Olli Savola

Effects of Head and Extracranial Injuries on Serum Protein S100b Levels in Trauma Patients

BACKGROUNDnSerum protein S100B determinations have been recently suggested as markers of traumatic brain injury. However, little is known about the effects of extracranial injuries on S100B levels in trauma patients.nnnMETHODSnWe studied 224 patients with head trauma (54 of whom also had extracranial injuries), 155 patients with various types of extracranial injuries, and 8 healthy pilots exposed to high Gz forces. The head trauma patients had either no brain injury (n = 35), mild brain injury (n = 165), or moderate to severe brain injury (n = 24). The extracranial injuries were divided into small and large injuries. Serum protein S100B levels were determined from samples taken within 6 hours after the trauma event.nnnRESULTSnThe head trauma patients had a significantly higher median S100B (0.17 microg/L) than the patients with extracranial injuries (0.07 microg/L) (p < 0.001). Serum S100B levels also correlated with the severity of brain injury (p < 0.001), the highest values occurring in the patients with moderate to severe brain injury (1.27 microg/L). However, large extracranial injuries also elevated S100B levels (0.35 microg/L), whereas small extracranial injuries in the absence of head trauma did not significantly affect S100B levels (0.07 microg/L). Above the cutoff level of 0.13 microg/L, there were 61% of the head trauma patients and 26% of those with extracranial injuries (Pearson chi test, p < 0.001). However, only 4% of the patients with purely extracranial injuries had a concentration of S100B above the cutoff level of 0.50 microg/L, whereas the head trauma patients with moderate to severe brain injury exceeded this cutoff in 67% of the cases. Exposure to high Gz forces did not influence serum S100B levels in healthy individuals.nnnCONCLUSIONnWe conclude that serum S100B is a sensitive marker of brain injury, which correlates with the severity of the injury. Large extracranial injuries also elevate S100B levels. However, S100B has a high negative predictive power, and the finding of a normal S100B value shortly after trauma should thus exclude significant brain injury with a high accuracy.

Early predictors of post-concussion symptoms in patients with mild head injury

A small proportion of patients with mild head injury (MHI) develop post‐concussion symptoms (PCSs). We searched simple measures for the early detection of patients who are probable to develop PCSs. We recorded signs and symptoms, history of previous diseases, medications, and lifestyle factors and measured serum protein S‐100B on admission in a series of 172 consecutive MHI patients admitted into the emergency room of a general hospital. A modified Rivermead Post‐Concussion Symptoms Questionnaire was used to identify the patients with and without PCSs 1u2003month after the injury. We identified 37 patients with MHI who developed PCSs (22%). Odds ratios (OR) and 95% confidence intervals (CI) after adjustment for possible confounding variables were calculated by logistic regression. Independent early risk factors for PCSs in the MHI patients were skull fracture (OR 8.0, 95% CI 2.6–24.6), serum protein S‐100Bu2003≥u20030.50u2003μg/l (OR 5.5, 95% CI 1.6–18.6), dizziness (OR 3.1, 95% CI 1.2–8.0), and headache (OR 2.6, 95% CI 1.0–6.5). Serum protein S‐100B proved to be a specific, but not sensitive predictor of PCSs. The presence of skull fracture, elevated serum protein S‐100B, dizziness, and headache may help the emergency room physician to identify patients at risk of PCSs and to refer them for further examination and follow‐up.

Fall‐related brain injuries and the risk of dementia in elderly people: a population‐based study

Severe head injury in early adulthood may increase the risk of dementia in older age, but it is not known whether head injury in later life also increases the risk of dementia. A representative sample (82%) of persons aged 70u2003years or older with a Mini‐Mental State Examination (MMSE) test score of ≥26 (nu2003=u2003325) were followed‐up for 9u2003years to record all their fall‐related head injuries resulting in traumatic brain injury (TBI). At the end of the follow‐up period, 152 persons (81% of the surviving population) were examined for clinical dementia, according to DSM‐IV criteria. Eight persons sustained a TBI and 34 developed dementia. Brain injury was associated with younger age at detection of dementia even when adjusted for sex and educational status (low educational status significantly associated with dementia); age‐specific hazard ratio (95% confidence interval) 2.80 (1.35–5.81). In a population scoring ≥28 points in the baseline MMSE an apolipoprotein E (ApoE) ɛ4 phenotype was also associated with younger age at the time of detecting dementia; 3.56 (1.35–9.34), and the effect of brain injury and ApoE ɛ4 phenotype was synergistic; 7.68 (2.32–25.3). We conclude that fall‐related TBI predicts earlier onset of dementia and the effect is especially high amongst subjects who carry the ApoE ɛ4 allele.

A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography

BACKGROUNDnThe accuracy and maintenance of syndesmosis reduction are essential when treating ankle fractures with accompanying syndesmosis injuries. The primary aim of this study was to compare syndesmosis screw and TightRope fixation in terms of accuracy and maintenance of syndesmosis reduction using bilateral computed tomography (CT).nnnSTUDY DESIGNnSingle centre, prospective randomised controlled clinical trial; Level of evidence 1.nnnMETHODSnThis study (ClinicalTrials.gov, NCT01742650) compared fixation with TightRope(®) (Arthrex, Naples, FL, USA) or with one 3.5-mm tricortical trans-syndesmotic screw in terms of accuracy and maintenance of syndesmosis reduction in Lauge-Hansen pronation external rotation, Weber C-type ankle fractures with associated syndesmosis injury. Twenty-one patients were randomised to TightRope fixation and 22 to syndesmotic screw fixation. Syndesmosis reduction was assessed using bilateral CT intraoperatively or postoperatively, and also at least 2 years after surgery. Functional outcomes and quality of life were assessed using the Olerud-Molander score, a 100-mm Visual Analogue Scale, the Foot and Ankle Outcome Score, and the RAND 36-Item Health Survey. Grade of osteoarthritis was qualified with follow-up cone-beam CT.nnnRESULTSnAccording to surgeons assessment from intraoperative CT, screw fixation resulted in syndesmosis malreduction in one case whereas seven syndesmosis were considered malreduced when TightRope was used. However, open exploration and postoperative CT of these seven cases revealed that syndesmosis was well reduced if the ankle was supported at 90˚. Retrospective analysis of the intra- and post-operative CT by a radiologist showed that one patient in each group had incongruent syndesmosis. Follow-up CT identified three patients with malreduced syndesmosis in the syndesmotic screw fixation group, whereas malreduction was seen in one patient in the TightRope group (P = 0.33). Functional scores and the incidence of osteoarthritis showed no significant difference between groups.nnnCONCLUSIONnSyndesmotic screw and TightRope had similar postoperative malreduction rates. However, intraoperative CT scanning of ankles with TightRope fixation was misleading due to dynamic nature of the fixation. After at least 2 years of follow-up, malreduction rates may slightly increase when using trans-syndesmotic screw fixation, but reduction was well maintained when fixed with TightRope. Neither the incidence of ankle joint osteoarthritis nor functional outcome significantly differed between the fixation methods.

Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles.

Objectives: The aim of our study was to assess the intersubject and intrasubject variations of distal tibiofibular syndesmosis on computed tomography (CT) scans and to define standardized measures to verify syndesmosis reduction. Design: A retrospective study of 107 CT scans of ankles with normal tibiofibular syndesmosis. Setting: Main trauma center, university teaching hospital. Patients: The CT scans of 64 patients were reviewed by 2 musculoskeletal radiologists. Main Outcome Measurements: Bilateral variation was estimated. The intra- and interobserver reliabilities were calculated using standardized measurement points. CT measurements included the length of the tibial incisura (LI), A width and P width of the incisura (PW), depth of the incisura, narrowest part of the incisura, and sagittal translation of the fibula. Results: In 97% of normal cases, the fibula is situated either centrally or anteriorly in the tibial incisura. There were significant differences in PW and LI between genders, and the difference between the PW and A width was significantly larger in males (2.7 mm, SD 2.1) than in females (1.9 mm, SD 1.6, P = 0.023, t test). Significant asymmetry was not detected between ankles in single subjects. All CT measurements demonstrated good inter- and intraobserver reliabilities. Conclusions: If P translation of the fibula is present, malreduction should be considered. Sagittal translation measurements are not affected by the size of the joint or the gender of the patient, in contrast to traditionally used cross-sectional measurement methods.

Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI.

BACKGROUNDnThis prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space.nnnMETHODSnSixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment.nnnRESULTSnThirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively).nnnCONCLUSIONSnOn the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture.

Effect of Syndesmosis Injury in SER IV (Weber B)–Type Ankle Fractures on Function and Incidence of Osteoarthritis

Background: Syndesmosis fixation of Lauge-Hansen SER IV, Weber B ankle fractures is controversial. This study compared a matched pair of SER IV patients with stress proven syndesmotic injuries with the same number without stress proven syndesmotic injury in terms of functional, pain, and radiologic result. Methods: The study was based on a RCT-study comparing syndesmotic transfixation to no fixation in SER IV (Weber B)–type ankle fractures. Twenty-four patients with a syndesmosis injury found on the intraoperative 7.5 Nm standardized external rotation test were compared to 24 patients with a stable syndesmosis. The pairs were matched by fracture morphology, sex, and age. The primary outcome measure was ankle function as assessed by the Olerud–Molander score. Weight-bearing plain radiographs and 3T MRI of the injured ankle were used to assess ankle joint congruity and osteoarthritis, according to Kellgren-Lawrence classification and cartilage defects. Results: The Olerud–Molander score was 86 in syndesmosis injury patients and 90 in patients with normal syndesmosis (P = .28). The incidence of ankle joint osteoarthritis on plain radiographs was not significantly different between the groups (Grade I 5% vs 21%; Grade II 86% vs 75%; Grade III 9% vs 4%; P = .34). MRI scans showed TC joint cartilage defects in 54% of the patients: 12 (56%) in the syndesmosis injury group vs 13 (54%) in the group without syndesmosis injury (P > .9). Conclusion: After 4 to 6 years of follow-up, clinical and radiologic outcome were not different in patients with syndesmosis injury compared to patients with stable syndesmosis in SER IV (Weber B)–type ankle fractures. Level of Evidence: Prognostic Level II, comparative study.

First Tarsometatarsal Joint Derotational Arthrodesis—A New Operative Technique for Flexible Hallux Valgus without Touching the First Metatarsophalangeal Joint

No operative technique for hallux valgus has been introduced in which the first metatarsophalangeal joint is not touched. We report the first tarsometatarsal joint derotational arthrodesis in which we mimic the function of the peroneus longus tendon without involving the first metatarsophalangeal joint, allowing function of the windlass mechanism without interference. We treated 66 patients (62 women and 4 men) with 84 flexible hallux valgus feet using our new operative technique. Preoperative and postoperative follow-up weightbearing radiographs were evaluated. Most patients had a pronation type foot (78%) preoperatively, and mean correction in hallux valgus and intermetatarsal angle was 20° and 9°, respectively (pxa0<xa0.001). The LaPorta classification showed a median change of 2.5 U (pxa0<xa0.001). We have described a new operative technique forxa0flexible hallux valgus. The first tarsometatarsal joint derotational arthrodesis showed notable correction angles in hallux valgus, although the first metatarsophalangeal joint was left intact.

Effect of First Tarsometatarsal Joint Derotational Arthrodesis on First Ray Dynamic Stability Compared to Distal Chevron Osteotomy

Background: Hallux valgus alters gait, compromising first ray stability and function of the windlass mechanism at the late stance. Hallux valgus correction should restore the stability of the first metatarsal. Comparative studies reporting the impact of different hallux valgus correction methods on gait are rare. We report the results of a case-control study between distal chevron osteotomy and first tarsometatarsal joint derotational arthrodesis (FTJDA). Methods: Two previously studied hallux valgus cohorts were matched: distal chevron osteotomy and FTJDA. Seventy-seven feet that underwent distal chevron osteotomy (chevron group) and 76 feet that underwent FTJDA (FTJDA group) were available for follow-up, with a mean of 7.9 years (range, 5.8-9.4 years) and 5.1 years (range, 3.0-8.3 years), respectively. Matching criteria were the hallux valgus angle (HVA) and a follow-up time difference of a maximum 24 months. Two matches were made: according to the preoperative HVA and the HVA at late follow-up. Matching provided 30 and 31 pairs, respectively. Relative impulses (%) of the first toe (T1) and metatarsal heads 1 to 5 (MTH1-5), weightbearing radiographs, and American Orthopaedic Foot & Ankle Society (AOFAS) (hallux metatarsophalangeal-interphalangeal [MTP-IP]) scores were studied. Results: The relative impulse of MTH1 was higher in the FTJDA group, whereas a central dynamic loading pattern was seen in the chevron group. This result remained when relative impulses were analyzed according to the postoperative HVA. The mean difference in the HVA at follow-up was 6.2 degrees (95% confidence interval, 3.0-9.5; P = .001) in favor of the FTJDA group. Conclusion: The dynamic loading capacity of MTH1 was higher in the FTJDA group in comparison to the chevron group. The follow-up HVA remained better in the FTJDA group. Level of Evidence: Level III, case-control study.