Bernhard Ciritsis

Quantitative and qualitative MR‐imaging assessment of vastus medialis muscle volume loss in asymptomatic patients after anterior cruciate ligament reconstruction

Background: To quantitatively and qualitatively assess vastus medialis muscle atrophy in asymptomatic patients with anterior cruciate ligament reconstruction, using the nonoperated leg as control. Methods: Prospective Institutional Review Board approved study with written informed patient consent. Thirty‐three asymptomatic patients (men, 21; women,12) with ACL‐reconstruction underwent MR imaging of both legs (axial T1‐weighted spin‐echo and 3D spoiled dual gradient‐echo sequences). Muscle volume and average fat‐signal fraction (FSF) of the vastus medialis muscles were measured. Additionally, Goutallier classification was used to classify fatty muscle degeneration. Significant side differences were evaluated using the Wilcoxon test and, between volumes and FSF, using student t‐tests with P‐value < 0.05 and < 0.025, respectively. Results: The muscle volume was significantly smaller in the operated (mean ± SD, 430.6 ± 119.6 cm3; range, 197.3 to 641.7 cm3) than in the nonoperated leg (479.5 ± 124.8 cm3; 261.4 to 658.9 cm3) (P < 0.001). Corresponding FSF was 6.3 ± 1.5% (3.9 to 9.2%) and 5.8 ± 0.9% (4.0 to 7.4%), respectively, with a nonsignificant (P > 0.025) difference. The relative muscle‐volume and FSF differences were −10.1 ± 8.6% (7.1 to −30.1%) and 10.9 ± 29.4% (39.7 to 40.1%). The qualitative assessment revealed no significant differences (P > 0.1). Conclusion: A significant muscle volume loss of the vastus medialis muscle does exist in asymptomatic patients with ACL‐reconstruction, but without fatty degeneration. J. Magn. Reson. Imaging 2015;42:515–525.

Gastrocnemius muscle herniation as a rare differential diagnosis of ankle sprain: case report and review of the literature

BackgroundMuscle herniation of the leg is a rare clinical entity. Yet, knowing this condition is necessary to avoid misdiagnosis and delayed treatment. In the extremities, muscle herniation most commonly occurs as a result of an acquired fascial defect, often due to trauma. Different treatment options for symptomatic extremity muscle herniation in the extremities, including conservative treatment, fasciotomy and mesh repair have been described.Case presentationWe present the case of a patient who presented with prolonged symptoms after an ankle sprain. The clinical picture showed a fascial insufficiency with muscle bulging under tension. Ultrasound and MRI imaging confirmed the diagnosis of muscle hernia of the medial gastrocnemius on the right leg. Conservative treatment did not lead to success. Therefore, the fascial defect was treated surgically by repairing the muscle herniation using a synthetic vicryl propylene patch.ConclusionsMuscle hernias should be taken into consideration as a rare differential diagnosis whenever patients present with persisting pain or soft tissue swelling after ankle sprain. Diagnosis is mainly based on clinical aspect and physical examination, but can be confirmed by radiologic imaging techniques, including (dynamic) ultrasound and MRI. If conservative treatment fails, we recommend the closure with mesh patches for large fascial defects.

Young adults with mild traumatic brain injury—the influence of alcohol consumption—a retrospective analysis

PurposeAlcohol abuse has been associated with aggressive behavior and interpersonal violence. Aim of the study was to investigate the role of alcohol consumption in a population of young adults with mild traumatic brain injuries and the attendant epidemiological circumstances of the trauma.Subjects and methodsAll cases of mild traumatic brain injury among young adults under 30 with an injury severity score <16 who were treated as inpatients between 2009 and 2012 at our trauma center were analyzed with regard to the influence of alcohol consumption by multiple regression analysis.Results793 patients, 560 men, and 233 women were included. The age median was 23 (range 14–30). Alcohol consumption was present in 302 cases. Most common trauma mechanism was interpersonal violence followed by simple falls on even ground. Alcohol consumption was present more often in men, unemployed men, patients who had interpersonal violence as a trauma mechanism, and in patients who were admitted to the hospital at weekends or during night time. It also increased the odds ratio to suffer concomitant injuries, open wounds, or fractures independently from the trauma mechanism. Length of hospital stay or incapacity to work did not increase with alcohol consumption.ConclusionsAmong young adults men and unemployed men have a higher statistical probability to have consumed alcohol prior to suffering mild traumatic brain injury. The most common trauma mechanism in this age group is interpersonal violence and occurs more often in patients who have consumed alcohol. Alcohol consumption and interpersonal violence increase the odds ratio for concomitant injuries, open wounds, and fractures independently from another.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome. DESIGN AND SETTING Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders. PARTICIPANTS In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures. RESULTS There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders. CONCLUSIONS There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

Reimbursement of care for severe trauma under SwissDRG

QUESTIONS Treatment of patients with severe injuries is costly, with best results achieved in specialised care centres. However, diagnosis-related group (DRG)-based prospective payment systems have difficulties in depicting treatment costs for specialised care. We analysed reimbursement of care for severe trauma in the first 3 years after the introduction of the Swiss DRG reimbursement system (2012-2014). MATERIAL/METHODS The study included all patients with solely basic insurance, hospital admission after 01.01.2011 and discharge in 2011 or 2012, who were admitted to the resuscitation room of the University Hospital of Zurich, aged ≥16 years and with an injury severity score (ISS) ≥16 (n = 364). Clinical, financial and administrative data were extracted from the electronic medical records. All cases were grouped into DRGs according to different SwissDRG versions. We considered results to be significant if p ≤0.002. RESULTS The mean deficit decreased from 12 065 CHF under SwissDRG 1.0 (2012) to 2 902 CHF under SwissDRG 3.0 (2014). The main reason for the reduction of average deficits was a refinement of the DRG algorithm with a regrouping of 23 cases with an ISS ≥16 from MDC 01 to DRGs within MDC21A. Predictors of an increased total loss per case could be identified: for example, high total number of surgical interventions, surgeries on multiple anatomical regions or operations on the pelvis (p ≤0.002). Psychiatric diagnoses in general were also significant predictors of deficit per case (p<0.001). CONCLUSION The reimbursement for care of severely injured patients needs further improvement. Cost neutral treatment was not possible under the first three versions of SwissDRG.

Direct nerve suture and knee immobilization in 90° flexion as a technique for treatment of common peroneal, tibial and sural nerve injuries in complex knee trauma

There are different ways to treat peripheral nerve injuries with concomitant defects in the lower extremity. One option is a direct nerve suture followed by immobilization of the knee in flexion as it is described for gunshot wounds that lead to lesions of the sciatic nerve and its terminal branches as well as isolated nerve lesions. We used this technique to treat a case of multiple nerve injuries of the lower extremity combined with a complex knee trauma including a lesion of both bones and the posterior capsule. To our knowledge, this technique has not yet been described for such a combined injury in literature.