Ralph Gaulke

Elevated systemic IL-18 and neopterin levels are associated with posttraumatic complications among patients with multiple injuries: a prospective cohort study.

INTRODUCTION Posttraumatic systemic inflammatory response syndrome (SIRS), sepsis and their subsequent complication, the multiple-organ dysfunction syndrome (MODS), remain major complications following polytrauma. This prospective clinical study aimed at evaluating the association between these and plasma interleukin-18 (IL-18) and neopterin levels. METHODS Inclusion in the series required an Injury Severity Score (ISS) >16, age 16-65 years, admission within 6 h of the accident and survival >48 h; 55 patients were enrolled. Over 14 days, plasma neopterin and IL-18 levels and the clinical course regarding MODS, SIRS and sepsis were recorded daily using the Marshall Score for MODS and the ACCP/SCCM criteria for SIRS and sepsis. RESULTS Neopterin and IL-18 plasma levels were increased in +MODS cases as compared with -MODS cases over almost the entire observation period. IL-18 concentrations over days 3-6 were significantly increased among participants with sepsis. These increases were all apparent 2-3 days before the clinical diagnosis of sepsis or MODS was made. In contrast, no significant differences in neopterin and IL-18 plasma levels were observed between participants with and without SIRS. CONCLUSIONS Determinations of neopterin and IL-18 concentrations might represent early markers for posttraumatic complications such as MODS and sepsis. They might help to differentiate between SIRS and sepsis and thereby guide the timing of the surgery for polytrauma. Neopterin and IL-18 levels should be used together with the clinical status and other inflammatory markers (IL-6, IL-8, etc.) for prediction of posttraumatic complications.

Incidence and significance of injuries to the foot and ankle in polytrauma patients—An analysis of the Trauma Registry of DGU

BACKGROUND Injuries to the foot and ankle are often missed or underestimated during the initial care for polytraumatized patients. Nonetheless, injuries to the lower extremity exert significant influence on long-term outcome after discharge from the acute care facility. Since the mortality of trauma decreased in the last decades, these injuries gain more effect on the overall outcome. We analysed foot and ankle injury patterns, associated procedures and special characteristics of this population during early care. METHODS Multiply injured patients of the Trauma Registry of DGU (TR-DGU; Injury Severity Score, ISS > or = 16) with injuries to the foot and ankle (group F&A) were compared to the remaining TR-DGU population (group Non-F&A) for differences in injury characteristics, surgical treatment and early outcome. A detailed comparative statistic is provided. RESULTS Demographic data and injury severity were comparable between the groups. The group F&A showed significantly more falls from a height above 3m and suicidal injuries. Their overall injury severity to the extremities, especially to the regions different from the foot and ankle, was significantly higher compared to group Non-F&A. Group F&A patients had more surgeries and less intensive care complications. Mortality was 11.6% (F&A) and 16.2% (Non-F&A). Concerning initial outcome when discharged from the acute care facility, group F&A patients more commonly were moderately or severely disabled in everyday life. CONCLUSIONS Our data enhance the need for a meticulous search for injuries to the foot and ankle in patients with falls, comparably light injuries to the trunk and head and especially in patients with multiple and severe injuries to the skeletal system. Since 88.4% of patients with foot and ankle injuries are discharged alive, early appropriate care should be given to these injuries that significantly affect long-term outcome.

Hands-on robotic distal interlocking in intramedullary nail fixation of femoral shaft fractures

INTRODUCTION Intramedullary nailing has become the gold standard in the treatment of femoral shaft fractures. This procedure involves the placement of distal interlocking bolts using the freehand technique. Accurate placement of distal interlocks can be a challenging task, especially in inexperienced hands. Misplacement of distal interlocking bolts can lead to iatrogenic fracture, instability of the bone-implant construct, or even malalignment of the extremity. Repeated drilling attempts increase radiation exposure and can cause additional bony and soft tissue trauma. We hypothesize that robot-guided placement of distal interlocks is more accurate, precise, and efficient than the freehand technique. METHODS A custom-designed drill guide was mounted onto the arm of an industrial robot. We developed a special device to secure a generic block (Synbone, Malans, Switzerland) into which an intramedullary nail could be inserted in a standardized way. A metric scale allowed later measurements of the drillings. Digital images were taken from each side of the block for analysis of the drilling trajectories. The fluoroscope was adjusted to obtain perfect circles of the distal interlocking holes. The number of images necessary to achieve this was recorded. The axis was recognized automatically by using the differences in contrast between the matrix of the generic bone and the implant (intramedullary nail). The drill trajectories were then computed. The robot with the mounted drill-guide automatically moved onto the calculated trajectory. The surgeon then executed the drilling. We performed 40 robot assisted drillings in generic blocks. Freehand drilling served as our control group. RESULTS Analysis of the digital images revealed a mean deviation of 0.94 mm and 2.7° off the ideal trajectory using robotic assistance. In 100% of the cases (n = 40), the distal locking hole was hit. A mean of 8.8 images was acquired. After manual drilling, 92.5% of the distal interlocks were hit. A mean deviation of 3.66 mm and 10.36° was measured. A mean of 23.4 fluoroscopic images were needed. The differences between the two methods were statistically significant. CONCLUSION Robot-guided drilling increases the accuracy and precision of distal interlocking while reducing irradiation. Considering economical and logistical aspects, this application should be integrated with robot-guided fracture reduction.

Robotized access to the medullary cavity for intramedullary nailing of the femur

INTRODUCTION The insertion site for an antegrade femoral intramedullary nail in the treatment of a femoral shaft fracture has traditionally been performed using a free-hand technique. An inappropriate starting point can result in suboptimal nail insertion leading to malreduction, or iatrogenic fracture. Furthermore, repeated attempts to establish the optimal starting point can cause additional soft tissue trauma and radiation exposure. In the following study we compared a robot-guided technique with the standard free-hand technique for establishing the entry point of an antegrade femoral nail. We hypothesized that the robot-guided technique is more reliable and efficient. METHODS A custom-made drill-guide was mounted onto the arm of an industrial robot. Two orthogonal fluoroscopic images were acquired from the proximal femur of five cadaveric human specimens. Images were processed with a special software in order to create an enhanced contour-recognition map from which the bone axes were automatically calculated. The drilling trajectory was computed along the extension of the bone-axis. The robot then moved the drill-guide on this trajectory toward the entry point. The drilling was then performed by the surgeon. In the control group, five cadaveric human femora were utilized to manually establish the starting point using the free-hand technique. RESULTS 100% of the intramedullary cavities were successfully accessed with both the robot-guided and the manual techniques. In the manual technique repositioning of the drill was necessary in three out of five cases. The mean number of acquired fluoroscopic images was significantly reduced from 11.6 (manual) to 4 (robot-guided). CONCLUSION Robot-assisted drilling of the entry-point in antegrade femoral nailing is more reliable and requires fewer radiographic images than the free hand technique. Yet, based on economical and logistical considerations, its application will probably only be accepted when a concomitant application for fracture reduction is available.

Effectiveness of bicycle safety helmets in preventing facial injuries in road accidents

Background The effectiveness of bicycle safety helmets in preventing head injuries is well- documented. Recent studies differ regarding the effectiveness of bicycle helmets in preventing facial injuries, especially those of the mid-face and the mandible. Objectives The present study was conducted to determine the protective effect of a bicycle helmet in preventing mid-face and mandibular fractures. Patients and Methods Data from an accident research unit were analyzed to collect technical collision details (relative collision speed, type of collision, collision partner, and use of a helmet) and clinical data (type of fracture). Results Between 1999 and 2011, 5,350 bicycle crashes were included in the study. Of these, 175 (3.3%) had fractures of the mid-face or mandible. In total, 228 mid-face or mandibular fractures were identified. A significant correlation was found between age and relative collision speed, and the incidence of a fracture. While no significant correlation was found between the use of a helmet and the incidence of mid-facial fractures, the use of a helmet was correlated with a significantly increased incidence of mandibular fractures. Conclusions Higher age of cyclists and increasing speed of the accident opponent significantly increase the likelihood of sustaining facial fractures. The use of bicycle helmets does not significantly reduce the incidence of mid-facial fractures, while being correlated with an even increased incidence of mandibular fractures.

Improvement in the workflow efficiency of treating non-emergency outpatients by using a WLAN-based real-time location system in a level I trauma center.

BACKGROUND Patient localization can improve workflow in outpatient settings, which might lead to lower costs. The existing wireless local area network (WLAN) architecture in many hospitals opens up the possibility of adopting real-time patient tracking systems for capturing and processing position data; once captured, these data can be linked with clinical patient data. OBJECTIVE To analyze the effect of a WLAN-based real-time patient localization system for tracking outpatients in our level I trauma center. METHODS Outpatients from April to August 2009 were included in the study, which was performed in two different stages. In phase I, patient tracking was performed with the real-time location system, but acquired data were not displayed to the personnel. In phase II tracking, the acquired data were automatically collected and displayed. Total treatment time was the primary outcome parameter. Statistical analysis was performed using multiple linear regression, with the significance level set at 0.05. Covariates included sex, age, type of encounter, prioritization, treatment team, number of residents, and radiographic imaging. RESULTS/DISCUSSION 1045 patients were included in our study (540 in phase I and 505 in phase 2). An overall improvement of efficiency, as determined by a significantly decreased total treatment time (23.7%) from phase I to phase II, was noted. Additionally, significantly lower treatment times were noted for phase II patients even when other factors were considered (increased numbers of residents, the addition of imaging diagnostics, and comparison among various localization zones). CONCLUSIONS WLAN-based real-time patient localization systems can reduce process inefficiencies associated with manual patient identification and tracking.

Simultaneous bilateral transitional fractures of the proximal tibia after minor sports trauma.

We report a very rare case of a 16-year-old healthy athletic boy who sustained simultaneous bilateral transitional fractures of the proximal tibia after kicking a football with his right leg during a soccer game. Following minimal invasive plate osteosynthesis with bridging of the growth plate, the patient recovered rapidly without any growth disturbances.

Development of a WLAN-based real time localization system for patient tracking in a Level I Trauma center

BACKGROUND Patient tracking helps improve workflow, decrease wait times, optimize costs, and enhance medical treatment in the outpatient setting. In that regard, real-time patient tracking may serve as a potential way to perform efficient patient care. In recent years, the increasing popularity of wireless local area networks (WLANs) has led to a growing number of devices utilizing wireless fidelity (WiFi) networks. This application has been used in various industries to enhance management processes. In that regard, we believe that this technology may enhance patient tracking, as the existing WLAN architecture in many clinics may allow for real-time tracking of patients. However, current literature regarding the clinical applicability of these devices is sparse. The aim of this study is to analyze the developmental process and feasibility of our protytope model for real-time patient tracking, using WLAN in the outpatient setting of our Level I Trauma center. METHODS We performed the study in various stages. First, we analyzed our current patient workflow, and then devised a study protocol and prototype model that implemented both this workflow schematic and our current technology infrastructure. Second, we implemented our prototype model to determine the accuracy, feasibility, and safety of data transmission in our clinical setting. The factors examined during prototype implementation included the accuracy of patient localization and the time spent by each patient in the various areas of our clinic (as determined by patient tracking). RESULTS In our outpatient clinic, our prototype was capable of localizing and automating patient data with excellent accuracy and security. CONCLUSIONS WLAN-based real-time patient localization systems can help overcome a number of common challenges and inefficiencies seen in the outpatient clinics. Real-time localization systems using WLAN technology performed adequately and safely in this pilot study. We believe that this will eventually lead to lower costs overall due to the improvements in efficiency. While the initial investment costs may be high, implemeting this system in a pre-existing WLAN and WiFi infrastructure should help minimize the start-up costs.

A standardized fracture reduction model for long bones - Implication and evaluation in the femur

Fractures of the femoral bone are frequent injuries with a wide range of affected individuals. New treatment strategies and technologies are being explored permanently. Their quality is biomechanically judged by the accuracy of the anatomical reduction. Malalignment of the fragments would have an eminent impact on the overall outcome and rehabilitation. To establish a method for investigations of the reduction results of femoral fractures, we developed a model, using a navigation system for taking measurement. The dynamic reference bases (DRBs) were mounted to the intact femoral bone and registered as the reference position. A special construction allowed removal and reattachment of the DRBs without provoking change in the DRB-bone system. The model was evaluated in its constancy. Translational deviations remained below 0.9 mm and rotational deviations below 0.3° after 40 repetitive reattachments. The model could prove to be valid and reliable. An application in long-bone trauma research is reasonable.

Die radiolunäre Rearthrodese

Since 1983, radiolunate arthrodesis has been the gold standard for stabilising the rheumatic wrist. Rearthrodesis of the radiolunate joint has not yet been described. In a prospective study on five radiolunate rearthrodeses with a dorsal mini titanium plate and oblique screw, bone healing was achieved in four. Fatigue fracture of the plate occurred in one case of delayed bone healing. After another rearthrodesis using the same technique, bone healing was achieved. Complete fusion of the wrist can be avoided after failed radiolunate fusion using the described operative technique for rearthrodesis of the radiolunate joint. Preserving some wrist mobility is of high value for these multimorbid patients.