Axel Ekkernkamp

The stabilizing effects of different orthoses in the intact and unstable upper cervical spine: a cadaver study.

BACKGROUNDnAlthough cervical orthoses are frequently used in prehospital stabilization and in the definitive treatment for lesions of the cervical spine, there is little information about the control of extension-flexion, lateral bending, and rotation given to individual segments by different designs.nnnMETHODSnIn an experimental in vitro study with four fresh frozen cadavers, the halo vest was compared with the soft collar, prefabricated Minerva brace, and Miami J collar. The controlling effects for the segments C1-2 and C2-3 were tested for all four devices in the intact and the unstable spine with an Anderson type II fracture of the odontoid.nnnRESULTSnAll four orthoses reduced the range of motion at both C1-2 and C2-3 of the intact spine significantly, although none of the three semirigid devices provided a halo-like immobilization in the intact spine. The osteotomy of the odontoid increased the range of motion in the segment C1-2. The soft collar did not give any clinically relevant stability to the unstable spine. Miami J and Minerva brace provided a similar moderate control in the sagittal plane but a much better control of torque in the upper cervical spine. The halo vest did not allow any measurable motion in any plane with our experimental external loading.nnnCONCLUSIONnThe halo vest seems to be the first choice for conservative treatment of unstable injuries of the upper cervical spine, although pin track problems, accurate fitting of the vest, and a lack of patient compliance lead to clinical failures.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or Will Rogers phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.

Original Paper: A likelihood ratio approach to meta-analysis of diagnostic studies

Objective: To develop a clinically and methodologically sound approach to diagnostic meta-analysis. Methods: Two-step model was used involving four fictitious sets of 10 studies each with varying sensitivity and specificity; this was followed by the application of the method to data from a published systematic review of emergency ultrasound. Multidimensional test characteristics (relating to the detection or exclusion of the condition of interest) were described by likelihood ratio scatterplots and pooled likelihood ratios. Likelihood ratios summarise the ability of a test to revise the prior probability of disease. They can be summarised by established fixed-effects and random-effects methods. Results: Likelihood ratios precisely describe both directions of test performance. By plotting positive against negative likelihood ratios, together with their 95% confidence intervals, a multidimensional forest plot is obtained that can be interpreted in analogy to therapeutic meta-analyses. There are accepted threshold values of positive and negative likelihood ratios (i.e. 10.0 and 0.1) to recommend a test for clinical use. In the matrix space, distinct test characteristics can even be assessed by eyeballing. With regard to data from the real meta-analysis, the suggested high discriminatory power of ultrasound was only partially qualified by likelihood ratios. The positive value confirms the reliability of a positive scan, whereas the negative value questions a normal sonogram. Conclusions: A full characterisation of test performance requires multidimensional effect measures. Likelihood ratios are recommended descriptors of the two dimensions of diagnostic research evidence and provide a convenient means to visualise and to communicate results as weighted summary estimates of a diagnostic meta-analysis.

Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation

ObjectiveMissed tears of the scapholunate ligament (SLL) and scapholunate dissociation (SLD) after wrist injuries pose a high risk of post-traumatic osteoarthritis of the carpus. Plain X-rays and dynamic radiographic studies are frequently used for initial diagnostic work-up. Given the limited evidence of their accuracy, we retrospectively compared the radiographic findings of patients with suspected traumatic SLD with wrist arthroscopy as the accepted reference standard.Design and methodsDuring a 6-year period, plain radiographs and DSA cineradiography scans were obtained from 198 patients who had sustained a hyperextension injury to their hand. Of those, 102 (72 men, 30 women, mean age of 42u2009±u200912xa0years) subsequently underwent diagnostic arthroscopy. Digital images were reevaluated by experienced radiologists unaware of the arthroscopic findings for the presence or absence of SLD. We calculated the sensitivity (SN) and specificity (SP) with 95% confidence intervals (CI), and computed areas under the receiver operating characteristic curves (AUC/ROC).ResultsArthroscopy revealed 42 SLL ruptures, 13, 10, and 19 of which were classified as grade I (partial), II (complete with dynamic instability), or III (complete with static instability) respectively. Plain radiographs correctly identified 24 injuries (SN 57.1%, 95% CI 41.0–72.3%), and produced 1 false-positive result (SP 98.3%, 95% CI 91.1–100.0%). The scapholunate distance and the SL angle contributed independently to the diagnostic variance, with an AUC/ROC of 85.7% (95% CI 76.8–92.2%). Cineradiography had a sensitivity of 36 out of 42 (85.7%, 95% CI 71.5–94.6%), and a specificity of 57 out of 60 (95.0%, 95% CI 86.1–99.0%).ConclusionPathological results on plain radiographs and cineradiography reliably indicate the presence of SLD after wrist trauma. Although non-conclusive, a negative dynamic study markedly reduces the pre-test probability of disease. Both methods remain key elements of primary diagnostic strategies for suspected traumatic SLD, and may facilitate the selection of additional tests.

The -1082 interleukin-10 polymorphism is associated with acute respiratory failure after major trauma: A prospective cohort study

BACKGROUNDnAcute respiratory failure is a common, life-threatening complication after severe trauma. Polymorphisms in cytokine genes, linked to cytokine inducibility, may influence the susceptibility to acute respiratory failure and serve as risk predictors.nnnMETHODSnThis PROSPECTIVE cohort study (n = 100) included Caucasian multiple trauma (Injury Severity Score [ISS] >15) patients at a level 1 trauma center in Berlin, Germany. Primary outcome measure acute respiratory failure was defined as a Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of <200 and the need for mechanical respiratory support. We investigated the association of polymorphisms of the interleukin (IL)-1beta, IL-6, and IL-10 genes with acute respiratory failure.nnnRESULTSnOf 100 patients with severe mechanic injury (median ISS 34, interquartile range 19-45), 49 developed acute respiratory failure. Acute respiratory failure frequency differed significantly with the IL-10 -1082 genotype (P = .007; P corrected, .03), whereas there was no significant relation to any other cytokine genotype after Bonferroni correction for multiple testing. The -1082 GG genotype was a marker of decreased risk to develop acute respiratory failure in univariate (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.6; P = .004) and multivariate (OR, 0.2; 95% CI, 0.1-0.9; P = .03) logistic regression analysis, with male gender, severe abdominal injury, and an APACHE II score >19 being significant risk factors.nnnCONCLUSIONnWe conclude that the IL-10 -1082 genotype may be a risk marker for development of acute respiratory failure after trauma.

Acute inversion injury of the ankle without radiological abnormalities: assessment with high-field MR imaging and correlation of findings with clinical outcome

BackgroundAcute inversion injuries of the ankle are the most common sports accidents, accounting for approximately 10% of emergency room admissions. In up to 85%, an injury of the lateral collateral ligaments is observed. Classically, the assessment of these injuries has relied on clinical examination and radiographs, including stress views. The aim of our study was to correlate prospectively the findings of high-field 3xa0T MRI in acute ankle distortion with clinical outcome.MethodsDuring a 6-month period, 38 patients were prospectively included. MRI was performed within 48xa0h of trauma and clinical examination using a protocol consisting of axial T2-weighted and coronal and sagittal T1-weighted images and a sagittal proton density (PDw) sequence. Each ligament injury was graded on a three-point scale. Functional outcome was evaluated using the AOFAS ankle-hindfoot scale.ResultsIn 24/38 patients (63.12%), ligament injury was observed. In 22/24 cases, this was an injury of the lateral ligaments and in 2/24 cases of the medial ligaments. Injury of the syndesmosis occurred in three patients, a bone bruise in four, and an osteochondral lesion in three cases. Patients with an injury of two or more ligaments or a bone bruise had a lower AOFAS score and returned to sports activities and full weight-bearing later (Pu2009<u20090.01).ConclusionMR imaging at 3 Tesla is an independent predictor for clinical outcome. Therefore MRI may be beneficial in those cases where the findings influence further treatment.

Ganglions of the wrist and associated triangular fibrocartilage lesions: a prospective study in arthroscopically-treated patients.

PURPOSEnWrist ganglions are the most common soft tissue tumors of the hand and wrist and can occur at any age. Their etiology remains controversial. A high prevalence of associated intrinsic ligamentous lesions has been described. We hypothesized that painful wrist ganglions are an indicator of an underlying joint abnormality, particularly of lesions of the triangular fibrocartilage complex (TFCC). The aim of our study was to prospectively determine the prevalence of associated TFCC lesions in patients with painful wrist ganglions.nnnMETHODSnForty-six patients (35 women, 11 men; mean age, 36 ± 11 y; range, 18-57 y) with painful wrist ganglions (20 radiopalmar and 26 dorsal) had surgery from January 2008 to June 2010. There were 18 primary and 28 recurrent ganglions. Clinical examinations, pain score evaluations, disabilities in daily life evaluations, plain radiographs, and magnetic resonance imaging were obtained before arthroscopic resection. Concomitant intrinsic lesions of the wrist were assessed with magnetic resonance imaging and re-evaluated by arthroscopy.nnnRESULTSnAll ganglions were successfully resected. Overall, arthroscopy identified 22 TFCC lesions (48%) and 2 intracarpal ligament lesions. The TFCC perforations were more commonly associated with radiopalmar ganglions with a positive ulnocarpal stress test result and with recurrent radiopalmar ganglions. At 1-year follow-up, all patients were meaningfully improved in terms of pain and disabilities in daily life.nnnCONCLUSIONSnArthroscopy allows for the simultaneous treatment of ganglions and other pathologies. Therefore, arthroscopy should be contemplated as the primary treatment option for patients with painful ganglions of the wrist if they are in a radiopalmar location with a positive ulnocarpal stress test and for patients with recurrent radiopalmar ganglions, which are also highly associated with TFCC abnormalities.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Postoperative monitoring of free vascularized bone grafts in reconstruction of bone defects

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing large bone defects. It is especially indicated in patients with challenging conditions, such as nonunions, postoncologic resections, severe trauma, and congenital defects. With increasing experience of reconstructive surgeons, improved microsurgical techniques, and more enhanced flaps, the failure rate of free flaps has been reduced in the last decades. Especially, the early‐postoperative period is decisive in the outcome of surgery. Several techniques have been described for monitoring the postoperative viability of microsurgical free vascularized graft, and their sensitivity and reliability continues to be the object of animal experiments and clinical trials. The qualities of an optimal monitoring device should be objective, continuous, noninvasive, safe, reproducible, easily managed, and interpretable for the nursing staff, inexpensive, and a clear indicator of changes in arterial and venous circulation. Presently, no one neither fulfills all of the criteria completely nor is uniformly accepted. In this article, relative advantages and disadvantages of these various postoperative monitoring techniques are discussed.

Gene expression profile in bone of diabetes-prone BB/OK rats fed a high-fat diet

A high-fat diet (HFD) has been recognized as a risk factor for diseases such as dyslipidemia, atherosclerosis, obesity, and osteoporosis. However, studies analyzing gene expression after HFD in bone are rare. That prompted us to analyze the expression of selected genes in bone of 4-week-old diabetes-prone B(io)B(reeding) rats. Two breeding pairs were fed a HFD (+10xa0% tallow) or were fed a normal diet (ND; Ssniff R-Z) before mating and afterward during pregnancy. After the birth of progeny, parents continued to be given HFD or ND until the progeny was weaned (3xa0weeks). Thereafter, offspring were weaned and were fed the same food as their parents up to an age of 4xa0weeks. Body weight was measured at an age of 4xa0weeks, and subsequently 13 HFD rats and 13 ND rats were killed and the tibial bone was harvested to analyze the expression of 53 genes in bone. All rats fed HFD were significantly heavier than rats fed ND after 3 and 4xa0weeks. The diet also influenced the expression of genes in bone. There were significant differences in 20 out of 53 genes studied between rats fed HFD compared with rats fed ND. Four out of 20 had a lower and 17 out of 20 genes a higher expression in HFD rats, but differences in gene expression showed obvious differences between males and females. There were only two genes that were similarly different between males and females: Bmp4 and Atf4. Two genes, Foxg1 and Npy, were inversely expressed in males and females. It seems that the gene expression is differently regulated by diet during pregnancy and later in life between males and females. Nevertheless, it cannot be excluded that HFD also acts as an epigenetic factor in the development of offspring in utero.

Journal of Trauma Management & Outcomes: a new platform for interdisciplinary, outcome-oriented research in trauma.

Welcome to Journal of Trauma Management & Outcomes an exciting, new, online journal, specifically dedicated to the epidemiology, care, and outcomes of severely injured patients. n nThe journal willconsider articles on all aspects of trauma research, with a focus on interventions with proven efficacy or inefficacy in improving clinically relevant outcomes such as mortality, morbidity, quality of life, function, and costs. It will serve as a scientific platform for clinical researchers and practitioners involved in the different stages of caring for patients with musculoskeletal, visceral, and multiple injuries. n nWhilst other established journals exist in this field, several factors convinced me, and the fine members of our international Editorial Board [1], to launch the Journal of Trauma Management & Outcomes together with BioMed Central. n nFirst, the projections of the World Health Organization on changes in the rank order of the global burden of disease are simply alarming. If they prove true (and there is no reason to doubt the forecasts), trauma will rank third (!) among all causes for disability in 2020 worldwide [2] – needless to say that this, apart from the detrimental consequences for patients and their families, will drain the global health care budgets. Similar to other important health-care issues like cardiovascular diseases, cancer, and HIV, there is an urgent need to foster public awareness of the importance of trauma, and to establish effective prevention campaigns. n nMobility is an integral part of our life, but we also have to deal with its adverse effects. With the exponential growth of motorization in developing nations, especially in Asia, and the demand for more powerful and faster vehicles in the industrial countries, the face of road crashes is changing. Traffic accidents affect both the rich and the poor, but the consequences on health-related outcomes are very different. There are few socio-economic areas where inequities and heterogeneity in health care services have such a strong influence on mortality and morbidity, beginning with proper resuscitation on scene, and not ending with physical and mental rehabilitation. n nOur interdisciplinary team had the opportunity of implementing accident research and prevention programs in Germany and Vietnam [3], and it is our responsibility to share our experience with other experts in the field. n nThis leads me to the second argument in favor of a new journal: Important biomedical information cannot change the world unless it is accessible to everybody. There are many highly reputed journals in the field, but few of them grant readers access to their full content. All articles published in Journal of Trauma Management & Outcomes are open access, meaning they are freely and universally accessible online. In addition, the authors hold copyright for their work and grant anyone the right to reproduce and disseminate the article, provided that it is correctly cited and no errors are introduced. The journals articles are archived in PubMed Central, the US National Library of Medicines full-text repository of life science literature, and also in other national repositories. n nPublishing online only meets the requirements of a modern world, and the quick turnover of medical information. It also shortens the time from peer-review to publication. All articles will primarily be reviewed in-house, and, if suiting the scope of JTMO, sent out to two or more international peer-reviewers. Peer-review will be conducted in an open manner, which, to my and the Editorial Boards members opinion, increases transparency. n nApart from all these advantages, there is a little downer: article processing charges need to be covered by authors. This has, however, not impeded the stable growth in the number of articles available open-access, and taking part in this success story may clearly outweigh the inconvenience of paying for publishing. Also, there are many opportunities to apply for a waiver of processing charges that can be found on our website. n nFinally, the findings from basic trauma research contributed importantly to the knowledge of human physiology and pathophysiology. However, the research efforts and discoveries on the cellular, genomic, and molecular level are not paralleled by a similar progress in clinical and population-based research on trauma. Many established diagnostic and therapeutic interventions in trauma care have not yet been proven by studies of high methodological rigor, and we currently know much more about the interplay of cytokines than the quality of life of severely injured patients. JTMO will not publish basic research, but target the key components of modern health care-function, quality of life, and costs. n nI am thankful to the wonderful people at BioMed Central who helped us in getting the journal started, the members of the Editorial Board, and, of course, the authors of the first articles who made JTMO the journal of their choice. n nI am pleased to lead this journal as the Editor-in-Chief, and I hope that the acronym JTMO will soon become widely known among authors and readers, for the sake and benefit of trauma patients in a world without borders.