 0.7 mm), implying a preferable stability of the repair. Overall, this study demonstrates good ex vivo mechanical stability for a proposed suture anchor repair technique for type IV FDP tendon avulsion injuries, which might enable early postoperative mobilization in patients. The technique's subcutaneous implant placement and low implant load are expected to reduce potential complications observed in other commonly used repair techniques. This approach warrants further evaluation in vivo.

Successful treatment of a painful neuroma using fascicular shifting in the ulnar nerve: Case report

The authors report the case of a forty-year old man with an inveterate ulnar nerve neuroma following a laceration injury of his left wrist twenty-three years ago. He presented with a typical ulnar claw-hand deformity and debilitating neuropathic pain in his hand (VAS 8.4). Pre-operative imaging revealed a neuroma of the ulnar nerve at the Guyon’s canal. Moreover, a complete atrophy of all intrinsic hand muscles innervated by the ulnar nerve was present. A Zancolli lasso procedure was performed to reduce the clawing effect. The neuroma was resected producing a nerve defect of five centimeters. Since the injury dated back more than two decades and any motor recovery was deemed impossible at that point, the motor fascicle of the ulnar nerve, i.e. the deep branch, was harvested and used as an autologous nerve graft to bridge the defect. The deep branch fascicle was dissected proximally, harvested and shifted into the defect to be coapted with the superficial branch fascicle in an end-to-end fashion. The presented procedure resulted in satisfying and sustained pain reduction (VAS 2.5) at two-year follow-up. Hence, the authors recommend considering fascicular shift procedure in peripheral sensory nerve reconstruction as a cost-effective alternative.

The top fifty most influential articles on hip fractures

PURPOSE

Hip fractures are one of the most common disabling fractures in elderly people and peri-operative management has advanced considerably over the past decades. The purpose of this study was to evaluate the change of scientific focus by creating a top 50 list of the most influential papers on this topic.

METHODS

The Clarivate Web of Science Search was used to identify the most cited articles. The used search phrase was [(hip OR pertrochanteric OR (femoral neck)) AND fracture AND (surgery OR treatment)]. The number of citations, citation density, study type, study design, published year, fracture type, country, evidence level and published journal were recorded.

RESULTS

The top 50 articles were published between 1973 and 2014 and cited between 88 and 496 times. The mean citation density increased noticeably after the year 2000, representing the knowledge gain of the last 20 years. The topics surgical treatment (n = 19), risk factor assessment (n = 19), perioperative hemodynamic management (n = 7), additional treatment (n = 4) and general reviews (n = 1) were covered. Twenty-five articles were published from institutions in Europe, 24 from institutions in North America and one from an institution in Asia.

CONCLUSION

While studies about surgical treatment options and risk factor assessment have been historically important, there was a rise of articles about additional treatment options for osteoporosis and the optimal postoperative care after the year 2005. The presented lists and map of citation classics give an overview of the most influential studies on hip fractures.

25-Year experience with adult polytraumatized patients in a European level 1 trauma center: polytrauma between 1995 and 2019. What has changed? A retrospective cohort study

PURPOSE

To analyze the changes of the clinical characteristics, injury patterns, and mortality rates of polytraumatized patients within the past 25 years in a European Level I trauma center.

METHODS

953 consecutive polytraumatized patients treated at a single-level 1 trauma center between January 1995 and December 2019 were enrolled retrospectively. Polytrauma was defined as AIS ≥ 3 points in at least two different body regions. Retrospective data analysis on changes of clinical characteristics and mortality rates over time.

RESULTS

A significant increase of the average age by 2 years per year of the study could be seen with a significant increase of geriatric patients over time. No changes of the median Injury Severity Score (ISS) could be seen over time, whereas the ISS significantly decreased by patient's year. The rates of concomitant severe traumatic brain injury (TBI) remained constant over time, and did not increase with rising age of the patients. Although, the mortality rate remained constant over time the relative risk of overall in-hospital mortality increased by 1.7% and the relative risk of late-phase mortality increased by 2.2% per patient's year.

CONCLUSION

The number of polytraumatized patients remained constant over the 25-year study period. Also, the mortality rates remained stable over time, although a significant increase of the average age of polytraumatized patients could be seen with stable injury severity scores. Severe TBI and age beyond 65 years remained independent prognostic factors on the late-phase survival of polytraumatized patients.

TRIAL REGISTRATION

NCT04723992.

LEVEL OF EVIDENCE

Prognostic study, level III.

Quality and readability of online resources on chronic ankle instability

BACKGROUND

Online resources on medical conditions often provide misleading or outdated information for patients. The aim of this study was to evaluate the quality of online patient information on ankle instability.

METHODS

The terms "ankle instability", "ankle instability treatment" and "ankle laxity" were entered into the three largest internet search engines. The quality, accuracy and readability were evaluated using the EQIP36, a custom 25-item list and the Flesch-Kincaid-Score.

RESULTS

The mean 25-item score of 102 included websites reached 10 ± 5, the mean EQIP36 score was 41 ± 11 and 96% of evaluated websites exceeded the recommended 8th-grade reading level for patient information. The quality was significantly higher with reading levels of college graduates (P < 0.001).

CONCLUSIONS

Online resources on ankle instability are often inaccurate or at inappropriately high reading level. The quality and accuracy depend on the reading levels, with high reading levels providing more in-depth information. Foot and ankle surgeons should be aware of available online resources to direct patients to adequate websites.

LEVEL OF EVIDENCE

Level V.

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study

INTRODUCTION

Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported.

MATERIALS AND METHODS

We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures.

RESULTS

The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%.

CONCLUSION

This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

Evaluation of Meniscal Tissue after Meniscal Repair Using Ultrahigh Field MRI

The study evaluates the meniscal tissue after primary meniscal suturing using 7-Tesla (T) magnetic resonance imaging with T₂* mapping at 6 and 12 months after surgery to investigate the differences between repaired meniscal tissue and healthy meniscal tissue in the medial and lateral compartment. This prospective study included 11 patients (9m/2f) with a mean age of 30.6 years (standard deviation 9.0). Patients with a meniscal tear that was treated arthroscopically with meniscus suturing, using an all-inside technique, were included. All patients and seven healthy volunteers were imaged on a 7-T whole-body system. T2* mapping of the meniscus was applied on sagittal slices. Regions-of-interest were defined manually in the red and white zone of each medial and lateral meniscus to measure T2*-values. In the medial posterior and medial anterior horn similar T₂*-values were measured in the red and white zone at 6- and 12-month follow-up. Compared with the control group higher T₂*-values were found in the repaired medial meniscus. After 12-months T₂*-values decreased to normal values in the anterior horn and remained elevated in the posterior horn. In the red zone of the lateral posterior horn a significant decrease in the T₂*-values (from 8.2 milliseconds to 5.9 milliseconds) (p = 0.04), indicates successful repair; a tendency toward a decrease in the white zone between the 6 and 12 months follow-up was observed. In the red zone of the lateral anterior horn the T₂*-values decreased significantly during follow-up and in the white zone of the lateral anterior horn T₂*-values were comparable. In comparison to the control group higher T₂*-values were measured at 6-months; however, the T₂*-values showed comparable values in the repaired lateral meniscus after 12 months. The T2* mapping results of the current study indicated a better healing response of the red zone of the lateral posterior horn compared with the medial posterior horn.

Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center

OBJECTIVE

Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence.

METHODS

Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score.

RESULTS

In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died.

CONCLUSION

The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery.

TRIAL REGISTRATION

(researchregistry 2686).

Does patient positioning influence blood loss and transfusion rate in hip replacement for femoral neck fractures? A single-centre, retrospective chart review

Background

We compared blood loss and transfusion frequency between the lateral decubitus and the supine position in patients undergoing hip replacement surgery due to femoral neck fractures.

Methods

We retrospectively included femoral neck fracture patients treated with either hemi (HA) or total hip arthroplasty (THA). We included a total of 626 patients, of which 313 patients underwent surgery in the lateral decubitus position and 313 patients in the supine position. Preoperative and day 1 postoperative blood measures including hemoglobin (Hb), hematocrit (Hct), and red blood cell count (RBC) were evaluated, as well as transfusion records analyzed.

Results

The following decrease of laboratory parameters between pre- and 1st day postoperative measures was noted: RBC: -0.77 G/L (± 0.5 G/L, median = -0.80 G/L; range: -0.50 – -1.10 G/L); Hct: -7.08 % (± 4.7 %, range: -4.70 – -9.90 G/L); Hb: -2.36 g/dL (± 1.6 g/dL, range: -1.50. – -3.40 g/dL). We did not observe significant differences in transfusion frequency between the two study cohorts (p = 0.735 for THA, p = 0.273 for HA). No influence of patient positioning on Hb-decrease, Hct-decrease, or RBC-decrease was noted in our two-way ANOVA models with consideration of implant type and fixation technique (F(3,618) = 1.838, p = 0.139; F(3,618) = 2.606, p = 0.051; F(3,618) = 1.407, p = 0.240).

Conclusions

We did not observe  significant differences in perioperative blood values and transfusion rates in association with patient positioning in patients undergoing hip replacement surgery for femoral neck fractures.

Level of evidence

Level III, retrospective cohort study.

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.

Age and traumatic brain injury as prognostic factors for late-phase mortality in patients defined as polytrauma according to the New Berlin Definition: experiences from a level I trauma center

BACKGROUND

The rationale of this study was to identify independent prognostic factors influencing the late-phase survival of polytraumatized patients defined according to the New Berlin Definition.

METHODS

Retrospective data analysis on 173 consecutively polytraumatized patients treated at a level I trauma center between January 2012 and December 2015. Patients were classified into two groups: severely injured patients (ISS > 16) and polytraumatized patients (patients who met the diagnostic criteria for the New Berlin Definition).

RESULTS

Polytraumatized patients showed significantly lower late-phase and overall survival rates. The presence of traumatic brain injury (TBI) and age > 55 years had a significant influence on the late-phase survival in polytraumatized patients but not in severely injured patients. Despite the percentage of severe TBI being nearly identical in both groups, severe TBI was identified as main cause of death in polytraumatized patients. Furthermore, severe TBI remains the main cause of death in polytraumatized patients > 55 years of age, whereas younger polytraumatized patients (< 55 years of age) tend to die more often due to the acute trauma.

CONCLUSION

Our results suggest that age beyond 55 years and concomitant (severe) TBI remain as most important influencing risk factor for the late-phase survival of polytraumatized patients but not in severely injured patients.

LEVEL OF EVIDENCE

Prognostic study, level III.

Pull-out forces of headless compression screws in variations of synthetic bone models imitating different types of scaphoid fractures in good bone quality

Screw osteosynthesis using headless compression screws has become the accepted gold standard for the surgical treatment of scaphoid fractures. Optimal screw specifications remain controversially discussed. We aimed to investigate the influence of bone model composition on screw stability tests using headless compression screws in different scaphoid fracture models. We conducted pull-out tests using Acutrak2^®mini, HCS^®, HKS^®, HBS^®, Herbert/Whipple^® and Twinfix^® screws. To imitate cortical and cancellous bone, two-layer polyurethane (PU) models with two distinct densities were produced. The cylinders were cut at different positions to replicate fracture localisations at increasing distances. The maximum pull-out force required to achieve up to 1 mm of pull-out distance (N_{to 1 mm}) was measured. Acutrak2^®mini and HCS^® followed by Twinfix^® showed the greatest average pull-out forces. N_{to 1 mm} was, on average, greater in the cortico-cancellous model than in the cancellous cylinder with the Acutrak2^®mini and the Herbert/Whipple^® screws, while it was the least with the HBS^® and the Twinfix^® screws; there were also differences between the HCS^® and HKS^®. There were no differences between the different fracture simulations in the synthesis strength using either the HKS^® or HBS^®. The pull-out forces of the HCS^® and Twinfix^® remained high also in simulations with the smaller screw base fragments. Varying imitations of cancellous and cortico-cancellous bone and fracture localisation reveal important information about the ex vivo strength of screw syntheses. The grip of the cortical structure should be used with the screws that fit more firmly in cortico-cancellous bone.

Wrist movements induce torque and lever force in the scaphoid: an ex vivo study

Purpose

We hypothesised that intercarpal K-wire fixation of adjacent carpal bones would reduce torque and lever force within a fractured scaphoid bone.

Methods

In eight cadaver wrists, a scaphoid osteotomy was stabilised using a locking nail, which also functioned as a sensor to measure isometric torque and lever forces between the fragments. The wrist was moved through 80% of full range of motion (ROM) to generate torque and force within the scaphoid. Testing was performed with and without loading of the wrist and K-wire stabilisation of the adjacent carpal bones.

Results

Average torque and lever force values were 49.6 ± 25.1 Nmm and 3.5 ± 0.9 N during extension and 41 ± 26.7 Nmm and 8.1 ± 2.8 N during flexion. Torque and lever force did not depend on scaphoid size, individual wrist ROM, or deviations of the sensor versus the anatomic axis. K-wire fixation did not produce significant changes in average torque and lever force values except with wrist radial abduction (P = 0.0485). Other than wrist extension, torque direction was not predictable.

Conclusion

In unstable scaphoid fractures, we suggest securing rotational stability with selected implants for functional postoperative care. Wrist ROM within 20% extension and radial abduction to 50% flexion limit torque and lever force exacerbation between scaphoid fragments.

Impact of Polytrauma and Acute Respiratory Distress Syndrome on Markers of Fibrinolysis: A Prospective Pilot Study

Acute respiratory distress syndrome (ARDS), which is associated with major morbidity and high mortality, is commonly developed by polytraumatized patients. Its pathogenesis is complex, and its development is difficult to anticipate, as candidate biomarkers for the prediction of ARDS were found not to be reliable for clinical use. In this prospective study, we assessed the serum antigen levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor type-1 (PAI-1) of 28 survivors of blunt polytrauma (age ≥18 years; injury severity score ≥16) at admission and on days 1, 3, 5, 7, 10, 14, and 21 of hospitalization. Our results show that these patients presented high mean tPA and PAI-1 antigen levels at admission; despite their decline, these parameters remained elevated for 3 weeks. Over this period, the mean tPA antigen level was higher in polytrauma victims suffering from ARDS than in those without ARDS, whereas the mean PAI-1 level was higher in polytrauma victims sustaining pneumonia than in those without pneumonia. Moreover, in each individual developing ARDS, the polytrauma-related elevated tPA antigen level either continued to rise after admission or suffered a second increase up to the onset of ARDS, declining immediately thereafter. Therefore, our findings support the assessment of serum tPA antigen levels after the initial treatment of polytraumatized patients, as this parameter shows potential as a biomarker for the development of ARDS and for the consequent identification of high-risk individuals.

Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center

Background

Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. It is hypothesized, that with the adequate treatment of SDH in children and adolescence, excellent clinical and functional outcomes can be achieved. The aim of this study was to present the severity and outcome of traumatic SDH in children and adolescence as well as to analyze differences between patients treated surgically and conservatively.

Methods

In this study 47 infants and children with a subdural hematoma (SDH) were treated between 1992 and 2010 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow outcome scale (GOS) scores at hospital discharge and at follow-up visits were used. Severity of SDH was classified according to the Rotterdam score.

Results

In total, 47 cases were treated (21 surgically, 26 conservatively), with 10 patients needing delayed surgery. Overall, 89% of the patients were able to leave hospital, 5 patients died, 2 patients (5%) within 24 h, another 2 (5%) after 48 h and 1 (2%) within 7 days. In 25 patients (53%) a good recovery was recorded at the last follow-up visit. Outcome was mainly influenced by the following factors: age, severity of TBI, and neurological status. Overall, in 70% good clinical and neurological outcomes could be achieved.

Conclusion

The results of this study confirmed that pediatric SDH is a rare, but serious condition. Despite a poor prognosis, most patients could be treated with good outcomes, given that the choice of treatment is correct.

Trial registration

Research registry 2686

Electronic supplementary material

The online version of this article (10.1007/s00508-020-01648-3) contains supplementary material, which is available to authorized users.

The impact of implant material and patient age on the long-term outcome of secondary cranioplasty following decompressive craniectomy for severe traumatic brain injury

Background

Secondary cranioplasty (CP) is considered to support the neurological recovery of patients after decompressive craniectomy (DC), but the treatment success might be limited by complications associated to confounders, which are not yet fully characterized. The aim of this study was to identify the most relevant factors based on the necessity to perform revision surgeries.

Methods

Data from 156 patients who received secondary CP following DC for severe traumatic brain injury (TBI) between 1984 and 2015 have been retrospectively analyzed and arranged into cohorts according to the occurrence of complications requiring surgical intervention.

Results

Cox regression analysis revealed a lower revision rate in patients with polymethylmethacrylate (PMMA) implants than in patients with autologous calvarial bone (ACB) implants (HR 0.2, 95% CI 0.1 to 1.0, p = 0.04). A similar effect could be observed in the population of patients aged between 18 and 65 years, who had a lower risk to suffer complications requiring surgical treatment than individuals aged under 18 or over 65 years (HR 0.4, 95% CI 0.2 to 0.9, p = 0.02). Revision rates were not influenced by the gender (p = 0.88), timing of the CP (p = 0.53), the severity of the TBI (p = 0.86), or the size of the cranial defect (p = 0.16).

Conclusions

In this study, the implant material and patient age were identified as the most relevant parameters independently predicting the long-term outcome of secondary CP. The use of PMMA was associated with lower revision rates than ACB and might provide a therapeutic benefit for selected patients with traumatic cranial defects.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04243-7) contains supplementary material, which is available to authorized users.

Hemiarthroplasty in a patient with femoral neck fracture and pyoderma gangrenosum: a case report and review of the literature

Background

Pyoderma gangrenosum is a rare ulcerating skin disease of unknown etiology, making its coincidence with orthopedic trauma a rare challenge. Patients are at risk of progression of the existing lesions and development of new lesions upon skin injury when surgical procedures are performed. To our knowledge, this is the first report in the literature of disease unrelated surgery during active pyoderma gangrenosum.

Case presentation

We present a case of femoral neck fracture in a Caucasian patient with concurrent pyoderma gangrenosum localized in the axilla. Hemiarthroplasty was safely performed after disease activity was reduced with systemic corticosteroids. Tissue-protective wound closure was used together with perioperative corticosteroids and antibiotics. No signs of pyoderma gangrenosum developed at the surgical wound site, and the axillary lesions showed constant improvement until healing with scar tissue.

Conclusions

In our patient, the preoperative steroid treatment, perioperative antibiotics, and soft tissue protective surgical technique led to successful management of this rare coincidence.

Ramp lesions are frequently missed in ACL-deficient knees and should be repaired in case of instability

PURPOSE

The aim of the current study was (1) to provide an overview of common definitions and classification systems of ramp lesions (RL) and (2) to systematically review the available literature with regard to the diagnosis and treatment of RLs in anterior cruciate ligament (ACL)-deficient knees.

METHODS

Following the PRISMA guidelines, MEDLINE and Scopus were searched for articles (1) reporting on acute or chronic ACL injuries, (2) with concomitant medial meniscus injury, (3) located at the posterior meniscocapsular attachment site (and red-red zone). Ex vivo studies, reviews and technical notes were excluded.

RESULTS

Twenty-seven studies were included based on the criteria mentioned above. RLs are common in ACL-deficient knees with a prevalence ranging from 9 to 24%. RLs should especially be suspected in younger patients, patients with an increased meniscal slope and in patients with prolonged time from injury to surgery. The sensitivity of MRI for the detection of RLs ranges from 48 to 86% at a specificity of 79-99%. For arthroscopy, RLs are easily missed through standard anterior portals (sensitivity 0-38%). RL repair leads to a significant improvement of subjective knee scores, regardless of the specific fixation technique. For stable RLs, the literature suggests equivalent postoperative stability for trephination and abrasion compared to surgical RL repair.

CONCLUSION

Ramp lesions are frequently missed in ACL-deficient knees on standard arthroscopy with anterior portals only. If a RL is suspected, exploration via an additional posteromedial portal is indicated. In case of instability, RL repair should be performed.

LEVEL OF EVIDENCE

IV.

Preserving the radial head in comminuted Mason type III fractures without fixation to the radial shaft: a mid-term clinical and radiographic follow-up study

BACKGROUND

The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications.

METHODS

The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P).

RESULTS

Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain.

CONCLUSIONS

Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.

A Comparison of Dynamic Hip Screw and Two Cannulated Screws in the Treatment of Undisplaced Intracapsular Neck Fractures-Two-Year Follow-Up of 453 Patients

One of the most common fractures is that of the intracapsular femoral neck; however, the optimal implant for head-preserving treatment remains controversial. The aim of the study was to compare the outcomes of treating undisplaced intracapsular femoral neck fractures with either the dynamic hip screw (DHS) or the double cannulated screw fixation (CSFN). This retrospective cohort study analysed the data of 453 patients, with a mean age of 76.9 years, whose intracapsular fractures were treated with the DHS or CSFN between 2005 and 2013. The analysis focused on the rates of revision surgeries and complications; however, the impact of confounding exogenous factors, such as smoking and alcohol, were also considered. No significant difference was observed between the revision rates of DHS and CSFN (15.0% vs. 13.1%; p = 0.565). According to the complication rate, the advantage in favour of the CSFN was not significant (20.5% vs. 13.1%, p = 0.038). The use of the DHS was associated with a 13 min longer surgery (p < 0.0001) and a one day longer hospitalization (p = 0.242). Excessive consumption of alcohol was associated with an increased incidence of avascular necrosis (18.6% vs. 8.7%, p = 0.035). The choice of implant showed no significant impact on rates of revision surgery and complications. In terms of socioeconomic factors, the fixation with two cannulated screws was more favourable, making it the more cost-effective and less stressful method.

Survival rate and Outcome of extracorporeal life support (ECLS) for treatment of acute cardiorespiratory failure in trauma patients

Extracorporeal life support (ECLS) remains the last option for cardiorespiratory stabilization of severe traumatic injured patients. Currently limited data are available and therefore, the current study assessed the survival rate and outcome of ECLS in a Level I trauma center. Between 2002 and 2016, 18 patients (7 females, 11 males) with an median age of 29.5 IQR 23.5 (range 1–64) years were treated with ECLS due to acute traumatic cardiorespiratory failure. Trauma mechanism, survival rate, ISS, SOFA, GCS, GOS, CPC, time to ECLS, hospital- and ICU stay, surgical interventions, complications and infections were retrospectively assessed. Veno-arterial ECLS was applied in 15 cases (83.3%) and veno-venous ECLS in 3 cases (16.6%). Survivors were significant younger than non-survivors (p = 0.0289) and had a lower ISS (23.5 (IQR 22.75) vs 38.5 (IQR 16.5), p = n.s.). The median time to ECLS cannulation was 2 (IQR 0,25) hours in survivors 2 (IQR 4) in non-survivors. Average GCS was 3 (IQR 9.25) at admission. Six patients (33.3%) survived and had a satisfying neurological outcome with a mean GOS of 5 (IQR 0.25) (p = n.s.). ECLS is a valuable treatment in severe injured patients with traumatic cardiorespiratory failure and improves survival with good neurological outcome. Younger patients and patients with a lower ISS are associated with a higher survival rate. Consideration of earlier cannulation in traumatic cardiorespiratory failure might be beneficial to improve survival.

IL-33 and its increased serum levels as an alarmin for imminent pulmonary complications in polytraumatized patients

Background

According to recently published findings, we hypothesized that serum interleukin-33 (IL-33) may qualify for predicting pulmonary complications in polytraumatized patients.

Methods

One hundred and thirty patients (age ≥ 18 years, ISS ≥ 16) were included in our prospective analysis after primary admission to our level I trauma center during the first post-traumatic hour. Serum samples immediately after admission and on day 2 after trauma were obtained and analyzed.

Results

Median initial IL-33 levels (in picograms per milliliter) were higher in polytrauma victims (1) with concomitant thoracic trauma [5.08 vs. 3.52; p = 0.036], (2) sustaining parenchymal lung injury (PLI) [5.37 vs. 3.71; p = 0.027], and (3) developing acute respiratory distress syndrome (ARDS) [6.19 vs. 4.48; p = 0.003], compared to the respective rest of the study group. The median initial IL-33 levels were higher in patients experiencing both PLI and ARDS compared to those sustaining PLI and not developing ARDS [6.99 vs. 4.69; p = 0.029]. ROC statistics provided an AUC of 0.666 (p = 0.003) and a cut-off value of 4.77 (sensitivity, 71.8%; specificity, 75.7%) for predicting ARDS. Moreover, a higher initial median IL-33 level was revealed in the deceased compared to the survivors [12.25 vs. 4.72; p = 0.021]. ROC statistics identified the initial level of IL-33 as a predictor of death with 11.19 as cut-off value (sensitivity, 80.0%; specificity, 80.0%; AUC = 0.805; p = 0.021).

Conclusions

Following tissue damage, IL-33 is abundantly released in the serum of polytraumatized patients immediately after their injuries occurred. As initial IL-33 levels were particularly high in individuals experiencing both PLI and ARDS, IL-33 release after trauma seems to be involved in the promotion of ARDS and might serve already at admission as a solid indicator of impending death in polytraumatized patients.

Systemic release of heat-shock protein 27 and 70 following severe trauma

Trauma represents a major cause of morbidity and mortality worldwide. The endogenous inflammatory response to trauma remains not fully elucidated. Pro-inflammation in the early phase is followed by immunosuppression leading to infections, multi-organ failure and mortality. Heat-shock proteins (HSPs) act as intracellular chaperons but exert also extracellular functions. However, their role in acute trauma remains unknown. The aim of this study was to evaluate serum concentrations of HSP 27 and HSP 70 in severely injured patients. We included severely injured patients with an injury severity score of at least 16 and measured serum concentration of both markers at admission and on day two. We found significantly increased serum concentrations of both HSP 27 and HSP 70 in severely injured patients. Concomitant thoracic trauma lead to a further increase of both HSPs. Also, elevated concentrations of HSP 27 and HSP 70 were associated with poor outcome in these patients. Standard laboratory parameters did not correlate with neither HSP 27, nor with HSP 70. Our findings demonstrate involvement of systemic release of HSP 27 and HSP 70 after severe trauma and their potential as biomarker in polytraumatized patients.

Migration of the Lag Screw after Intramedullary Treatment of AO/OTA 31.A2.1-3 Pertrochanteric Fractures Does Not Result in Higher Incidence of Cut-Outs, Regardless of Which Implant Was Used: A Comparison of Gamma Nail with and without U-Blade (RC) Lag Screw and Proximal Femur Nail Antirotation (PFNA)

The best intramedullary nail for the treatment of unstable AO/OTA 31.A2.1-3 fractures remains uncertain. A total of 237 patients (45 male, 192 female) were eligible for the assessment with an average age of 81.9 ± 10.5 years and a minimum follow-up of six months. We assessed the cut-out rate, the TAD and calTAD (Tip Apex distance) of three different implants. An overall cut-out rate of 2.5% (n = 6) was observed. The cut-out rate was 1.2% (n = 1) in the Proximal Femur Nail Antirotation (PFNA) group, 3.7% (n = 3) in the Gamma Nail group and 2.9% (n = 2) in the Gamma3^® with a U-Blade (RC) lag-screw group. The TAD and calTAD differed between the cut-out and non-cut group-20.0 mm vs. 18.5 mm and 13.1 mm vs. 15.3 mm, respectively. A significantly higher TAD of 32.5 mm could be seen in the cut-out after PFNA (p < 0.0001). The only significant change in follow-up using Parker's ratio was observed in the PFNA group (p < 0.0001). The rate of patients requiring surgery after complications was 8.4% (n = 20) without any significant difference between the three groups. The PFNA blade showed significant migration within the femoral head, however the cut-out rate remained the smallest compared to Gamma3 with or without additional U-Blade (RC) lag screw.

Increased serum concentrations of soluble ST2 are associated with pulmonary complications and mortality in polytraumatized patients

BACKGROUND

We sought to evaluate the role of soluble ST2 (suppression of tumorigenicity) serum concentrations in polytraumatized patients and its potential role as biomarker for pulmonary complications.

METHODS

We included severely injured patients (injury severity score≥16) admitted to our level I trauma center and analyzed serum samples obtained on the day of admission and on day 2. Furthermore, patients with isolated thoracic injury and healthy probands were included and served as control groups. Serum samples were analyzed for soluble ST2 concentrations with a commercially available ELISA kit.

RESULTS

A total of 130 patients were included in the present study. Five patients with isolated thoracic injury and eight healthy probands were further included. Serum analyses revealed significantly elevated concentrations of soluble ST2 in polytraumatized patients compared to patients suffering from isolated thoracic trauma and healthy probands. In polytraumatized patients who developed pulmonary complications (acute respiratory distress syndrome and pneumonia) and in patients who died, significantly higher serum concentrations of soluble ST2 were found on day 2 (p<0.001). Serum concentrations of soluble ST2 on day 2 were of prognostic value to predict pulmonary complications in polytraumatized patients (area under the curve=0.720, 95% confidence interval=0.623-0.816). Concomitant thoracic trauma had no further impact on serum concentrations of soluble ST2.

CONCLUSIONS

Serum concentrations of soluble ST2 are upregulated following polytrauma. Increased concentrations were associated with worse outcome.

The impact of polytrauma on sRAGE levels: evidence and statistical analysis of temporal variations

Background

According to recently published findings, levels of the soluble receptor of advanced glycation end products (sRAGE) and its clearance from the blood may reflect the evolution of lung damage during hospitalization. Thus, the objective of this study was to reveal the course of sRAGE levels over the first three posttraumatic weeks, focusing on the severity of thoracic trauma and the development of acute respiratory distress syndrome (ARDS) and/or pneumonia.

Methods

Twenty-eight consecutive surviving polytraumatized patients suffering thoracic trauma, age ≥ 18 years, Injury Severity Score ≥ 16, and directly admitted to our level I trauma center were enrolled in this prospective study. Blood samples were taken initially and on days 1, 3, 5, 7, 10, 14, and 21 during hospitalization. Luminex multi-analyte-technology was used for biomarker analysis.

Results

Common to all our patients was an almost continuous decline of sRAGE levels within the first five posttraumatic days. Day 0 levels in polytrauma victims with severe thoracic trauma were more than twice as high than in those suffering mild thoracic trauma (p = 0.035), whereas the difference between the two groups did not reach significance from day 1. Neither the development of ARDS and/or pneumonia nor the necessity of secondary surgery did result in significant differences in sRAGE levels between the subgroups with and without the particular complication at any time point.

Conclusions

sRAGE levels assessed immediately after hospital admission might serve as a diagnostic marker for the vehemence of impacts against the chest and thus might be applied as an additional tool in diagnosis, risk evaluation, and choice of the appropriate treatment strategy of polytraumatized patients in routine clinical practice.

Clinical outcomes after treatment of quadriceps tendon ruptures show equal results independent of suture anchor or transosseus repair technique used - A pilot study

Biomechanical studies have shown the use of suture anchors (SA) to be superior to the traditional transosseous sutures (TS) in the repair of quadriceps tendon rupture (QTR). This study aimed to analyze and compare the functional outcomes of patients treated for quadriceps tendon ruptures using suture anchors or transosseous sutures. Patients having undergone suture anchor repair or transosseous suture repair for quadriceps tendon rupture between 2010 and 2015 at one of the two participating hospitals were included. Patients from site A underwent TS repair (TS group) while patients from site B underwent SA repair (SA group). Exclusion criteria included previous or concomitant injuries of the involved knee, penetrating injuries and pre-existing neurological conditions. Clinical outcome was assessed by subjective scores (Lysholm and Tegner Scores, International Knee Documentation Committee (IKDC) Score, Visual Analog Scale (VAS) for pain), quadriceps isokinetic strength testing, Insall-Salvati Index (ISI), and physical examination. Non-parametrical statistical analysis was conducted using the Mann-Whitney U test. Twenty-seven patients were included in the study of which 17 patients (63%) were available for follow-up (SA group: 9, TS group: 8). All patients were male with a mean age of 62.7 (SD: 8.8) and 57.9 (SD: 12.7) years for the SA group and TS group, respectively. The groups did not differ in terms of demographic characteristics. No clinically significant differences were identified between the two groups. There were no re-ruptures in either group. Treatment of quadriceps tendon rupture using suture anchors provides a clinically valid alternative treatment to the gold-standard transosseous suture repair.

Thoracic trauma and acute respiratory distress syndrome in polytraumatized patients: a retrospective analysis

BACKGROUND

Although thoracic trauma has often been associated with the development of acute respiratory distress syndrome (ARDS) in general, its impact on ARDS in combination with severe concomitant injuries has still to be elucidated. Therefore, the objective of this study was to determine the frequency of thoracic trauma and ARDS in polytraumatized patients, and to evaluate the impact of thoracic trauma on the occurrence and the onset of ARDS.

METHODS

Included in this retrospective cohort study were all polytraumatized patients over 18 years of age, with an injury severity score (ISS) of at least 16, who were admitted to our level I trauma center over a three-year time period.

RESULTS

Two hundred and eighty-eight patients met the inclusion criteria. 54.9% suffered from thoracic trauma, 51.7% developed ARDS, 21.5% pneumonia and 0.7% pulmonary embolism. Independent of the ISS, the presence of thoracic trauma increased the odds of ARDS occurrence (OR=2.242; 95% CI: 1.381-3.640; P<0.001) and resulted in a significantly earlier onset of ARDS (median, day 2 vs. day 3; P<0.01). Of those patients suffering from ARDS, ventilation time and length of stay at the ICU were longer if a concomitant thoracic injury was present (P<0.001). In general, ARDS was diagnosed prior to pneumonia and was therefore identified as its risk factor (OR=11.033; 95% CI: 4.812-25.299; P<0.001). Finally, an overall mortality rate of 21.2% was observed, which was neither affected by thoracic trauma nor ARDS.

CONCLUSIONS

Thoracic trauma was identified as major risk factor for ARDS occurrence and earlier onset in polytrauma victims.

Matrix Production Affects MRI Outcomes After Matrix-Associated Autologous Chondrocyte Transplantation in the Knee

BACKGROUND

Matrix-associated autologous chondrocyte transplantation (MACT) has been an effective therapy for large, full-thickness cartilage lesions for years. However, little is known about how graft maturation is affected by characteristics of transplanted chondrocytes.

PURPOSE

To investigate the influence of gene expression of chondrocytes at the time of transplantation on MRI outcomes up to 2 years after MACT.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study included 25 patients with 27 symptomatic traumatic defects of articular cartilage, who had undergone MACT in the knee. Postoperative MRI examinations were conducted at 3, 6, 12, and 24 months after surgery. Biochemical graft maturation was assessed by measuring T2 relaxation time values of the transplant and healthy native cartilage areas. The MOCART (magnetic resonance observation of cartilage repair tissue) score was used to evaluate the morphological quality of regeneration tissue. Gene expression (collagen type I, collagen type II, aggrecan, versican, and interleukin-1β) was determined by real-time polymerase chain reaction (PCR) in transplant residuals at the time point of transplantation and was correlated with MRI outcomes using Spearman's rank correlation coefficient. A Friedman test with post hoc analysis (Wilcoxon signed rank test) conducted with a Bonferroni correction was applied to compare scores at different time points.

RESULTS

T2 relaxation time of regeneration tissue improved from a mean ± SD of 74.6 ± 20.1 milliseconds at 3 months to 47.9 ±13.3 milliseconds at 24 months ( P < .003). These values were similar to the T2 relaxation times of the native surrounding cartilage (50.9 ± 15 ms). The calculated T2 index (ratio of regeneration tissue to native cartilage) improved from 1.63 ± 0.76 at 3 months to 1.0 ± 0.4 at 24 months ( P < .011). The MOCART score increased from 51.6 ± 15 points to 72.4 ± 12.2 points ( P < .001). Improvement of the T2 index over time significantly correlated with aggrecan, COL1A1, COL2A1, and versican expression ( r_s = 0.9, P < .001; r_s = 0.674, P < .012; r_s = 0.553, P < .05; and r_s = 0.575, P < .04, respectively). No correlation was found for IL-1β.

CONCLUSION

These data demonstrate that matrix production in transplanted chondrocytes affects maturation of MACT grafts in MRI 2 years after surgery.

Redifferentiation of aged human articular chondrocytes by combining bone morphogenetic protein-2 and melanoma inhibitory activity protein in 3D-culture

Melanoma inhibitory activity (MIA) affects the differentiation to hyaline cartilage and can inhibit the osteogenic potential of bone morphogenetic protein (BMP)-2 in mesenchymal stem cells (MSC). The aim of this study was to investigate if MIA also inhibits the osteogenic potential of BMP-2 in human articular chondrocytes during redifferentiation, which may lead to a higher grade of differentiation without calcification. HAC of four female patients (mean age: 73.75 ±6.98) were seeded into 3D culture for 28 days; after adding the recombinant proteins, four groups were formed (Control, BMP-2, MIA, BMP-2+MIA). Samples were analysed for gene expression, glycosaminoglycan (GAG) content and histology on day 0, 14 and 28. Collagen type 2 (COL2A1) was significantly increased in the BMP-2 containing groups on day 28; BMP-2 (100-fold, p = 0.001), BMP-2+MIA (65-fold, p = 0.009) and similar to the level of native cartilage. Higher aggrecan (Agg) levels were present in the BMP-2 (3-fold, p = 0.007) and BMP-2+MIA (4-fold, p = 0.002) group after 14 days and in the BMP-2 (9-fold, p = 0.001) group after 28 days. Collagen type 10 (COL10A1) was increased in the BMP-2 containing groups (6-fold, p = 0.006) but these levels were significantly below native cartilage. Alkaline phosphatase (ALP), collagen type 1 (COL1A1) and the glycosaminoglycan (GAG) content did not reveal any relevant differences between groups. BMP-2 is a potent inducer for differentiation of HAC. A significant enhancement of this effect in combination with MIA could not be observed. Furthermore no significant reduction of osteogenic markers during re-differentiation of chondrocytes was present combining BMP-2 and MIA.

Thoracic trauma and acute respiratory distress syndrome in polytraumatized patients: a retrospective analysis

BACKGROUND

Although thoracic trauma has often been associated with the development of acute respiratory distress syndrome (ARDS) in general, its impact on ARDS in combination with severe concomitant injuries has still to be elucidated. Therefore, the objective of this study was to determine the frequency of thoracic trauma and ARDS in polytraumatized patients, and to evaluate the impact of thoracic trauma on the occurrence and the onset of ARDS.

METHODS

Included in this retrospective cohort study were all polytraumatized patients over 18 years of age, with an injury severity score (ISS) of at least 16, who were admitted to our level I trauma center over a three-year time period.

RESULTS

Two hundred and eighty-eight patients met the inclusion criteria. 54.9% suffered from thoracic trauma, 51.7% developed ARDS, 21.5% pneumonia and 0.7% pulmonary embolism. Independent of the ISS, the presence of thoracic trauma increased the odds of ARDS occurrence (OR=2.242; 95% CI: 1.381-3.640; P<0.001) and resulted in a significantly earlier onset of ARDS (median, day 2 vs. day 3; P<0.01). Of those patients suffering from ARDS, ventilation time and length of stay at the ICU were longer if a concomitant thoracic injury was present (P<0.001). In general, ARDS was diagnosed prior to pneumonia and was therefore identified as its risk factor (OR=11.033; 95% CI: 4.812-25.299; P<0.001). Finally, an overall mortality rate of 21.2% was observed, which was neither affected by thoracic trauma nor ARDS.

CONCLUSIONS

Thoracic trauma was identified as major risk factor for ARDS occurrence and earlier onset in polytrauma victims.

Treatment options and outcome after bony avulsion of the flexor digitorum profundus tendon: a review of 29 cases

INTRODUCTION

The objective of this retrospective review was to evaluate the functional and esthetic outcomes in patients with non- or minimally (<2 mm), and severely (>2 mm) displaced bony avulsions of the flexor digitorum profundus (FDP) tendon.

MATERIALS AND METHODS

Between 1996 and 2010, 29 patients with a bony avulsion of the FDP tendon were treated. The displacement magnitude of the avulsed fragment determined, whether conservative or surgical treatment was performed. Persisting functional deficit, radiological findings, remaining disabilities using the Disability of the Arm, Shoulder, and Hand (DASH) score, as well as treatment-related deformities and complications were evaluated retrospectively and at a mean follow-up of 7 years.

RESULTS

In 16 patients, conservative therapy by initial static splinting due to a fragment displacement of <2 mm was conducted. These patients reported no functional impairment at follow-up. In 13 cases, major displacement (>2 mm) of the bony fragment led to an open reconstruction of the avulsion injury either by screw fixation or a Lengemann pull-out wire. In a majority, an extension deficit in the DIP joint and a decrease of tip pinch strength by 25% was present at follow-up. In five patients, peri- or short-term postoperative complications occurred and in five, a nail deformity remained. DASH score revealed satisfying results after both therapeutic approaches.

CONCLUSIONS

Conservative treatment in non- or minimally displaced avulsions leads to satisfying functional results. Patients receiving surgery after major fragment displacement need to be aware of a possible impaired ROM at the DIP joint. The use of the Lengemann pull-out wire may place patients at an increased complication risk and frequently induces nail deformities.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Does an additional antirotation U-Blade (RC) lag screw improve treatment of AO/OTA 31 A1-3 fractures with gamma 3 nail?

INTRODUCTION

Poor bone quality and unstable fractures increase the cut-out rate in implants with gliding lag screws. The U-Blade (RC) lag screw for the Gamma3^® nail was introduced to provide monoaxial rotational stability of the femoral head and neck fragment. The purpose of this study was to evaluate whether the use of the U-Blade (RC) lag screw is associated with reduced cut-out in patients with OTA/AO 31A1-3 fractures.

MATERIAL & METHODS

Between 2009 and 2014, 751 patients with OTA/AO 31A1-3 fractures were treated with a Gamma3^® nail at our institution. Out of this sample 199 patients were treated with U-blade (RC) lag screws. A total of 135 patients (117 female, 18 male) with standard lag screw (treatment group A) were matched equally regarding age (±4 years) sex, fracture type and location to 135 patients with U-blade (RC) lag screw (treatment group B). Within a mean follow up of 9.2 months (range 6-18 months) we assessed the cut-out rate, the calTAD, lag screw migration, the Parker's mobility score and the Parker's ratio at postoperatively, six and 12 months following surgery. Furthermore we recorded all complications, ASA-Score, hospital stay and duration of surgery retrospectively.

RESULTS

The most common fracture among group B with a cut-out of the lag screw were AO/OTA 2.3 and 3.2 fractures whereas in group A cut-out was most commonly seen in AO/OTA 2.1, 2.2 and 2.3 fractures, there was no significant reduction of the cut-out rate in group B 2.2% (n=3) compared to group A 3.7% (n=5). The duration of surgery was significantly shorter in group A (p<0.05). There was no significant difference in lag screw placement, the Parker's ratio and mobilization.

CONCLUSION

In our study the U-Blade (RC) lag screw did not reduce the cut-out in treatment of OTA/AO 31A1-3 fractures at all. Considering the longer duration of surgery and the higher costs of the U-Blade (RC) lag screw, our results do not justify its use. However, further prospective randomized studies will be necessary.

Soluble Receptor for Advanced Glycation End Products Quantifies Lung Injury in Polytraumatized Patients

BACKGROUND

Biomarkers caused by blunt chest trauma might leak into the vascular compartment and therefore reflect the severity of parenchymal lung injury (PLI). Five promising proteins were preselected after a literature scan. The objective of our study was to identify a biomarker that is released abundantly into the serum shortly after trauma and reliably quantifies the loss of functional lung tissue.

METHODS

Polytraumatized patients (aged ≥18 years, Injury Severity Score [ISS] ≥16) were included in our prospective observational study if they were admitted directly to our level I trauma center during the first hour after trauma occurred. Immediately after stabilizing the patient's condition, blood samples were taken and a whole-body computed tomographic (CT) scan was obtained. Biomarker levels were measured directly after admission and on day 2. PLI volume was calculated using volumetric analysis.

RESULTS

One hundred thirty patients met the inclusion criteria. Compared with a matched healthy control population, median levels of the soluble receptor for advanced glycation end products (sRAGE) was almost 3 times higher and decreased by 41% on day 2. Higher initial median sRAGE levels were detected in patients with PLI compared with patients without PLI and in individuals with severe PLI compared with those with mild PLI. Spearman correlation analysis and a univariate linear log regression model revealed a significant correlation/equation between initial sRAGE levels and relative PLI volume. Receiver operating characteristic (ROC) statistics identified the initial sRAGE level as an indicator of severe PLI.

CONCLUSIONS

sRAGE levels measured shortly after trauma seem to be a promising diagnostic tool to assess the severity of PLI in polytraumatized patients.

The clinical benefit of a follow-up thoracic computed tomography scan regarding parenchymal lung injury and acute respiratory distress syndrome in polytraumatized patients

PURPOSE

To evaluate the increase of parenchymal lung injury (PLI) volume between the initial and a follow-up computed tomography (CT) scan and to ascertain which of the 2 scans was more appropriate to predict acute respiratory distress syndrome (ARDS).

MATERIAL AND METHODS

From 2011 to 2015, polytraumatized patients (≥18 years; ISS ≥ 16) directly admitted to our level I trauma center were included in our prospective study if a follow-up CT scan was possible 24 to 48 hours after the trauma. The PLI volume was measured using volumetric analysis. Statistical calculations were performed to identify patients at risk for ARDS.

RESULTS

One hundred thirty patients (mean age, 41.3 years; mean ISS, 31.9) met the inclusion criteria. Median relative PLI volume was higher in the follow-up than in the initial CTs (9.65% vs 4.84%; P = .001). The ARDS developed in 42 patients (32.3%). Their initial PLI volume was higher compared with those without ARDS (11.23% vs 2.14%; P < .0001). The ARDS incidence increased with increasing initial PLI volume. Receiver operating characteristic statistics identified initial (area under the curve = 0.753) and follow-up relative PLI volume as a predictor for ARDS (area under the curve = 0.725).

CONCLUSIONS

The CT scans performed directly after admission are sufficient to define patients at risk for ARDS. Therefore, solely the incidence of PLI does not justify a routine follow-up CT scan.

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.

Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center

BACKGROUND

Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children.

HYPOTHESIS

We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached.

PURPOSE

To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome.

PATIENTS AND METHODS

Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score.

RESULTS

Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up.

DISCUSSION

Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

Preliminary findings on biomarker levels from extracerebral sources in patients undergoing trauma surgery: Potential implications for TBI outcome studies

BACKGROUND

Despite several experimental studies on the role of S100B and NSE in fractures, no studies on the influence of surgery on the biomarker serum levels have been performed yet.

METHODS

The serum levels of S100B and NSE were analysed in patients with fractures that were located in the spine (group 1, n = 35) or in the lower extremity (group 2, n = 32) pre- and post-operatively.

RESULTS

The mean S100B serum level showed a significant increase (p = 0.04) post-surgery in the patients of group 1. In patients undergoing acute surgery (< 24 hours) the mean S100B serum level was 0.23 ± 0.22 μg L(-1) pre-operatively and 1.24 ± 1.38 μg L(-1) post-operatively. Likewise, the mean S100B serum level significantly increased in group 2 after surgery (p < 0.0001). In this group patients undergoing acute surgery showed a mean S100B serum level of 0.23 ± 0.14 μg L(-1) and 1.11 ± 0.73 μg L(-1) pre- and post-operatively.

CONCLUSION

This study demonstrates significant alterations of the biomarker S100B serum levels in patients undergoing surgery. Higher S100B serum levels were found within 24 hours and might be related to the acute fracture. The NSE serum levels were unchanged and this biomarker may offer the probability to serve as a future outcome predictor in studies with patients with traumatic brain injury and additional extracerebral injuries.