Christoph E. Heyde

Current Concepts of Polytrauma Management

AbstractIn recent years, the implementation of standardized protocols of polytrauma management led to a significant improvement of trauma care in European countries and to a decrease in posttraumatic morbidity and mortality. As such, the “Advanced Trauma Life Support” (ATLS®) protocol for the acute management of severely injured patients has been established as a gold standard in most European countries since the 1990s. Continuative concepts to the ATLS® program include the “Definitive Surgical Trauma Care” (DSTC™) algorithm and the concept of ”damage control” surgery for polytraumatized patients with immediate life–threatening injuries. These phase–oriented therapeutic strategies appraise the injured patient in the whole extent of the sustained injuries and are in sharp contrast to previous modalities of “early total care” which advocate immediate definitive surgical interventions. The approach of “damage control” surgery takes the influence of systemic posttraumatic inflammatory and metabolic reactions of the organism into account and is aimed at reducing both the primary and the secondary – delayed – mortality in severely injured patients. The present paper shall provide an overview on the current state of management algorithms for polytrauma patients.

The Role of Neuroinflammation in Traumatic Brain Injury

In industrialized countries, traumatic brain injury (TBI) still represents the leading cause of death and persisting neurologic impairment among young individuals < 45 years of age. Patients who survive the initial injury are susceptible to sustaining secondary cerebral insults which are initiated by the release of neurotoxic and inflammatory endogenous mediators by resident cells of the central nervous system (CNS). The presence of hypoxia and hypotension in the early resuscitative period further aggravates the inflammatory response due to ischemia/reperfusion-mediated injuries. These are induced by the intrathecal generation of free radicals and activation of the complement cascade. Posttraumatic neuroinflammation is further exacerbated by the subsequent intracranial recruitment of blood-derived immunocompetent cells, leading to secondary cerebral edema and increased intracranial pressure. The profound endogenous neuroinflammatory response after TBI, which is phylogenetically aimed at defending the CNS from invading pathogens and repairing lesioned tissue, is, in large part, responsible for the development of secondary brain damage and adverse outcome. However, aside from these deleterious effects, posttraumatic inflammation mediates neuroreparative mechanisms after TBI as well. This “dual effect” of neuroinflammation has been the focus of extensive experimental and clinical research in the past years and has led to an expanded basic knowledge on the cellular and molecular mechanisms which regulate the intracranial inflammatory response after trauma. The present article provides an up-to-date overview on the pathophysiological mechanisms of neuroinflammation after TBI. New potential therapeutic strategies for reducing the extent of secondary brain damage after neurotrauma are discussed.

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging

Objectives: The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon. Method: This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI). Results: Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12–17 months) after surgery. Conclusions: Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.

Kyphoplasty in osteoporotic vertebral compression fractures - Guidelines and technical considerations

Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity.Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.

Current Concepts in the Treatment of Proximal Humeral Fractures

Preoperative classification of proximal humeral fractures in addition to thorough knowledge of the specific anatomy and vascular blood supply is more important for successful treatment than the choice of implant. If reduction and fixation is necessary, aggressive reduction maneuvers can compromise humeral head perfusion with subsequent humeral head necrosis regardless of the implant used. Modern implants such as intramedullary proximal humeral nails and anatomically designed proximal humeral angular stable plates offer high primary stability even in osteoporotic bone with preservation of periosteal blood supply to the humeral head. These implants allow early functional exercises and showed good to excellent results in the majority of patients with an acceptable complication rate. Increasing experience with these relatively new implants and further technical development might improve clinical results and reduce complications. Minimally invasive, percutaneous techniques also demonstrate favorable results comparable to those mentioned above, although mean patient age tends to be younger in these studies and complications requiring reoperation tend to be more pronounced in elderly patients due to poor bone quality. Alternatively, nonoperative treatment of displaced two- and three-part fractures in elderly patients with severe morbidity and high perioperative risks should be considered. In elderly patients with selected displaced four-part fractures or fracture dislocations and head-split fractures, hemiarthroplasty offers high subjective patient satisfaction despite moderate function with most of the patients being pain free.

ATLS® and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patients immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS® polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS® protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.

Complications and safety aspects of kyphoplasty for osteoporotic vertebral fractures: a prospective follow-up study in 102 consecutive patients.

BackgroundKyphoplasty represents an established minimal-invasive method for correction and augmentation of osteoporotic vertebral fractures. Reliable data on perioperative and postoperative complications are lacking in the literature. The present study was designed to evaluate the incidence and patterns of perioperative complications in order to determine the safety of this procedure for patients undergoing kyphoplasty.Patients and MethodsWe prospectively enrolled 102 consecutive patients (82 women and 20 men; mean age 69) with 135 operatively treated fractured vertebrae who underwent a kyphoplasty between January 2004 to June 2006. Clinical and radiological follow-up was performed for up 6 months after surgery.ResultsPreoperative pain levels, as determined by the visual analogous scale (VAS) were 7.5 +/- 1.3. Postoperative pain levels were significantly reduced at day 1 after surgery (VAS 2.3 +/- 2.2) and at 6-month follow-up (VAS 1.4 +/- 0.9). Fresh vertebral fractures at adjacent levels were detected radiographically in 8 patients within 6 months. Two patients had a loss of reduction with subsequent sintering of the operated vertebrae and secondary spinal stenosis. Accidental cement extravasation was detected in 7 patients in the intraoperative radiographs. One patient developed a postoperative infected spondylitis at the operated level, which was treated by anterior corporectomy and 360 degrees fusion. Another patient developed a superficial wound infection which required surgical revision. Postoperative bleeding resulting in a subcutaneous haematoma evacuation was seen in one patient.ConclusionThe data from the present study imply that percutaneous kyphoplasty can be associated with severe intra- and postoperative complications. This minimal-invasive surgical procedure should therefore be performed exclusively by spine surgeons who have the capability of managing perioperative complications.

Evidence supporting the use of bone morphogenetic proteins for spinal fusion surgery

Bone morphogenetic proteins (BMPs) are capable of promoting bone healing and even induce de novo osteogenesis. Their clinical application in spinal fusion surgery has recently increased in popularity. This is especially true for the use of BMPs in combination with artificial bone substitutes that have the capability to replace autologous bone graft, which can be associated with severe harvesting complications. This review will examine the use of BMP-2 and BMP-7 as commercially available products that have proven their osteoinductive capacity in spinal fusion. We will perform an overview of the literature for scientific evidence supporting the use of these new technologies. Despite their high osteoinductive potency, the use of BMPs does not replace proper surgical stabilization in spinal fusion. Safety issues with BMPs are osteoclast activation, postoperative swelling and hyperostosis. Despite these issues, manufacturers continue to expend more effort concerning proper application, dosage and carriers for these devices for spinal fusion, both presently and in the future.

Successful treatment of spondylodiscitis using titanium cages: a 3-year follow-up of 22 consecutive patients.

Background and purpose The use of metal implants in large defects caused by spinal infection to support the anterior column is controversial, and relatively few results have been published to date. Despite the fact that there is bacterial adhesion to metal implants, the strong immunity of the highly vascularized spine because of rich muscle covering is unique. This possibly allows the use of metal implants, which have the advantage of high stability and reduced loss of correction. This is a retrospective study of patients with spondylodiscitis treated with metal implants. Patients and methods We retrospectively analyzed the outcome in 22 consecutive patients (mean age 69 (43–82) years, 15 men) with spondylodiscitis (20 lumbar and 12 thoracic discs) who had received an anterior titanium cage implantation. In 13 cases, the pathogen could be identified. Antibiotic treatment was continued for at least 12 weeks postoperatively. Results The mean follow-up was 36 (32–47) months. Healing of inflammation was confirmed by clinical, radiographic, and laboratory parameters. The mean VAS improved from 9.1 (6–10) preoperatively to 2.6 (0–6) at the final follow-up, and the mean Oswestry disability index was 17 (0–76) at the final follow-up. Interpretation Our findings highlight the high healing rate and stability when titanium implants are used. Prerequisites are a radical debridement, correction of deformity, and additional bony fusion by bone grafting. The increased stability, with facilitated patient mobilization, and the relatively little loss of correction using anterior and posterior implants are of considerable advantage in the treatment of the patients with multiple co-morbidities.

Traumatic proximal tibiofibular joint dislocation treated by open reduction and temporary fixation: a case report

Isolated dislocations of the proximal tibiofibular joint are a rare condition. Missed diagnosis can lead to chronic knee pain and disability. Early recognition should be followed by immediate closed reduction or open reduction and joint transfixation. We present a young athlete with this injury which was treated successfully by open reduction.