In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®

PURPOSE

Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma.

METHODS

We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality.

RESULTS

We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group.

CONCLUSIONS

There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.

[Treatment strategy for severe implosion injuries of the lateral chest wall]

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update

PURPOSE

Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change.

CONCLUSION

Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.

[VATS in Thorax Trauma]

Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group - as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) - has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today's better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH₂O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

[Treatment of Persistent Parenchymal Lung Injuries in Thoracic Trauma: Lung Laceration, Pleural Fistula and Pneumothorax]

Thoracic trauma is a frequent injury pattern with high patient morbidity and mortality. Preclinical and clinical emergency treatment is consented in a national S3-guideline. Following emergency therapy one third of patients may develop lung lacerations, pleural fistulation and persisting pneumothorax. An interdisciplinary working group of the German Society for Thoracic Surgery and the German Society for Traumatology reviewed the published medical literature on treatment of those injuries and assessed the existing evidence according to consensus recommendations. An inconsistent classification of those subsequent lung injuries was found. Evidence for diagnostic and therapeutic recommendations is small.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry

Purpose

In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.

Methods

Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS)  ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.

Results

After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).

Conclusions

We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

Is intrathoracic rib plate fixation advantageous over extrathoracic plating? A biomechanical cadaveric study

BACKGROUND

The high morbidity following surgical interventions on the chest wall because of large incisions often prevents surgeons from operative rib fracture treatment. Minimally invasive approaches to the intrathoracic side of the rib could allow for smaller incisions with lower morbidity while maintaining stability of fixation. The aim of this study was to explore the biomechanical competence of intrathoracic versus extrathoracic plating in a human cadaveric rib fracture model and investigate the effect of plating using two versus three screws per fracture fragment.

METHODS

Twenty pairs of fresh-frozen human cadaveric ribs from elderly female donors aged 82.4 ± 7.8 years were used. First, the stiffness of each native rib was calculated via nondestructive (2 N-5 N) biomechanical testing under two loading conditions: ramped two-point bending and combined ramped tensile bending with torsional loading. Second, the ribs were fractured under three-point bending with their intrathoracic side put under tensile stress. Third, specimens were assigned to four groups (n = 10) for either intrathoracic or extrathoracic plating with two or three screws per fragment. Following instrumentation, all ribs were dynamically tested over 400,000 cycles under combined sinusoidal tensile bending with torsional loading (2 N-5 N at 3 Hz). Finally, all specimens were destructively tested under ramped two-point bending.

RESULTS

Following instrumentation and cyclic testing, significantly higher construct stiffness was observed for intrathoracic vs. extrathoracic plating under anatomical loading conditions (p ≤ 0.03). No significant differences were detected for implant subsidence after plating with two or three screws per fragment (p ≥ 0.20).

CONCLUSION

This study demonstrates significantly higher construct stiffness following intrathoracic over extrathoracic plating, thus indicating superior plate support of the former. In the clinical context, using only two instead of three screws per fragment not only could maintain stability of fixation but also decrease surgery time and costs, and allow for smaller incisions with lower morbidity.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®

Purpose

In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay.

Methods

Data from the TraumaRegister DGU^® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability.

Results

In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h.

Conclusions

In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®

Purpose

Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax.

Methods

A retrospective analysis of the TraumaRegister DGU^® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF.

Results

73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF.

Conclusion

Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia : A prospective feasibility study

BACKGROUND AND OBJECTIVE

Due to changing demographics geriatric patients with multiple comorbidities and proximal femoral fractures are an increasing patient population. In these patient groups, peripheral regional anesthesia could become increasingly more important besides established procedures, such as neuraxial or general anesthesia. The aim of this single center feasibility study was to evaluate a combined blockade technique of the lumbosacral plexus for three predefined subgroups depending on the type of hip fracture.

METHODS

We used a unilateral double injection three-step technique to block the sacral (parasacral block) and lumbar plexus (anterior quadratus lumborum and psoas compartment block, n = 78). The blockade was performed both under ultrasound guidance and simultaneous nerve stimulation and 20 ml ropivacaine 0.375% was injected at each of the 3 injection sites (total dose 225 mg).

RESULTS

In 42% of cases the surgery was opioid-free (n = 33). In 5 patients a conversion to general anesthesia (insertion of a laryngeal mask and pressure-controlled or pressure-supported ventilation) was necessary (6%). The overall success rate of combination anesthesia (peripheral nerve blocks with supplemental sedative (propofol 1-2 mg/kg*h) or analgesic (incremental doses of 5 µg sufentanil) medication) was 94%, regardless of fracture type and surgical treatment.

CONCLUSION

The combined anesthetic technique presented in this study enables surgical treatment of proximal femoral fractures. The associated effort and requirement for expert knowledge in regional anesthesia indicates that this method should be considered especially in cases with high anesthetic risk, suitable sonoanatomy, and non-compromised coagulation.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

Digital versus analogue record systems for mass casualty incidents at sea-Results from an exploratory study

Objective

Mis-triage may have serious consequences for patients in mass casualty incidents (MCI) at sea. The purpose of this study was to assess outcome, reliability and validity of an analogue and a digital recording system for triage of a MCI at sea.

Methods

The study based on a triage exercise conducted with a cross-over-design. Forty-eight volunteers were presented a fictional MCI with 50 cases. The volunteers were randomly assigned to start with the analogue (Group A, starting with the analogue followed by the digital system) or digital system (Group B, starting with the digital followed by the analogue system). Triage score distribution and agreement between the triage methods and a predefined standard were reported. Reliability was analysed using Cronbach’s Alpha and Cohen’s Kappa. Validity was measured through sensitivity, specificity and predictive value. Treatment, period and carry-over-effects were analysed using a linear mixed-effects model.

Results

The number of patients triaged (total: n = 3545) with the analogue system (n = 1914; 79.75%) was significantly higher (p = 0.001) than with the digital system (n = 1631; 67.96%). A trend towards a higher percentage of correct triages with the digital system was observed (p = 0.282). Ratio of under-triage was significantly smaller with the digital system (p = 0.001). Validity measured with Cronbach’s Alpha and Cohen’s Kappa was higher with the digital system. So was sensitivity (category; green: 80.67%, yellow: 73.24%, red: 83.54%; analogue: green: 93.28%, yellow: 82.36%, red: 94.04%) and specificity of the digital system (green: 78.07%, yellow: 63.75%, red: 66.25%; analogue: green: 85.50%, yellow: 79.88%, red: 91.50%). Comparing the predictive values and accuracy, the digital system showed higher scores than the analogue system. No significant patterns of carry-over-effects were observed.

Conclusions

Significant differences were found for the number of triages comparing the analogue and digital recording system. The digital system has a slightly higher reliability and validity than the analogue triage system.

Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU

Background Thorax trauma frequently occurs in which injuries to the bony chest, lung contusions (LCs), and others are diagnosed. The significance of this violation is described very differently and is mostly based on monocentric data.

Methods A retrospective analysis of the TraumaRegister DGU® (TR-DGU) dataset (Project 2014–062) was performed between 2009 and 2014 (injury severity score [ISS] ≥ 16, primary admission to a trauma center, no isolated traumatic brain injury). Patients with LC (Abbreviated Injury Scale [AIS] 3 + 4) were compared with the control group, and an analysis of different age groups was performed.

Results A total of 49,567 patients were included, thereunder 14,521 (29.3%) without relevant thoracic trauma (TT); 95.9% blunt traumas. 18,892 patients (38.1%) had LC and 14,008 (28.3%) had severe LC with AIS 3 + 4; thereunder 72.7% males. For severe LC, the average age was the lowest (44.7 ± 19.7 years) and ISS the highest (30.4 ± 12.1 points).

Intubation, intensive care, (multi-) organ failure, sepsis, and extrathoracic injuries were most common in severe LC. Shock, chest tubes, further thoracic injuries, and patient death occurred most frequently in TT without LC.

Younger patients showed a higher incidence of LC than the older ones; however, high patient age was a highly significant risk factor for the development of complications and poor outcome.

Conclusion Since LC was present in almost 40% of the severely injured and was related to higher morbidity, LC should be detected and managed at the earliest possible time. Proper follow-ups employing chest X-rays and computed tomography (CT) scans are recommended.

Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data

Introduction

Although shoulder girdle injuries are frequent, those of the medial part are widely unexplored. Our aim is to improve the knowledge of this rare injury and its management in Germany by big data analysis.

Methods

The data are based on ICD-10 codes of all German hospitals as provided by the German Federal Statistical Office. Based on the ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD), anonymized patient data from 2012 to 2014 were evaluated retrospectively for epidemiologic issues. We analyzed especially the concomitant injuries and therapy strategies.

Results

A total of 114,003 cases with a clavicle involving shoulder girdle injury were identified with 12.5% of medial clavicle injuries (MCI). These were accompanied by concomitant injuries, most of which were thoracic and craniocerebral injuries as well as injuries at the shoulder/upper arm. A significant difference between MCF and SCJD concerning concomitant injuries only appears for head injuries (p = 0.003). If MCI is the main diagnosis, soft tissue injuries typically occur as secondary diagnoses. The MCI are significantly more often associated with concomitant injuries (p < 0.001) for almost each anatomic region compared with lateral clavicle injuries (LCI). The main differences were found for thoracic and upper extremity injuries. Different treatment strategies were used, most frequently plate osteosynthesis in more than 50% of MCF cases. Surgery on SCJD was performed with K-wires, tension flange or absorbable materials, fewer by plate osteosynthesis.

Conclusions

We proved that MCI are rare injuries, which might be why they are treated by inhomogeneous treatment strategies. No standard procedure has yet been established. MCI can occur in cases of severely injured patients, often associated with severe thoracic or other concomitant injuries. Therefore, MCI appear to be more complex than LCI. Further studies are required regarding the development of standard treatment strategy and representative clinical studies.

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®

AIM OF THE STUDY

Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated.

METHODS

All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded.

RESULTS

99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries.

CONCLUSION

Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]

BACKGROUND

Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed.

OBJECTIVE

A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options.

MATERIAL AND METHODS

Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed.

RESULTS AND DISCUSSION

Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

From pullout-techniques to modular elastic stable chest repair: the evolution of an open technique in the correction of pectus excavatum

BACKGROUND

Traditionally open procedures have been replaced by minimally invasive techniques in the correction of pectus excavatum. Efforts to improve the extent of mobilization of the chest wall and its stabilization have led to constant modifications. There is currently no consensus about the best procedure for correction of pectus excavatum.

METHODS

Based on the contributions of a single institution for the last 60 years, we present the various strategies used for the correction of pectus excavatum and the evolution of operational procedures. These approaches are compared with those performed internationally at similar periods.

RESULTS

Resections with external extension achieved moderate results and were modified in 1962 to the "Shred" method. The establishment of the "Strut" method in 1963 and, in 1977, its extension with the erection of the lower rib arches significantly improved patient outcomes. The "minimization" of the procedure in 2006 was accompanied by an increase in wound healing disorders and recurrent deformities. Since 2010, elastic stable chest repair (ESCR) has provided lossless mobilization and sternal elevation for healing costosternal pseudarthrosis and allowed correction of complex recurrences with excellent cosmetic-functional results. Strong asymmetric or broad-base deformities can now be stabilized using a modular hybrid technique of transsternal bar and locked plates.

CONCLUSIONS

ESCR marks the end of the 60-year development of an open procedure and, after loss-free mobilization of the chest wall by elastic-stable biomechanical management, optimizes the possibility of anatomical reconstruction of the chest wall during initial and re-interventions, achieving a permanent, physiologically stable remodeling of the chest wall.

Elastic stable chest repair and its hybrid variants in 86 patients with pectus excavatum

Background

Complex and mature funnel chest deformities are traditionally managed with open surgical procedures. Elastic stable chest repair (ESCR) has been used successfully and safely for relapse corrections. Does pure plate osteosynthesis in ESCR allow comparable corrective potency and implant safety as hybrid methods with metal bars?

Methods

Data from 86 patients with open funnel chest correction between 2011 and 2015 were analyzed in this retrospective study. Exclusion criteria included being under 12 years of age, and having a history of septic wound healing disorder or other malignant diseases. Main groups consisted of ESCR and hybrid techniques, subgroups were primary and recurrence correction. Correction results and follow-up examinations at six and 12 weeks and at 1 year were statistically analyzed.

Results

A total of 38 ESCR and 48 hybrid methods were analyzed. Bar implantation was required in 77% (recurrence 34%) of patients. All patients received plates with different combinations e.g., longitudinal-sternal, costosternal and costo-sterno-costal. In all groups, follow-up uptake showed a funnel chest correction result at the anatomical level with healthy values according to the Haller index (ESCR 4.36-2.84, hybrid 6.99-2.74, P<0.001). No material dislocations were observed in any subgroup.

Conclusions

ESCR and hybrid techniques represent promising and safe therapeutic approaches.

Age Distribution and Concomitant Injuries in Pulmonary Contusion: An Analysis Based on Routine Data

Background As the population ages, low-energy thoracic injuries are becoming increasingly relevant in individual injuries, particularly pulmonary contusions (PCs) and their common concomitant injuries. The objective of this study was to determine the prevalence and age distribution of thoracic trauma, especially PC, to make conclusions about common secondary diagnoses and developments in management.

Methods A retrospective analysis of 209,820 cases, based on German routine data from the years 2009 to 2015, with a main diagnosis (MD) or secondary diagnosis (SD) of thoracic trauma (S27 according to ICD-10) was performed. The entire patient collective with a MD of S27 was examined as well as those with PCs (S27.31).

Results In all 61,016 patients with a MD of S27, 7,558 (12.4%) had a MD of PC and among the 148,804 patients with a SD of S27, 58,247 patients (39.1%) had a SD of PC. PC occurs mostly in the age groups of 20 to 25, 45 to 50, and 70 to 75 years. The proportion of older people tends to be increasing. The most concomitant thoracic injuries were serial rib fractures (27.1%), pneumothorax (11.9%), and sternum fractures (6.2%). Computed tomography scan is the most common diagnostic tool in PC (MD >80%, SD >60%). Therapeutically, intensive care (>50%) and chest drainage are most important (MD: 12.5%, SD: 60.1%), while operative measures are rare (≤ 4%).

Conclusion PC shows a marked increase in the incidence, especially in older patients and as a companion diagnosis in thoracic injuries. It should be diagnosed early as well as its concomitant injuries to avoid complications.

[Lesions of the anterior chest wall-significance of additional fractures of the spine]

BACKGROUND

Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures.

OBJECTIVE

The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature.

MATERIAL AND METHODS

Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented.

RESULTS

In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment.

CONCLUSION

In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification

Introduction: Although shoulder girdle injuries are frequent, those of the medial clavicle are widely unexplored. An applied classification is less used just as a standard management. Methods: A retrospective analysis of medial clavicle injuries (MCI) during a 5-year-term in a Level-1-Trauma-Center. We analyzed amongst others concomitant injuries, therapy strategies and the classification following the AO standards. Results: 19 (2.5%) out of 759 clavicula injuries were medial ones (11 A, 6 B and 2 C-Type fractures) thereunder 27,8% were displaced and thus operatively treated Locked plate osteosynthesis was employed in unstable fractures and a reconstruction of the ligaments at the sternoclavicular joint (SCJ) in case of their disruption. 84,2% of the patients sustained relevant concomitant injuries. Numerous midshaft fractures were miscoded as medial fracture, which limited the study population. Conclusions: MCI resulted from high impact mechanisms of injury, often with relevant dislocation and concomitant injuries. Concerning medial injury's complexity, treatment should occur in specialized hospitals. Unstable fractures and injuries of the SCJ ligaments should be considered for operative treatment. Midshaft fractures should be clearly distinguished from the medial ones in ICD-10-coding. Further studies are required also regarding a subtyping of the AO classification for medial clavicle fractures including ligamental injuries.

Surgical Stabilization of Costoclavicular Injuries - A Combination of Flail Chest Injuries and a Clavicula Fracture

Background: Flail chest injuries (FCI) are associated with a high morbidity and mortality rate. As a concomitant clavicle fracture in FCI even worsens the outcome, the question is how can those costoclavicular injuries (CCI) be managed surgically. Methods: 11 patients with CCI were surgically treated by a locked plate osteosynthesis of the Clavicle and the underlying ribs through limited surgical approaches under general anesthesia. Patients were followed up after 2, 6, 12, 26 and 52 weeks. Results: All patients showed severe chest wall deformity due to severely displaced fractures of the ribs and the clavicle. They were suffering from pain and restriction of respiratory movements. The chest wall could be restored to normal shape in all cases with uneventful bone healing and a high patient convenience. Fractures of the clavicle and the second rib were managed through an innovative clavipectoral approach, the others through standard approaches to the anterolateral and the posterolateral chest wall. Two patients complained about numbness around the lateral approach and lasting periscapular pain. Conclusions: Surgical stabilization might be the appropriate therapy in CCI with dislocated fractures since they would cause severe deformity and loss of function of the chest wall and the shoulder.

The Operative Management of Flail Chest Injuries with Concomitant Sternal Fracture

Background: Flail Chest Injuries (FCI) are one of the most severe thoracic injuries. Moreover, an additional sternal fracture (SF) even worsens the outcome, such as the duration of mechanical ventilation, therefore an surgical fixation of the fractures could be considered in certain cases to improve the weaning from the ventilator. This paper aims to emphasize on the management of different types of SF in FCI. Methods: All surgically treated cases (2012-2016) that showed the combination of FCI and SF have been evaluated for their clinical details, the morphology of the fractures and the technical aspects of the surgical procedure in a retrospective investigation. Results: All of the SF (n=15) had been fixed by locked plate osteosynthesis through a median approach in a supine position. Three main regions of the sternum showed the need for different fixation strategies: the upper manubrium, central and lower corpus sterni. Concomitant rib fractures were addressed either through the same approach or through additional limited incisions. Conclusions: Combinations of SF and FCI are high risc injuries with high demand on surgical skills. They can be properly fixed with a locking plate osteosynthesis through a combination of limited incisions employing different types of plates depending on the type of SF.

Fractures of the manubrium sterni: treatment options and a possible classification of different types of fractures

Background

Sternum fractures are mostly located on the sternal corpus, seldom on the manubrium. Fractures of the sternal manubrium are, however, more frequently associated with severe concomitant injuries of thoracic organs, and therefore deserve special attention. In addition, in its function as a capstone in between the anterior chest wall and the shoulder girdle, it is exposed to a multiplicity of forces. Therefore the questions arise what types of fractures are observed in today's clinical practice, how to classify them and which treatment options are available. This study reports on different types of fractures which involve the manubrium sterni.

Methods

Between January 2012 and October 2014, data was collected from all severely injured patients (ISS ≥16), which received a CT scan of the thorax in our Level-I-Trauma Center and retrospectively analyzed concerning sternal fractures. Fracture type, collateral injuries, age, and information about the circumstances of the accident were noted.

Results

Of 890 evaluable patients, 154 (17.3%) had a fracture of the sternum and 23 (2.6%) of the manubrium. Fractures of the manubrium appeared in following types: A-type-transverse fracture (n=11) in 1st intercostal space by direct blunt trauma or flexion of the torso with sagittal instability; B-type-oblique fracture (n=9) by seat belt injury with rotatory instability; C-type-combined, more fragmentary fracture (n=3) by direct blunt trauma with simultaneous flexion of the torso and multi directional instability. Fractures only little dislocation were treated conservatively, and unstable fractures were surgically stabilized (n=10).

Conclusions

In summary, three main types of fractures could be found. A-type fractures were stabilized with a longitudinal plate osteosynthesis and B-type fractures with transverse positioned plates. To treat complex C-type fractures, plates with a T- or H-form could be a good solution. Level of evidence: Level III retrospective prognostic cohort study.

Injuries of the Sternoclavicular Joint - An Innovative Approach in the Management of a Rare Injury: Tight Rope Fixation of the Costo-Clavicular Ligament

Background: The costoclavicular ligament (CCL) provides the most tight stability within the sternoclavicular joint (SCJ), followed by the most cited sternoclavicular ligaments (SCL). Their disruption may cause severe instability of the SCJ. Different treatment options, such as the use of plates, wires or autologous tendons are associated with mainly limited functional outcome. Could a stabilization of CCL next to an anatomic fixation of the SCL provide sufficient reconstruction of the SCJ? Methods: A 58-year-old male showed severe anterior and painful instability of the SCJ following a fall on his shoulder 8 weeks ago. The SCJ had been reconstructed in an open procedure with stabilization of the CCL employing 2 tight ropes and anatomical suture of the SCL. Follow-up was carried out 78 weeks after operation. Results: The reduction of the SCJ was successful. X-ray proved the anatomic position of the SCJ. Pain was decreased in between the first 6 weeks. The patient showed uneventful follow-up and returned to work 6 months after the procedureas a hard working farmer. Conclusions: Innovative stabilization of the CCL with tight ropes additional to a suture of the SCL may enable anatomic reconstruction of the SCJ considering cosmetic and functional results.

Analysis on the Age Distribution of Sternum Fractures

BACKGROUND

Sternum fractures (SFs) are described as a rare entity of bony fractures. Various accident mechanisms may cause SF such as the direct impact of traffic accidents and also by indirect mechanisms within the framework of falls. Osteoporotic fractures also play an increasing role in SF, but no reliable data on the age distribution of SF in a representative collective have been published so far.

MATERIAL AND METHODS

The age distribution of all inpatients treated with SF (S22.2) in Germany from 2005 to 2012 using diagnosis-related group-based routine data was evaluated. Various accident statistics are included in the interpretation of age peaks.

RESULTS

A total of 47,893 patients (24,960 as main diagnosis and 22,933 as secondary diagnosis) were included in the study. SF is a rarity in childhood, with a share of 1.83% before the age of 16 years, followed by a sudden increase in the frequency up to the age of 20 years. A decrease in the frequency is observed up to the age of 35 years before it increases again to the age of 75 years. Three age peaks can be observed at 18, 55, and 75 years. Those who are older than 65 years account for 43.3% of total SF.

DISCUSSION AND CONCLUSION

The first age summit after the age of 16 years shows an identical course to the frequency of traffic accidents of this age group, as well as the decline to the fourth decade and the subsequent resurgence up to the fifth decade. After 65 years, the incidence of accidents increases, in particular, the risk of falling in elderly people. In the context of a weaker bone structure, low falls are a common course for fragility fractures. The present analysis of routines shows for the first time the age distribution of the SF taking into account all hospital cases of the observation period.

Does an external chest wall measurement correlate with a CT-based measurement in patients with chest wall deformities?

BACKGROUND

Measurements in chest wall deformities are typically conducted using a thorax caliper or a CT scan of the chest wall. This paper focuses on the possible correlation between these two methods to validate the reliability of the thorax caliper, minimize radiation exposure, and limit the usage of expensive imaging techniques.

METHODS

We evaluated 95 consecutive patients (77 pectus excavatum (PE), 17 pectus carinatum (PC), 1 mixed deformity) who received surgical correction of the anterior chest wall. The results of the external chest wall measurements and the CT-based measurements were statistically compared.

RESULTS

A significant correlation between the two measurements was observed in PE and PC at the highest point of the deformation. The strongest correlation was noted in PE. We also noted a correlation between the transverse diameter of the external measurement and the inner thoracic diameter of the CT scan but not for the sagittal diameters in the upper parts of the sternum.

CONCLUSIONS

Thorax caliper measurements are suitable for determining the sagittal thoracic diameter at the maximum level of the deformity and the transverse diameter with an accuracy comparable to that of CT measurements. Since these values key, the thorax caliper is reliable for monitoring and documenting chest wall malformations.

LEVEL OF EVIDENCE

Study of diagnostic test. Testing previously developed diagnostic criteria in a consecutive series of patients and a universally "gold" standard-Level I.

Three-Dimensional Biomechanical Analysis of Rearfoot and Forefoot Running

Background:

In the running community, a forefoot strike (FFS) pattern is increasingly preferred compared with a rearfoot strike (RFS) pattern. However, it has not been fully understood which strike pattern may better reduce adverse joint forces within the different joints of the lower extremity.

Purpose:

To analyze the 3-dimensional (3D) stress pattern in the ankle, knee, and hip joint in runners with either a FFS or RFS pattern.

Study Design:

Descriptive laboratory study.

Methods:

In 22 runners (11 habitual rearfoot strikers, 11 habitual forefoot strikers), RFS and FFS patterns were compared at 3.0 m/s (6.7 mph) on a treadmill with integrated force plates and a 3D motion capture analysis system. This combined analysis allowed characterization of the 3D biomechanical forces differentiated for the ankle, knee, and hip joint. The maximum peak force (MPF) and maximum loading rate (LR) were determined in their 3 ordinal components: vertical, anterior-posterior (AP), and medial-lateral (ML).

Results:

For both strike patterns, the vertical components of the MPF and LR were significantly greater than their AP or ML components. In the vertical axis, FFS was generally associated with a greater MPF but significantly lower LR in all 3 joints. The AP components of MPF and LR were significantly lower for FFS in the knee joint but significantly greater in the ankle and hip joints. The ML components of MPF and LR tended to be greater for FFS but mostly did not reach a level of significance.

Conclusion:

FFS and RFS were associated with different 3D stress patterns in the ankle, knee, and hip joint, although there was no global advantage of one strike pattern over the other. The multimodal individual assessment for the different anatomic regions demonstrated that FFS seems favorable for patients with unstable knee joints in the AP axis and RFS may be recommended for runners with unstable ankle joints.

Clinical Relevance:

Different strike patterns show different 3D stress in joints of the lower extremity. Due to either rehabilitation after injuries or training in running sports, rearfoot or forefoot running should be preferred to prevent further damage or injuries caused by inadequate biomechanical load. Runners with a history of knee joint injuries may benefit from FFS whereas RFS may be favorable for runners with a history of ankle joint injuries.

Antibacterial Effect of a 4x Cu-TiO₂ Coating Simulating Acute Periprosthetic Infection-An Animal Model

The purpose of our study was to investigate the antibacterial effect of a spacer (Ti6Al4V) coated with 4x Cu-TiO₂ in an animal model simulating an acute periprosthetic infection by Staphylococcus aureus. Ti6Al4 bolts contaminated with Staphylococcus aureus were implanted into the femoral condyle of rabbits (n = 36) divided into 3 groups. After one week in group 1 (control) the bolts were removed without any replacement. In group2 Ti6Al4V bolts with a 4x Cu-TiO₂ coating and in group 3 beads of a gentamicin-PMMA chain were imbedded into the borehole. Microbiological investigation was performed at the primary surgery, at the revision surgery and after scarification of the rabbits 3 weeks after the first surgery. Blood tests were conducted weekly. The initial overall infection rate was 88.9%. In group 2 and 3 a significant decrease of the infection rate was shown in contrast to the control group. The C-reactive protein (CRP) levels declined one week after the first surgery except in the control group where the CRP level even increased. This is the first in vivo study that demonstrated the antibacterial effects of a fourfold Cu-TiO₂ coating. For the future, the coating investigated could be a promising option in the treatment of implant-associated infections.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND

Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants.

METHODS

11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred.

RESULTS

Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years..

CONCLUSIONS

A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

Concomitant Sternal Fracture in Flail Chest: An Analysis of 21,741 Polytrauma Patients from the TraumaRegister DGU®

Background Isolated sternal fractures (SFs) rarely show complications, but their influence in a thorax trauma of the seriously injured still remains unclear. Methods A retrospective analysis of the TraumaRegister DGU^® was performed involving the years 2009 to 2013 (Injury Severity Score [ISS] ≥ 16, primary admission to a trauma center). Cohort formation: Unilateral and bilateral flail chest (FC) injuries with and without a concomitant SF, respectively. Results In total, 21,741 patients (25% female) met the inclusion criteria, with 3,492 (16.1%) showing SF. Unilateral FC patients were on average 53.6 ± 18.4 years old, and bilateral FC patients were on average 55.2 ± 17.7 years old. The ISS in unilateral FC and bilateral FC amounted to 31.2 ± 13.0 and 43.4 ± 13.1 points, respectively. FC with an SF occurred more frequently as an injury to car occupants and less frequently as an injury to motorcyclists or in injuries due to falls. Conclusion Patients with an SF additional to an FC had longer hospital and intensive care unit stays and were longer artificially respirated than those patients without an SF. SF indicates possible cardiac and thoracic spine injuries.

[Essential measures for prehospital treatment of severely injured patients: The trauma care bundle]

BACKGROUND

In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients.

MATERIAL AND METHODS

The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process.

RESULTS AND DISCUSSION

A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability

PURPOSE

Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions.

METHOD

Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib^®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis^® retractor.

RESULTS

One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation.

COMPLICATIONS

pneumothorax (2) and seroma (2).

CONCLUSION

Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.

Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.

This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture’s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.

Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.

Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

Elastic Stable Chest Repair as a Means of Stabilizing the Anterior Chest Wall in Recurrent Pectus Excavatum with Sternocostal Pseudarthrosis: An Innovative Fixation Device

INTRODUCTION

Open surgical procedures in the treatment of pectus excavatum (PE) involve predetermined incisions in the parasternal cartilage and the bony ribs. For some procedures, the ribs are even dissected from the sternum for better sternal mobilization and thus better elevation of the funnel. Secure restoration of the sternocostal junction is then required, with the consequence that healing may be quite impaired. Patients may also subsequently suffer from sternocostal nonunion, for example, pseudarthrosis, and dislocated ribs, as well as pain and a recurrence of PE.

MATERIALS AND METHODS

Patients underwent another open surgery with revision of the pseudarthrotic sternocostal junctions and sufficient mobilization of the anterior chest wall, followed by an open reduction and internal fixation using Matrix Rib titanium plates (Synthes, Oberdorf, Switzerland). This procedure consisted of elevating the anterior chest wall and fixing the ribs to the sternum. In 2011 and 2012, we studied this procedure, known as elastic stable chest repair (ESCR), in a series of 20 patients. The patients underwent clinical and ultrasound examinations and X-ray radiographs after the operation, after 6 weeks, and at 3- and 12-month intervals.

RESULTS

Follow-up showed high patient tolerance, although a loose plate was observed in one patient and a broken plate in three patients. A stable union was achieved for all sternocostal pseudarthroses. PE improved highly significantly (p < 0.001), as the Haller index decreased from 3.6 (range: 2.7-6.6, standard deviation [SD]: 0.92) to 2.7 (range: 2.0-3.7, SD: 0.42). Pain in the anterior chest wall was significantly reduced after the operation in the majority of cases. All but one patient was mobilized already the day after the operation.

CONCLUSIONS

ESCR in recurrent PE achieved functional stabilization of the anterior chest wall combined with satisfactory results.

[Use of negative pressure wound therapy on surgical incisions (prevena™) after surgery of pectus deformities reduces wound complications]

INTRODUCTION

Pectus surgery can lead to postoperative wound complications in some cases. The purpose of this study is to determine whether preventive negative pressure wound therapy (NPWT) could reduce wound complications after open pectus surgery.

MATERIAL AND METHODS

100 patients after open procedure for the treatment of pectus excavatum or pectus carinatum in the years 2010 to 2012 were retrospectively analysed. 50 patients treated with Prevena™ (KCI Medical Products GmbH, Wiesbaden, Germany) were compared with 50 patients whose wounds were covered with OPSITE® film (Smith & Nephew, Hamburg, Germany). Wound closure was performed following a standard procedure as well as the placement of subcutaneous drains. Therefore two comparable groups of patients were formed and analysed by standardised parameters. The wound dressing was placed epicutaneously immediately after wound closure in the operating room and removed after 5 days in each case. Follow-ups were performed immediately after removal of the wound dressing, at the time of discharge from hospital as well as 6 and 12 weeks after operation. The wounds were checked for tenderness, pain, secretion, redness and fistulas.

RESULTS

The Prevena group showed 10 % wound complications which needed operative treatment, whereas the OPSITE group showed complications in 24 %. Some patients who were treated with Prevena showed superficial skin lesions at the rim of the foam and the film. All of these lesions healed well.

CONCLUSION

Treating wounds postoperatively with preventive measures (NPWT) showed a remarkable reduction of wound complications following open pectus surgery whereas statistically the difference was not significant (p = 0.074).

Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates--surgical safety through depth limited drilling

PURPOSE

Operative treatment of sternal fractures has become a matter of increasing interest. Anterior plating seems to be the most appropriate method for fixing sternal fractures. However, there are several concerns in relation to the operative procedure such as severe injuries to mediastinal organs, patient comfort and proper stabilisation, for example. This paper describes a safe method of anterior sternal plating using locked plate fixation with limited depth drilling.

METHODS

Ten patients with sternal fractures were included in this cohort study and were treated by anterior plating using one or two plates in parallel through a median approach to the sternum. Follow up was performed after six weeks, 12 weeks and six months.

RESULTS

Follow up revealed no serious complications. One patient suffered from postoperative wound seroma. No problems were caused by the plates.

CONCLUSIONS

Sternal plating using low profile locked titanium plates seems to be a safe and stable method with a high level of patient comfort.

Sternocostal dislocation following open correction of pectus excavatum-"stairway phenomenon": complication management by means of sternocostal locking titanium plate osteosynthesis

INTRODUCTION

Some open surgical methods describe complete sternocostal dissection with subsequent resynthesis. Lack of consolidation with painful sternocostal instability and retrosternal dislocation of sternal rib tips are possible complications.

MATERIALS AND METHODS

Seven patients with symptomatic unilateral sternocostal dislocation were included in this study. After diagnosis, confirmed by three-dimensional computed tomography (CT), patients underwent open surgery. All affected ribs were reset and fixed to the sternum with the aid of titanium implants.

RESULTS

The patients had, on average, unilateral dislocation of 3.4 rib joints with 15.4 mm retrosternal dislocation, which was fixed with 2.3 plates. A titanium splint was also employed. The recurrent nature of the problem made procedures very time-consuming (average operation time: 3 hours 25 minutes). One patient suffered strong intraoperative bleeding requiring transfusion of blood products and access enlargement. Follow-up examinations showed high patient satisfaction (grade of 1.7; rating scale 1-6). Remaining rib instabilities were observed just as infrequently as were material failures. The sternocostal rib splint in the costal cartilage became loose and was removed. One patient exhibited a pectoral muscle asymmetry. No other complications were observed.

CONCLUSION

The term "stairway phenomenon" describes the dislocation of sternocostal joints. Observed after open pectus excavatum correction it can trigger substantial physical complaints. Thus, preserving those joints during pectus repair is strongly recommended. Locking titanium plates are a safe alternative to sternocostal suture fixation and is characterized by high patient satisfaction.

Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty

PURPOSE

The purpose of this study was to evaluate the use of negative pressure wound therapy (NPWT) to improve wound healing after total hip arthroplasty (THA) and its influence on the development of postoperative seromas in the wound area.

MATERIALS

The study is a prospective randomised evaluation of NPWT in patients with large surgical wounds after THA, randomising patients to either a standard dressing (group A) or a NPWT (group B) over the wound area. The wound area was examined with ultrasound to measure the postoperative seromas in both groups on the fifth and tenth postoperative days.

RESULTS

There were 19 patients randomised in this study. Ten days after surgery, group A (ten patients, 70.5 ± 11.01 years of age) developed seromas with an average size of 5.08 ml and group B (nine patients, 66.22 ± 17.83 years of age) 1.97 ml. The difference was significant (p = 0.021).

CONCLUSION

NPWT has been used on many different types of traumatic and non traumatic wounds. This prospective, randomised study has demonstrated decreased development of postoperative seromas in the wound and improved wound healing.

Epitope mapping of polyclonal clotting factor VIII-inhibitory antibodies using phage display

Clotting factor VIII (fVIII)-inhibitory antibodies represent a major problem in the treatment of haemophilia A. To understand the inactivation mechanisms and to pave the way towards modifications of recombinant clotting factors that reduce their immunogenicity, the exact localization of immunodominant epitopes is required. Here, a random peptide phage display library was employed to identify epitopes of polyclonal fVIII antibodies isolated from patient's plasma by affinity chromatography. FVIII-binding specificity and inhibitory activity of the isolated fVIII antibodies were confirmed by ELISA and Bethesda assays. Phage selection on the individual samples yielded several phages which were displaced from binding to the respective antibody preparation by fVIII. Their homology with amino acid motifs of human fVIII and immunoprecipitation results with radioactively labelled fVIII fragments suggested putative epitopes in the A1, A2 and C1 domains of fVIII for one and in the C2 domain for another patient. Synthetic peptides corresponding to the A2, C1 and C2 domain epitopes blocked antibody binding to fVIII and partially neutralized the inhibitory activity of the respective plasma in Bethesda assays. These results provide the proof of principle that random peptide libraries can be used for the mapping of epitopes in a polyclonal antibody preparation.