Hans Christoph Pape

Treatment Results of Patients with Multiple Trauma: An Analysis of 3406 Cases Treated between 1972 and 1991 at a German Level I Trauma Center

The quality and progress of treatment for 3406 multiple trauma patients was reviewed retrospectively. Two periods (1972 to 1981, the first decade, and 1982 to 1991, the second decade) were compared. Sixty-nine percent of patients with multiple trauma had cerebral injuries, 62% thoracic trauma, and 86% fractures (40% open fractures). Concerning injury combinations, there was an increase of head/extremity injuries and thoracic/extremity injuries, whereas all combinations with abdominal injuries decreased. The relation between severity of injury as well as number of injured body regions and the mortality rate was significant. In the second decade prehospital care became more aggressive with an increase in use of intravenous fluid resuscitation (from 80% to 98%), intubation (from 84% to 91%), and chest tube insertion (from 37% to 76%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal hemorrhage, ultrasound (89%) nearly replaced peritoneal lavage (10%) and led to earlier surgical approach. For diagnosis of head injury, CT scan was used more frequently. Primary stabilization of long bone fractures, especially of the lower limb, is recommended. Concerning complications, the change in volume therapy helped to nearly eliminate acute renal failure (from 8.4% to 3.7%), the modification of respirator treatment led to a decrease of pulmonary insufficiency (ARDS; from 18.2% to 12.0%), whereas the rate of multiple organ failure increased. The mortality rate declined from 37% in the first decade to 22% in the second decade. The incidence of lethal multiple organ failure increased from 13.8% in the first decade to 18.6% in the second decade, whereas the mortality rate of ARDS decreased from 32.4% to 15.9%. Further reduction of incidents of death is only possible with causal therapy of posttraumatic organ failure immediately after injury.

Pulmonary damage after intramedullary femoral nailing in traumatized sheep--is there an effect from different nailing methods?

Stabilization of femoral shaft fractures is a controversial issue in the management of patients with multiple trauma. Intramedullary nailing usually is preferred primarily; in recent years, however, pulmonary complications (e.g., ARDS) have been reported that were attributed to the reaming procedure. To study the effects of different nailing methods in a model of severe trauma, hemorrhagic shock and lung contusion were created at day 1 in sheep prepared by the method described by Staub. After recuperation (day 3) the animals in the study group (group 1) underwent intramedullary nailing of a closed femur without prior reaming; group 2 was treated with reaming and nailing according to AO standards. The reaming procedure led to an acute increase of pulmonary arterial pressure only in group 2 (19.8 +/- 2.1 to 31.0 +/- 4.6 mm Hg). Pulmonary triglyceride levels increased at parallel time points from 18.27 +/- 2.3 to 33.04 +/- 7.37 mg/dL only in group 2. Stimulatory capacity of polymorphonuclear leukocytes (PMNL) increased in the study group and decreased in controls (group 1: 2.652 +/- 0.23 x 10(6) cpm to 3.387 +/- 1.34 x 10(6) cpm; group 2: 2.699 +/- 0.34 x 10(6) cpm to 2.460 +/- 0.187 x 10(6) cpm). Intramedullary nailing caused an increase of lung capillary permeability in both groups; in the study group less damage was seen (group 1: 0.390 +/- 0.0006 to 0.354 +/- 0.011; group 2: 0.391 +/- 0.0004 to 0.336 +/- 0.015; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Scaffolds for bone healing: concepts, materials and evidence.

Critical sized bone defects have to be filled with material to allow bone healing. The golden standard for this treatment is autogenous bone grafting. Because of donor size morbidity, equivalent synthetic bone scaffolds should be developed. Different materials, especially ceramics and polymers are in the focus of research. Calcium phosphate ceramics show similar properties to bone and are degradable. Different modifications can improve the bioactive features. This article gives an overview about the current materials and their evidence of clinical use.

Current concepts in the development of heterotopic ossification

H. C. Pape, MD, Professor C. Krettek, ProfessorDepartment of Trauma, Hannover Medical School, Unfallchirurgische Klinic, Hannover 305625, Germany. S. Marsh, MB, BS, House SurgeonTrauma & Orthopaedics, St James’s University Hospital, Leeds, UK. J. R. Morley, FRCS (Ed), Lecturer P. V. Giannoudis, MD, EEC (Ortho), ProfessorTrauma & Orthopaedics, School of Medicine, University of Leeds, St. James’s Hospital University Hospital, Beckett Street, Leeds LS9 7TF, UK.Correspondence should be sent to Professor P. V. Giannoudis.©2004 British EditorialSociety of Bone andJoint Surgerydoi:10.1302/0301-620X.86B6.15356

Autologous Bone Graft: Properties and Techniques

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Inflammatory serum markers in patients with multiple trauma CAN THEY PREDICT OUTCOME

Bone grafting is involved in virtually every procedure in reconstructive orthopaedic surgery. Although autologous bone grafts have excellent biologic and mechanical properties, considerable donor site morbidity and the limited volume available must be taken into consideration. Currently, there are no heterologous or synthetic bone substitutes available that have superior biologic or mechanical properties. This review article summarizes the biologic and mechanical properties of autologous bone grafts, differentiates various autologous bone graft types, and compares them with other bone substitutes.

Current theories on the pathophysiology of multiple organ failure after trauma

Clinical trials have provided information concerning the various immunological alterations that occur after trauma which may cause the multiple organ dysfunction syndrome (MODS) and death. Once multiple systems are dysfunctional the rates of mortality are as high as 50%, the morbidity is severe and the costs of health care are enormous. 1,2 Although external support such as ventilators, dialysis machines and inotropic drugs, is provided to all patients to compensate for the internal dysfunction until they can support themselves, the end result is often unpredictable. Early evaluation of the prognosis in polytraumatised patients is difficult. Traditionally, the clinical condition and management of the patient are assessed by evaluation of cardiovascular, renal, liver and respiratory functions. Nevertheless, the significance of such clinical parameters as the urinary output, oxygen saturation, blood gases, C-reactive protein, base excess, etc, is limited since only patients with a clearly impaired organ function can be distinguished. Organ dysfunction which is not detectable by these parameters does not guarantee a condition of the patient which is stable enough for operation especially if in the ‘borderline condition’. 3

Missed injuries in trauma patients: A literature review

Despite the enormous efforts to elucidate the mechanisms of the development of multiple organ failure (MOF) following trauma, MOF following trauma is still a leading cause of late post-injury death and morbidity. Now, it has been proven that excessive systemic inflammation following trauma participates in the development of MOF. Fundamentally, the inflammatory response is a host-defence response; however, on occasion, this response turns around to cause deterioration to host depending on exo- and endogenic factors. Through this review we aim to describe the pathophysiological approach for MOF after trauma studied so far and also introduce the prospects of this issue for the future.

Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response?

BackgroundOverlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries.MethodsManuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980–1990), (n = 6, 1990–2000), and (n = 9, 2000-Present).ResultsWe found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade.ConclusionThe lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.

Internal fixation of multiple fractures in patients with polytrauma.

BACKGROUND Reaming of the femoral canal has been demonstrated to introduce intramedullary contents into the circulation with subsequent pulmonary embolization. The aim of this study was to investigate whether this effect can be minimized by use of a reamer system that provides simultaneous irrigation and aspiration of intramedullary contents. METHODS A unilateral lung contusion was created and intramedullary femoral nailing was subsequently performed in eighteen female skeletally mature Merino sheep. The animals were divided into three groups, of six animals each, to receive one of three types of treatment: reamed femoral nailing; reaming, irrigation, and aspiration; and unreamed femoral nailing. Blood samples were obtained and a bronchoalveolar lavage was performed at baseline, immediately after creation of the lung contusion, immediately after intramedullary nailing, and at four hours after surgery. Pulmonary permeability, polymorphonuclear leukocyte activity, and systemic hemostatic response were measured. Lung specimens were obtained for histological evaluation. RESULTS At baseline and immediately after creation of the lung contusion, endothelial permeability was comparable among the three groups. At four hours postoperatively, pulmonary permeability was significantly higher in the group treated with reamed femoral nailing (urea/protein ratio; 256.7) than in the group treated with reaming, irrigation, and aspiration (urea/protein ratio, 91.5) and the group treated with unreamed femoral nailing (urea/protein, 110.64) (p < 0.05). The stimulatory capacity of the polymorphonuclear leukocytes was significantly decreased (p < 0.05) only in the group treated with reamed femoral nailing; the other two groups had no significant decrease postoperatively (p > 0.05). The D-dimer level at four hours postoperatively was significantly higher in the group treated with reamed femoral nailing than it was in the other two groups (p < 0.05). Histological examination showed that the grades of edema and polymorphonuclear leukocyte diapedesis were also highest in the group treated with reamed femoral nailing. CONCLUSIONS It appears that, in the presence of a unilateral pulmonary injury, the systemic effects of intramedullary reaming of an intact femur can be minimized with use of a modified reamer design that simultaneously irrigates the canal and removes debris. Additional clinical validation of this reaming system is necessary.