Lukas L. Negrin

Clinical outcome after microfracture of the knee: a meta-analysis of before/after-data of controlled studies

PurposeThe aims of this study were to systematically review the medical literature, in order to find controlled studies about microfracture in the treatment of patients with full-thickness cartilage lesions of the knee, to statistically combine these studies in order to determine a best estimate of the average treatment effect, and to gather information to detect cartilage-specific and patient-specific factors that might have an influence on the clinical outcome.MethodsWe searched four electronic databases for controlled clinical trials or controlled prospective observational studies. We pooled before/after-data of study arms using the term microfracture.ResultsWe calculated an overall best estimate of 1.106, with [0.566; 1.646] as 95% confidence interval of the mean standardized treatment effect for a representative patient population.ConclusionsOur meta-analysis revealed a clinically relevant improvement of the postoperative clinical status as compared to the preoperative status. An increase of 22 overall KOOS points may provide a rough estimate for the mean expected treatment effect achieved by microfracturing.

Periprosthetic femoral fractures--incidence, classification problems and the proposal of a modified classification scheme.

IntroductionThe increasing incidence of periprosthetic fractures correlates directly with the year-after-year increasing frequency of primary joint replacement surgery. The most common fracture localisation is the femur. The undisputed leader in frequency is the fracture that occurs around a total hip arthroplasty. Unfortunately, no general epidemiologic data exist dealing with exact fracture incidence numbers. Furthermore, existing classifications are lacking important information like time point of fracture occurrence, type of the implanted prosthesis and implantation technique (cemented vs. cementless). Additionally, information about mechanical quality of the bone structure and the fracture type are also missing in part.MethodsWe scanned the literature for adequate and widely used classifications in the field of hip and knee arthroplasty. In a next step we analyzed those classification systems in order to find out to what extent they are able to describe the specific aspects of the fracture event. Therefore we compared the existing classifications and presented their most relevant emphasis. Furthermore, we looked at our own patient population to evaluate incidence of fracture occurrence over time and percentage of loosened components.ResultsThe existing classification systems address themselves specifically to the task of describing fracture localization and to some extent fracture type, or combine these two in order to calculate the possibility of loosening of the implanted prosthesis. Some of the important criteria like mechanical quality of the bone stock, primary implantation technique or time point of the prosthesis loosening (prior to or because of the fracture) remain ignored. The incidence of periprosthetic femur fractures at our department increased approximately 2.5 fold over the past two decades. The risk of suffering from a periprosthetic fracture was substantially higher after THA than after TKA. We observed a loose femoral component of the THA in about 45 % of the cases. Finally, we postulate the application of a modified classification for periprosthetic fractures as an alternative to the already published ones; not only for the femur, but also universally for all joints with an arthroplasty.ConclusionThe classification that is introduced in this study allows, in our opinion, a differentiated reflection of the given post-traumatic pathologic changes and enables the description of the fracture itself according to a generally accepted fracture classification scheme.

Today’s Role of External Fixation in Unstable and Complex Pelvic Fractures

Introduction:The treatment of pelvic fractures has undergone a change over the past few years. As there seems to be a trend away from external towards internal fixation, the goal of this study was to investigate whether the use of an external fixator is still a standard procedure for the initial as well as — if necessary — for the definitive treatment of complex and unstable pelvic injuries.Methods:During a period of five years at the Level I Trauma Center, an external fixator was applied in 28 (11%) out of 236 pelvic ring fracture cases. The common indications were open fractures, complex fractures and multiple injuries with hemodynamic instability. Hemorrhage control, fracture stabilization and infection prophylaxis in cases of open fracture were achieved by variable placement and fixation of Schanz screws. In some cases, the assembly of a hybrid combined with internal osteosynthesis was used to increase stability.Results:Of the 28 patients, 20 survived, while eight (28.6%) died in the course of treatment due to fatal hemorrhage, craniocerebral trauma, multi-organ failure and sepsis. A satisfactory result (anatomical and functional outcome) was achieved in 16 of the 20 cases (80%). The remaining four (20%) suffered from serious complications, the majority of them caused by the initial type of injury.Conclusions:The use of the external fixator for the initial and in some cases for the definitive fixation of unstable and complex pelvic injuries with hemodynamic instability is still a successful treatment of multiply injured patients.

Extensor mechanism ruptures of the knee: Differences in demographic data and long-term outcome after surgical treatment

UNLABELLED Extensor mechanism ruptures are rare injuries. Until now, only few reports of medium or long-term outcomes have been published. PURPOSE The objective of this study was to quantify differences in demographic data and complications referring to patients with either quadriceps tendon ruptures (QTR) or patellar tendon (PTR) ruptures and to evaluate if complete functional restitution can be achieved after surgical treatment. METHODS A search was conducted through the database of our level I trauma center in order to identify all patients surgically treated for QTRs or PTRs within 15 years and with a follow-up period of at least three years. Demographic data were collected by scanning their medical records. Of all patients available for a final check-up, their outcomes were assessed using the Knee Society Clinical Rating System (KSS), the Oxford Knee Score (OKS) and the Reduced WOMAC Function Scale (rWOMAC). Furthermore, patient perception (PP) was evaluated. RESULTS 130 patients (93 QTRs and 43 PTRs) met the inclusion criteria. 8% of the QTR- and 13% of the PTR-patients suffered wound healing disorders/septic complications. 8% in the QTR-group sustained a rerupture. 62% of all patients were available for clinical evaluation, the mean follow-up period was 10.3 years in the QTR-group and 9.0 years in the PTR-group. In both groups good to excellent outcomes were revealed. Of the KSS-Knee, the mean score value was 93.1 in the QTR-group and 91.4 in the PTR-group; KSS-Function: 89.7/96.4; OKS: 14.6/13.1; rWOMAC: 95.7/98.3; PP: 88.5/93.3. QTR-patients suffering a rerupture had a significantly worse outcome in all scores except for the KSS-Knee (p≤0.026), whereas PTR-patients with healing disorders/septic complications showed a significant inferior outcome solely in the PP-scale (p=0.02).

Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures.

PURPOSE This retrospective, institutional review board approved study with no patients excluded was designed to test the hypothesis that the prone position is advantageous for repair of acetabular fractures, via a posterior approach. METHODS In 104 consecutive cases fixed by open reduction and internal fixation using the Kocher-Langenbeck approach, 50 were performed in the prone position and 54 in the lateral position by four attending surgeons at a level I trauma center. These cases were assigned to each surgeon according to the call schedule and positioned on the operating table depending on the preference of the assigned surgeon. Arbeitsgemeinschaft fuer Osteosynthese/Association for the Study of Internal Fixation (AO/ASIF) classification and radiologic outcome were evaluated by standard radiographs of the hip and computerized tomography scans, demographic data were taken from the medical records. Except for the time from injury to surgery (p = 0.003), both groups were comparable, nevertheless the fractures were more severe in the prone one. RESULTS With equivalent radiologic outcomes according to Matta, Brooker, Epstein, and Helfet between both groups, a significantly higher rate of infection (p = 0.017) and need for revision surgery (p = 0.009) were found in the prone group. CONCLUSION No advantage to either position for the posterior approach to acetabular fractures could be found. Because most of the severe fractures were performed prone, we propose that the larger number of more difficult fractures in this group may cause an increased likelihood of loss of reduction. The higher infection rate in the prone group may be caused by the longer inpatient wait for definitive fixation, leading to a higher risk of nosocomial colonization.

The Kocher-Langenbeck Approach: Differences in Outcome of Transverse Acetabular Fractures Depending on the Patient’s Position

Introduction:The Kocher-Langenbeck approach is most frequently used for open reduction and internal fixation of transverse acetabular fractures, the positioning of the patient still falling to the preference of the surgeon. The impact of ‘prone’ and ‘lateral’ positioning on radiographic outcome and postoperative complication rates was evaluated by this retrospective study.Methods:Between 2002 and 2007, 27 consecutive cases of transverse acetabular fractures were treated randomly by four attending surgeons at a Level I trauma center, 18 done in a lateral and nine in a prone position, with no significant difference in age and pre- and intraoperative parameters; no patients were excluded. The complication rate was analyzed by medical records. After an average of 9 months postoperatively, the radiographic outcome was evaluated by plain X-rays and computed tomography (CT) scans using the Matta system, the Epstein classification, and the Brooker grades. Post-traumatic arthrosis and avascular necrosis of the femoral head were documented.Results:We found a significantly poorer quality of fracture reduction (p = 0.032) and higher rate of posttraumatic arthrosis (p = 0.049) for patients who were operated for transverse acetabular fracture in the lateral versus the prone position. No revision surgery was needed; no infection was detected overall, whereas two iatrogenic nerve damages (one temporary, one persistent) were found only in the lateral group. There was no significant difference concerning extensive blood loss, femoral head necrosis, Epstein grades, heterotopic ossification, and secondary surgery needed.Conclusions:The weight of the leg may make reduction more difficult in the lateral position, leading to a poorer radiographic outcome.

Club cell protein 16 and cytokeratin fragment 21-1 as early predictors of pulmonary complications in polytraumatized patients with severe chest trauma

Background Acute respiratory distress syndrome (ARDS) and pneumonia have a great impact on the treatment regimen of polytraumatized patients with severe chest trauma. The objective of our study was to determine whether biomarker levels assessed shortly after multiple trauma may predict the occurrence of these conditions. Methods and findings Our patient population included 71 men and 30 women (mean age, 40.3 ± 15.8 years) with an Injury Severity Score that ranged from 17 to 59 and an Abbreviated Injury Scale Thorax of at least 3. They were admitted to our level I trauma center within one post-traumatic hour and survived for at least 24 hours after the trauma occurred. Thirty-five patients developed ARDS, 30 patients pneumonia and 21 patients both. Five individuals died during hospitalization. The levels of five selected biomarkers, which were identified by a literature search, were assessed at admission (initial levels) and on day 2 after trauma. We performed comparisons of medians, logistic regression analyses and receiver operating characteristic analyses for initial and day-2 levels of each biomarker. With regard to ARDS, initial levels of cytokeratin fragment 21–1, the soluble fragment of cytokeratin 19 (CYFRA21-1) and of the club cell protein 16 (CC16) provided significant results in each statistical analysis. With regard to pneumonia, each statistical analysis supplied significant results for both initial and day-2 levels of CYFRA21-1 and CC16. Consistently, initial CYFRA21-1 levels were identified as the most promising predictor of ARDS, whereas day-2 CC16 levels have to be considered as most appropriate for predicting pneumonia. Conclusions CYFRA21-1 levels exceeding cut-off value of 1.85 ng/ml and 2.49 ng/ml in the serum shortly after multiple injury occurred may identify polytraumatized patients at risk for ARDS and pneumonia, respectively. However, CC16 levels exceeding 30.51 ng/ml on day 2 may allow a firmer diagnosis for the development of pneumonia.

Epidemiological and economic aspects of polytrauma management in Austria.

ZusammenfassungEINLEITUNG: In Österreich hat sich eine flächendeckende Schwerstverletztenversorgung etabliert, die zwar einen erheblichen finanziellen Aufwand bedeutet, jedoch im internationalen Vergleich eine Versorgung auf internationalem Niveau gewährleistet. Eine national und international kontrovers diskutierte Frage, ob polytraumatisierte Patienten ausschließlich in Zentren oder in Schwerpunktkrankenhäusern behandelt werden sollten, bleibt weiterhin umstritten. Beide Systemvarianten haben Vor- und Nachteile, gemeinsames Prädikat ist und bleibt die Frage der hohen finanziellen Belastung des Gesundheitssystems. Ziel dieser Arbeit ist die Erfassung der Polytraumaversorgung an den österreichischen unfallchirurgischen Abteilungen im internationalen Vergleich. MATERIAL UND METHODIK: Es erfolgte an den 54 österreichischen unfallchirurgischen Abteilungen eine Datenerhebung mittels Fragebogen. Dabei wurden Personalzahlen, Infrastruktur und Versorgungsmöglichkeiten erfragt. ERGEBNISSE: 96,3 % der befragten unfallchirurgischen Abteilungen retournierten den Fragebogen. In Level I Traumazentren beträgt der unfallchirurgische Bettenanteil 11 % der gesamten Spitalsbettenkapazität, 13 % in Level II Zentren und 18 % in Level III Einheiten. Level I Zentren sind durchschnittlich 35 % der Intensivbetten mit unfallchirurgischen Patienten belegt. 53 % und 51 % ist dieser Anteil bei den Level II und III Zentren. In Level I Krankenhäuser haben durchschnittlich 28,3 unfallchirurgische Ärzte, in Level II und III Abteilungen sind durchschnittlich 14,0 bzw. 7,5 unfallchirurgische Ärzte beschäftigt. Durchschnittlich werden 94 % der Patienten in Notarztbegleitung in die Krankenanstalten eingeliefert. 94 % der unfallchirurgischen Einheiten setzten Thoraxdrainagen, 70 % führen Schädeltrepanationen und Gefäß-Nervenrekonstruktion durch. Jede dritte Abteilung führt Replantationen durch. DISKUSSION: Die erhobenen Daten belegen das breite Spektrum der Polytraumaversorgung an österreichischen Unfallabteilungen. Die viel diskutierte Notwendigkeit der Zentralisation der Schwerstverletztenversorgung kann aufgrund dieser Daten nicht begründet werden. Limitierend aus medizinischer Sicht ist jedoch die mangelnde Vergleichbarkeit der Versorgungsqualität aufgrund derzeit fehlender objektiver Qualitätskriterien.SummaryINTRODUCTION: In Austria, treatment of multiple trauma patients has developed into an established nationwide trauma center specialty with its own unique identity. Although it represents a substantial financial investment, it ensures supply at international standards. The question of whether multiple trauma patients should be treated only in specialized trauma centers or in several hospitals remains controversial on both national and international grounds. The aim of this study was to assess Austrian trauma departments for international comparison. MATERIAL AND METHODS: We performed a survey of all 54 Austrian trauma departments by collecting data through questionnaires. The number of staff, potential of infrastructure, and treatment strategies were obtained. RESULTS: 93.3% of the trauma departments responded to the questionnaires. In level I trauma centers the amount of trauma beds reached 11% of the total bed capacity, 13% in level II, and 18% in level III units. Level I centers showed an average of 35% of intensive care beds for trauma patients. 53% and 51% were the proportions for level II and III centers. Level I hospitals displayed an average of 28.3 trauma surgeons, while level II and III units had less doctors at their disposal in the trauma departments. On average, 94% of the patients arrived by emergency medical support at the hospital. 94% of the trauma departments used chest tubes, 70% performed craniotomies and neurovascular reconstruction. 33% of the centers were equipped to perform replantations. DISCUSSION: The data demonstrate the broad spectrum of polytrauma treatment in Austrian trauma centers. The discussed need for centralization of polytrauma care cannot be justified based on these data. Limiting from a medical perspective, however, is the lacking comparability of quality of care due to the currently missing objective quality criteria.

Increased serum concentrations of soluble ST2 are associated with pulmonary complications and mortality in polytraumatized patients

Abstract Background: We sought to evaluate the role of soluble ST2 (suppression of tumorigenicity) serum concentrations in polytraumatized patients and its potential role as biomarker for pulmonary complications. Methods: We included severely injured patients (injury severity score≥16) admitted to our level I trauma center and analyzed serum samples obtained on the day of admission and on day 2. Furthermore, patients with isolated thoracic injury and healthy probands were included and served as control groups. Serum samples were analyzed for soluble ST2 concentrations with a commercially available ELISA kit. Results: A total of 130 patients were included in the present study. Five patients with isolated thoracic injury and eight healthy probands were further included. Serum analyses revealed significantly elevated concentrations of soluble ST2 in polytraumatized patients compared to patients suffering from isolated thoracic trauma and healthy probands. In polytraumatized patients who developed pulmonary complications (acute respiratory distress syndrome and pneumonia) and in patients who died, significantly higher serum concentrations of soluble ST2 were found on day 2 (p<0.001). Serum concentrations of soluble ST2 on day 2 were of prognostic value to predict pulmonary complications in polytraumatized patients (area under the curve=0.720, 95% confidence interval=0.623–0.816). Concomitant thoracic trauma had no further impact on serum concentrations of soluble ST2. Conclusions: Serum concentrations of soluble ST2 are upregulated following polytrauma. Increased concentrations were associated with worse outcome.

Küntscher – A historical vignette:

Gerhard Küntscher was born on 1 December 1900 in Zwickau (Germany). Generally, he is regarded as the father of intramedullary locked nailing and as the developer of intramedullary osteosynthesis. On 9 November 1939, he performed the first procedure at the ‘‘Chirurgische Klinik’’ in Kiel (Germany); in March 1940, he presented the results of 11 femur nails as well as one forearm and one humerus nail at the Congress of the German Surgical Society in Berlin. The announcement of his innovative method led to a generally hostile discussion amongst Germany’s pre-eminent surgeons. Only his chief AW Fischer took Küntscher’s side and supported him. In December 1939, Küntscher was granted with the industrial property rights for intramedullary nailing. In 1941, he reported for duty at the eastern front where he worked in main dressing stations and in battlefield hospitals. In 1942, after a meeting of the Supreme Army Command in Krasnodar, intramedullary nailing of the femur was introduced to the German army due to the advice of Sauerbruch, Handloser, Frey, Böhler andWachsmut. In 1943, Küntscher was detached to the German military hospital in Kemi (Finnland) where he served as a consulting surgeon till 1944 (Cross, 2001). In 1945, Kuntscher returned to Germany. Unable to work in Kiel, he went to SchleswigHesterberg where he was treated for diphtheria for several months (Ratschko and Mehs, 2011). In the same year, the book ‘‘Technik der Marknagelung’’, written by Küntscher and Richard Maatz, a surgery resident at the University Clinic for Surgery in Kiel was published by the Thieme-Verlag in Leipzig. Küntscher thought that the principle of the stabilization of his cloverleaf shaped slotted nail in the intramedullary canal of long bones was based on an elastic transversely directed deadlock caused by the tube-in-tube conjunction. He claimed to be able to nail every single bone in the case of a fracture. Therefore, in collaboration with Ernst Pohl, a brilliant orthopedic technician, he almost constantly designed new implants; many of them were commercially marketed. Between 1946 and 1957, Küntscher was the head of the Department of Surgery in the hospital of Schleswig-Hesterberg and in 1957, he became medical director and head of the Department of Surgery in the Harbor Hospital of Hamburg. In 1965, he tried to obtain a prolongation of his employment in Hamburg by all available means, but the city government refused (Schroeder, 2001). His efforts to be appointed to a professorship for trauma surgery in Germany were also unsuccessful. In 1965, Küntscher received the title of honorary doctor of the mathematical and scientific faculty of the Christian-Albrechts-University in Kiel. In that year, his attempt to get a foothold