M. Grotz

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.

Intestinal cytokine response after gut ischemia: role of gut barrier failure.

OBJECTIVE To investigate the effect of intestinal ischemia with and without a reperfusion injury on intestinal cytokine production and gut permeability. SUMMARY BACKGROUND DATA In humans and in animal models, the gut has been implicated as a cytokine-producing organ after ischemia/reperfusion (I/R)-type injuries. Because of the limitations of in vivo models, it has been difficult to demonstrate directly that the gut releases cytokines after an I/R injury or whether there is a relation between the magnitude of the ischemic process and the cytokine response. METHODS Ileal mucosal membranes from rats subjected to sham or 45 or 75 min of superior mesenteric occlusion (SMAO) or 45 minutes of SMAO and 30 minutes of reperfusion (SMAO 45/30) were mounted in the Ussing chamber system. Levels of tumor necrosis factor-alpha and interleukin-6 were serially measured in the mucosal and serosal reservoirs of the Ussing system, as was mucosal permeability as reflected by the passage of bacteria or phenol red across the ileal membrane. In a second group of experiments, Escherichia coli C25 was added to the mucosal reservoir to determine if the cytokine response would be increased. RESULTS Mucosal and serosal levels of tumor necrosis factor-alpha were equally increased after SMAO, with the highest levels in the 75-minute SMAO group. The highest levels of interleukin-6 were found in rats subjected to 75 minutes of SMAO or SMAO 45/30; the serosal levels of interleukin-6 were four to sixfold higher than the mucosal levels. The addition of E. coli C25 resulted in a significant increase in the amount of interleukin-6 or tumor necrosis factor-alpha recovered from the mucosal reservoir. Increased ileal membrane permeability was observed only in rats subjected to 75 minutes of SMAO or SMAO 45/30. CONCLUSION These results directly document that the levels of tumor necrosis factor-alpha and interleukin-6 released from the gut increase after an ischemic or I/R injury, such as SMAO, and that there is a relation between the magnitude of the gut ischemic or I/R insult and the cytokine response.

Pattern of organ failure following severe trauma

Abstract. Multiple organ failure (MOF) is considered to be the leading cause of death after severe trauma. Although there is extensive literature on MOF, little is known about the pattern, sequence, and onset of this clinical syndrome. The first goal of this clinical study was to define MOF; the second was to assess the typical onset, sequence, and pattern of MOF; and the third was to define certain risk factors for the development of MOF in 342 multiple trauma patients. Patients with an Injury Severity Score (ISS): > 20 (mean 35.7) were included. Three well established MOF scoring methods were used to give strict definitions of MOF: 11.4% of the total patient population developed MOF, and 88.6% did not. Respiratory failure was most frequent in patients developing MOF (74.4%), and these patients had the highest mortality rate (65.5%) compared to patients with failure of other organ systems (liver, cardiovascular system). Generally, the lung is the first organ to fail after injury (failure after 3.7 ± 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other signs of organ dysfunction (gastric, central nervous system) are difficult to verify. Typical risk factors for the development of MOF after severe trauma are the severity, type, and distribution of injury as well as the indicators of prolonged hemorrhagic shock (elevated lactate levels). The main therapeutic efforts, therefore, should be the effective treatment of traumatic hemorrhagic shock during the initial phase, adequate resuscitation, optimal oxygenation, and early surgical treatment.

30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution.

The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n=1469) and 1985-1994 (decade II; n=1937) and 1995-2004 (decade III; n=1443) were compared. 65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death. These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.

Does the reamer type influence the degree of lung dysfunction after femoral nailing following severe trauma? An animal study.

Summary: In multiple trauma patients with lung contusion, pulmonary complications have been reported that were attributed to intramedullary stabilization of the femur. The reaming procedure of the medullary canal is thought to play a major role. We investigated whether different types of reamers might exert different amounts of fat mobilization into the vascular system and different degrees of pulmonary dysfunction. Adult female Merino sheep were submitted to hemorrhagic shock (2 h, 50 mm Hg) and a unilateral lung contusion; in addition, a lung lymph fistula was created. Pulmonary capillary permeability, central venous triglyceride levels, 11-dehydro-thromboxane B2 (dh- TXB2) levels, and pulmonary artery pressure were determined. After recovery, animals were randomly assigned to intramedullary femoral nailing using several types of reamers: group A, AO reamer (n=8); group B, Biomet reamer (n=7); group H, Howmedica reamer (n=6); group C, controls, no reaming (n=4). Intramedullary reaming caused a significant (p<0.05) increase in pulmonary artery pressure in groups A and B; dh-TXB2 levels increased in all groups. Statistically significant (p<0.05) pulmonary capillary permeability damage was measured in group A only. Intramedullary femoral nailing can cause transient pulmonary hemodynamic and mediator effects as well as increased pulmonary capillary permeability. In the present study, this effect was evident in group A reamer systems only, which may be due to reamer construction.

Trauma care in Germany.

Trauma Care in Germany fulfils all requirements to deal with injured young and mobile individuals as well as with an increasing number of injured elderly patient. Furthermore, it is prepared to cope with mass casualties of injured. As a public task the Trauma System in Germany is well organized and follows clear cut demands. To perform technical and medical therapy at highest available level as soon as possible, a ground system of physician staffed ambulances is supported by a network of physician-staffed HEMS all over Germany. Therefore, enormous efforts in financing, basic research and quality management have been undertaken during recent years to create such a sophisticated rescue system.

Hindlimb Growth After a Transphyseal Reconstruction of the Anterior Cruciate Ligament: A Study in Skeletally Immature Sheep With Wide-Open Physes

Background There is a lot of controversy in the recent literature with regard to the optimal treatment of anterior cruciate ligament (ACL) injuries during growth. Iatrogenic growth disturbance due to physeal damage is a potential complication, forcing many orthopaedic surgeons to treat these injuries conservatively. Hypothesis It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances. Study Design Descriptive laboratory study. Materials and Methods Four-month-old skeletally immature sheep underwent a transphyseal ACL reconstruction of the right knee. The surgical technique followed the criteria known to be essential to avoid growth disturbances in humans; the tibial tuberosity was spared to prevent a genu recurvatum, thermal damage to the growth plates was avoided, the physes were perforated with a small-diameter drill in the center of the growth plate, a soft tissue graft was used, graft fixation was achieved far away from the growth plates, the perforated growth plates were filled by the soft tissue graft, and the graft was moderately pretensioned before fixation. The left knee served as a control. A computer-assisted evaluation of long radiographs (frontal and sagittal plane) of the exarticulated hindlimbs was performed to exactly evaluate the limb alignment, joint orientation, and leg length. The animals were sacrificed in groups of 6 after 3, 6, 12, and 24 weeks. Results No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth. Conclusion This large-animal study supports the clinical observation that it is possible to perform an ACL reconstruction without creating growth disturbances as long as a number of key principles are followed. Clinical Relevance Previous animal studies argued against ACL reconstruction in skeletally immature patients. This large-animal study provides support for early operative treatment of ACL ruptures even in young patients with open physes.

Femoral biologic plate fixation

New techniques of fracture fixation such as indirect reduction, careful soft tissue handling, and elastic fixation are being used in place of older methods of mechanical stabilization. These new techniques led to the concept of biologic plate fixation. We systematically reviewed the literature and provide an overall evaluation of femoral biologic fixation for fracture treatment. We analyzed 19 studies with 687 patients with 697 femoral fractures. Twenty-three percent of the fractures were subtrochanteric, 29% were diaphyseal, and 48% were supracondylar. Twenty-two percent were open fractures. The majority (81%) were comminuted and AO Types B and C. The overall union rate was 98.4%, with a mean time to union ranging from 10.7 to 24 weeks. Primary or secondary bone-grafting procedures were reported in all but one study with a frequency ranging from 0-55%. The most frequently recorded complications were malunion (0-29%) and reoperation (0-23%). The high union rate, low infection rate (2%), and occasional need for bone graft indicate biologic plate fixation is a viable alternative to modern nailing techniques, particularly in patients with polytrauma.Level of Evidence: Therapeutic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Glycine reduces the inflammatory response and organ damage in a two-hit sepsis model in rats.

The goal of this study was to investigate whether prefeeding of glycine reduces the immunoinflammatory response, the degree of distant organ injury (liver), and/or the mortality rate in a two-hit model using intestinal ischemia/reperfusion and endotoxin (ET) challenge 6 h later in rats. The liver damage was greatest at 24 h after ET challenge and completely inhibited by glycine. The early systemic increase of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL) -6 as well as the secretion of the antiinflammatory cytokine IL-10 was reduced by glycine. Tissue cytokine mRNA expression (TNF-alpha, IL-1beta, IL-10) was decreased in the lung and the liver but not in the mesenteric lymph node or ileum, in the glycine-fed group. However, glycine did not decrease the mortality rate. These results suggest that prefeeding of glycine reduces liver damage as well as the systemic and local (lung and liver) inflammatory response after intestinal ischemia/reperfusion and endotoxin challenge in rats.

Multiple organ failure (MOF) after severe trauma - a sheep model

Objective: To perform a reproducible long-term (10 days) large animal model of multiple systems organ failure without necessity of a continuous stimulus.Design: Adult female merino sheep submitted to a 5-day stimulation period followed by a 5-day observation period. Day 1: Hemorrhagic shock was combined with a traumatic surgical insult (reamed intra-medullary femoral nailing), followed by serial administrations every 12 h for 5 days of a combination of endotoxin and zymosan activated plasma. Organ function was followed for 5 further days.Results: Cardiac index increased significantly during the study (day 1: 491 ± 8 mmHg; day 10: 427 ± 20, p<0.05). Liver function was impaired and bilirubin levels increased significantly (day 1: 2.9 ± 0.3 µmol/1; day 10: 7.2 ± 0.9; p<0.05). Creatinine clearance decreased initially (day 1: 54 ± 7 ml/min), increased to a peak on day 2 (104 ± 27), and then deteriorated again (day 10: 53 ± 18).Conclusion: This new large animal model of trauma-induced MOF is reproducible and may be suitable for the study of new therapeutic approaches to therapy.