Marco M. Schneider

Epidemiology and risk factors of multiple-organ failure after multiple trauma: an analysis of 31,154 patients from the TraumaRegister DGU.

BACKGROUND In the severely injured who survive the early posttraumatic phase, multiple-organ failure (MOF) is the main cause of morbidity and mortality. An enhanced prediction of MOF might influence individual monitoring and therapy of severely injured patients. METHODS We performed a retrospective analysis of a nationwide prospective database, the TraumaRegister DGU of the German Trauma Society. Patients with complete data sets (2002–2011) and a relevant trauma load (Injury Severity Score [ISS] ≥ 16), who were admitted to an intensive care unit, were included. RESULTS Of a total of 31,154 patients enclosed in this study, 10,201 (32.7%) developed an MOF according to the Sequential Organ Failure Assessment score. During the study period, mortality of all patients decreased from 18.1% in 2002 to 15.3% in 2011 (p < 0.001). Meanwhile, MOF occurred significantly more often (24.6% in 2002 vs. 31.5% in 2011, p < 0.001), but mortality of MOF patients decreased (42.6% vs. 33.3%, p < 0.001). MOF patients who died survived 2 days less (11 days in 2002 vs. 8.9 days in 2011, p < 0.001). Independent risk factors for the development of MOF following severe trauma were age, ISS, head Abbreviated Injury Scale (AIS) score of 3 or higher, thoracic AIS score of 3 or higher, male sex, Glasgow Coma Scale (GCS) score of 8 or less, mass transfusion, base excess of less than −3, systolic blood pressure less than 90 mm Hg at admission, and coagulopathy. CONCLUSION Over one decade, we observed an ongoing decrease of mortality after multiple trauma, accompanied by decreasing mortality in the subgroup with MOF. However, incidence of MOF in the severely injured increased significantly. Thus, MOF after multiple trauma remains a challenge in intensive care. The risk factors from multivariate analysis could be instrumental in anticipating the early development of MOF. Furthermore, a reliable prediction model might be supportive for patient enrolment in trauma studies, in which MOF marks the primary end point. LEVEL OF EVIDENCE Epidemiologic study, level III.

Reliable Alignment in Total Knee Arthroplasty by the Use of an iPod-Based Navigation System

Axial alignment is one of the main objectives in total knee arthroplasty (TKA). Computer-assisted surgery (CAS) is more accurate regarding limb alignment reconstruction compared to the conventional technique. The aim of this study was to analyse the precision of the innovative navigation system DASH® by Brainlab and to evaluate the reliability of intraoperatively acquired data. A retrospective analysis of 40 patients was performed, who underwent CAS TKA using the iPod-based navigation system DASH. Pre- and postoperative axial alignment were measured on standardized radiographs by two independent observers. These data were compared with the navigation data. Furthermore, interobserver reliability was measured. The duration of surgery was monitored. The mean difference between the preoperative mechanical axis by X-ray and the first intraoperatively measured limb axis by the navigation system was 2.4°. The postoperative X-rays showed a mean difference of 1.3° compared to the final navigation measurement. According to radiographic measurements, 88% of arthroplasties had a postoperative limb axis within ±3°. The mean additional time needed for navigation was 5 minutes. We could prove very good precision for the DASH system, which is comparable to established navigation devices with only negligible expenditure of time compared to conventional TKA.

Limited reliability of grading scapular notching according to Nerot–Sirveaux on anteroposterior radiographs

IntroductionIncidences of scapular notching (SN) in reverse shoulder arthroplasty (RSA) range between 0% and 96%, and controversy remain as to its relevance for patient outcome. We assessed the reliability of scapular notching (SN) grading based on the Sirveaux classification system using anteroposterior radiographs.Materials and methods206 RSA procedures with 5-year postoperative anteroposterior shoulder radiographs were classified independently by seven assessors according to Sirveaux (session 1). After a review meeting, three assessors re-classified the radiographs along with quality criteria (session 2). SN grading by the majority of assessors was taken as the reference. Classification interobserver reliability was analyzed using Kappa statistics.ResultsThe incidence of SN was estimated at 53% and 37% at the first and second sessions, respectively. Interobserver reliability Kappa coefficients resulting from the first and second sessions were 0.27 and 0.43, respectively. Case selection based on radiographic quality criteria did not improve SN grading reliability in the second session.ConclusionAgreement between individual surgeons was low when grading SN in RSA according to Sirveaux using anteroposterior radiographs. Consensus among several assessors may increase reliability in research settings.

The Impact of Pinless Navigation in Conventionally Aligned Total Knee Arthroplasty

Background Restoration of the mechanical axis is a main objective in total knee replacement (TKR). Aim of this study was to analyse the verification tool of a pinless navigation system in conventional TKR (cTKR). Methods In a prospective study, 147 TKR were performed by conventional technique. Using the “pinless verification” mode of a smartphone based navigation system, the cutting block position and final resection plane for distal femur and proximal tibial resection were measured. If necessary, the block position or resection level were optimized, corrections were protocolled. Postoperatively, standardized radiographs were performed. Results In 65.3%, intraoperative measurements changed the surgical procedure (corrections: 20.4% femoral, 25.9% tibial, 19% both). The additional time for surgery compared to cTKR averaged 6 minutes (79 ± 15 versus 73 ± 17 minutes). Using navigation data, the final femoral and tibial axes were in 93% within a range of ±2°. A mean difference of 1.4° and 1.6° could be shown between the final measurement of the navigation system and the postoperative mLDFA and mMPTA. Conclusion Intraoperative pinless navigation has impact on the surgical procedure in the majority of cTKR. It represents a less time-consuming tool to improve implant position while maintaining the routine of conventional technique.

Direct comparison of different surgical approaches in a woman with bilateral osteochondrosis dissecans of her knees: a case report.

BackgroundOsteochondrosis dissecans is a disorder of the subchondral bone potentially affecting the adjacent articular cartilage. There remains disunity with regard to treatment methods.Case presentationWe present the case of a 21-year-old Swiss woman who presented with clinically symptomatic bilateral osteochondrosis dissecans lesions at both medial femoral condyles. She underwent sequential surgical intervention and was prospectively monitored using clinical scores and magnetic resonance imaging. Her left knee was treated with an open refixation of the osteochondrosis dissecans lesion with two 2.0 mm screws in combination with a cancellous bone graft and subchondral drilling since the cartilage of the osteochondrosis dissecans lesion was intact. On her right knee, she underwent open removal of the defective bone and cartilage, cancellous bone graft with subchondral drilling and coverage with a bilayered collagenous membrane (autologous matrix-induced chondrogenesis technique) since the cartilage of the osteochondrosis dissecans lesion was not intact. At final follow-up 12 months after surgery her Lysholm score had improved from 79 to 95 on her left side and from 74 to 78 on her right. Magnetic resonance imaging displayed good integration of the cancellous bone graft with a slight irregularity at the articular surface on her left side (magnetic resonance observation of cartilage repair tissue (MOCART) 75). The magnetic resonance imaging of her right knee depicted satisfying bony reconstitution with yet more irregularity at the joint surface (magnetic resonance observation of cartilage repair tissue 65) in comparison to her left femoral condyle.ConclusionsIn cases of failed conservative treatment of osteochondrosis dissecans lesions of the knee joint surgery should be taken into consideration. Considering this case, we believe that the focus should be the preservation of the cartilaginous layer whenever possible or at least replacement with high quality replacement tissue, such as autologous chondrocyte implantation.

Avulsion fracture of the coracoid process in a patient with chronic anterior shoulder instability treated with the Latarjet procedure: a case report

IntroductionShoulder dislocations can cause acute and chronic instabilities that need to be addressed in order to restore joint functioning. The transfer of the coracoid process has become a feasible surgical procedure in patients with shoulder instability. Several concomitant injuries after recurrent dislocations have been described.Case presentationA 32-year-old German man presented to our department with a history of recurrent shoulder dislocations. He was diagnosed with an avulsion fracture of the coracoid process and dislocation of an osseous piece with attachment to the conjoined tendons during the surgical transfer of the coracoid process. Therefore, we performed an open Latarjet procedure and reattached the bony piece with the conjoined tendons to the glenoid rim. Three months after the operation the patient presented with a satisfying range of motion and without instabilities or pain. He was able to return to his job.ConclusionsPatients suffering from anterior shoulder dislocation might develop accompanying lesions after numerous dislocations that are not present upon first visit. Different techniques for the reconstruction of the glenoid rim and the restoration of shoulder joint stability have been described in the literature. We opted for a coracoid transfer and achieved an optimal reconstruction, as shown on the postoperative computed tomography scan. An avulsion fracture of the coracoid process with dislocation of the conjoined tendons can not only be found in patients suffering a direct trauma as pointed out in the literature, but also in patients with anterior shoulder instability with recurrent anterior shoulder dislocation.