Ralph Zettl

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study.

BACKGROUND The surgical treatment for displaced humeral head fractures overlooks a broad variety of surgical techniques and implant systems. A standard operative procedure has not yet been established. In this article, we report our experience with a second-generation locking plate for the humeral head fracture that is applied in a standardized nine-step minimally invasive surgical technique (MIS). METHODS In a prospective study from May 2008 until November 2009, a cohort of 79 patients with 80 proximal humerus fractures were operated in a MIS procedure using a polyaxial locking plate. Follow-up examination at 6 weeks and 6 months postoperative included radiologic examinations and a clinical outcome analysis by the Constant Score, the Visual Analog Scale for pain, and the Daily Activity Score. RESULTS The mean patient age was 65.5 years ± 19 years. According to the Neer classification, there were 18 (22.5%) two-part (Neer III), 48 (60%) three-part (Neer IV), and 14 (17.5%) four-part fractures (Neer IV/V). The operation time averaged 65.6 minutes ± 27 minutes. In 13 patients (16.3%), revision was necessary because of procedure-related complications. After 6 months, the Visual Analog Scale for pain was 2.7 ± 1.6 and the Daily Activity Score showed 19.6 ± 6 points. The average age-related Constant Score after 6 months was 67.5 ± 24 points. CONCLUSIONS MIS surgery of displaced humeral head fractures can be performed in all types of humeral head fractures leading to low complication rates and good clinical outcome. A standardized stepwise procedure in fracture reduction and fixation is recommended to achieve reliable good results.

Embalmed and fresh frozen human bones in orthopedic cadaveric studies: which bone is authentic and feasible?

Background and purpose The most frequently used bones for mechanical testing of orthopedic and trauma devices are fresh frozen cadaveric bones, embalmed cadaveric bones, and artificial composite bones. Even today, the comparability of these different bone types has not been established. Methods We tested fresh frozen and embalmed cadaveric femora that were similar concerning age, sex, bone mineral density, and stiffness. Artificial composite femora were used as a reference group. Testing parameters were pullout forces of cortex and cancellous screws, maximum load until failure, and type of fracture generated. Results Stiffness and type of fracture generated (Pauwels III) were similar for all 3 bone types (fresh frozen: 969 N/mm, 95% confidence interval (CI): 897–1,039; embalmed: 999 N/mm, CI: 875–1,121; composite: 946 N/mm, CI: 852–1,040). Furthermore, no significant differences were found between fresh frozen and embalmed femora concerning pullout forces of cancellous screws (fresh frozen: 654 N, CI: 471–836; embalmed: 595 N, CI: 365–823) and cortex screws (fresh frozen: 1,152 N, CI: 894–1,408; embalmed: 1,461 N, CI: 880–2,042), and axial load until failure (fresh frozen: 3,427 N, CI: 2,564–4290; embalmed: 3,603 N, CI: 2,898–4,306). The reference group showed statistically significantly different results for pullout forces of cancellous screws (2,344 N, CI: 2,068–2,620) and cortex screws (5,536 N, CI: 5,203–5,867) and for the axial load until failure (> 7,952 N). Interpretation Embalmed femur bones and fresh frozen bones had similar characteristics by mechanical testing. Thus, we suggest that embalmed human cadaveric bone is a good and safe option for mechanical testing of orthopedic and trauma devices.

Nonsurgical treatment of a severe tracheal rupture after endotracheal intubation.

OBJECTIVE We report the case of an 82-yr-old woman with a large complete longitudinal tracheal rupture, following endotracheal intubation. The patient was treated nonoperatively with excellent outcome. The diagnostic and therapeutic course as well as other therapeutic options are discussed.

The Two-incision, Minimally Invasive Approach in the Treatment of Acetabular Fractures

Objectives: To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures. Design: Prospective consecutive case series. Setting: Level I University Trauma Centre. Patients: Twenty-six patients (mean age, 67 ± 19 years). Intervention: The first TIMI-incision is performed by a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall, the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held using a retraction system. After fracture reduction and fixation by isolated screws, a conventional reconstruction plate is inserted for fracture neutralization. Main Outcome Mesurements: Perioperative course, postoperative radiological evaluation, functional outcome Harris hip score, and quality of life (EQ 5D). Results: Mean operative time was 109 ± 30 mins. All incisions healed primarily. Postoperative radiological exam revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft-tissue complications, and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The Harris hip score was 86,6 ± 8. Quality of life was comparable to persons in the same age group. Conclusion: The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited incisions, a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in those patients with a higher risk for postoperative soft-tissue complications. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Primärer Fixateur externe mit konsekutivem Verfahrenswechsel beim Polytrauma

ZusammenfassungZielsetzung. Mit dieser Studie wird untersucht, ob die rasch und einfach anzuwendende primäre Osteosynthese mit Fixateur externe und späterem Verfahrenswechsel bei Frakturen schwerverletzter Patienten (ISS>15 Punkte, >2 Extremitäten- und Beckenfraktur) ein sicheres und komplikationsarmes, die Schwerverletzten nicht zusätzlich traumatisierendes Verfahren darstellt. Methode.Über 2 Jahre wurden alle Krankheitsverläufe schwerverletzter Patienten mit operationspflichtigen Frakturen prospektiv erfasst. Dabei wurden Verletzungsschwere (Abbreviated Injury Score, AIS), primäre Operationen und Osteosynthesen, intensivmedizinischer Behandlungsverlauf (Organversagen, Infektparameter, systemische/lokale Komplikationen), Zeitpunkt, Art und Dauer der Verfahrenswechsel sowie damit in Zusammenhang stehende Komplikationen analysiert. Ergebnis. Von 679 Verletzten (ISS 22) wurden in der primären Phase 118 Patienten wegen isoliertem SHT und 175 wegen anderer Indikationen operiert. Bei 45 Verletzten (ISS 37) wurden 83 Fixateur-externe-Osteosynthesen durchgeführt. Bei 59 sekundär durchgeführten Verfahrenswechseln, durchschnittlich nach 13 Tagen, war es bei einer Patientin zu einer tiefen Wundinfektion gekommen, ansonsten waren keine weiteren lokalen Komplikationen zu verzeichnen. Die durchschnittliche Operationsdauer der definitiven Versorgung war gegenüber der primären Fixateur-externe-Stabilisierung dreimal so lang (43 vs. 139 min). Schlussfolgerung. Die primäre Frakturstabilisierung beim Schwerverletzten mit Fixateur externe ist zeitsparend und komplikationsarm. Sie stellt ein sicheres und schonendes Osteosyntheseverfahren dar. Die erforderlichen Verfahrenswechsel zur definitiven Versorgung weisen keine erhöhte Komplikationsrate auf.SummaryAim of study. It is the purpose of the current investigation to determine whether immediate external fixation of fractures, which is a simple and fast procedure, followed by secondary planned conversion represents a safe and reliable procedure without additional trauma in multiply injured patients (ISS>15). Methods. With a prospective protocol, all data of multiply injured patients with fractures which required immediate osteosynthesis were registrated. Demographic data, severity of injury (AIS and ISS), data of primary surgery and osteosyntheses, course of intensive care (organ failure, local/systemic complications, infectious protocol), secondary conversion (time, duration, osteosynthesis related complications) and further course were analysed. Results. Out of 679 mulitply injured patients (ISS 22), 118 required immediate surgical procedures for intracranial injury and 175 for further indications. In 45 multiply injured patients (ISS 37), 83 external fixations were performed. According to 59 planned secondary conversions (13 days), one patient developed deep infection, no other local complication was registrated. The average time for conversion procedures lasted three times longer as in immediate external fixation (43 vs. 139 min). Conclusions. Immediate external fixation in multiply injured patients is fast and poor of complications. It is a expedient procedure which is safe and careful for critically ill patients. The required conversion procedure shows no raised rate of complications.

Penetrating gunshot injuries to the head and brain : diagnosis, management and prognosis

ZusammenfassungKopfschussverletzungen sind außerhalb von Kriegszeiten in Deutschland und Westeuropa selten. Aufgrund eher geringer Fallzahlen hierzulande sind die diagnostischen und therapeutischen Behandlungsstandards uneinheitlich und kontrovers. Ursache dieser Verletzung sind nicht selten Selbsttötungsabsichten oder Unfälle. Diagnostisch stehen dem behandelnden Mediziner in erster Linie die Computertomographie mit Kontrastmittel und – in Ausnahmefällen – auch die Magnetresonanztomographie zur Verfügung. Was das operative Vorgehen angeht, wird das Débridement des Schusskanals mit evtl. Entfernung des Projektils kontrovers diskutiert, die Indikation zur Anlage eine Ventrikeldränage sollte hingegen großzügig gestellt werden. Werden diese Verletzungen, die eine außerordentlich hohe Mortalität haben, überlebt, ist die Prognose der von geschlossenen Schädel-Hirn-Traumen vergleichbar.AbstractGunshot injuries to the head and brain are rare in Germany and the rest of western Europe. With the relatively low number of these injuries here, there are no standard methods of diagnosis and management, and there is some controversy over both. Quite a high proportion of such injuries result from suicide attempts and accidents. The main diagnostic procedure available is computed tomography of the head with contrast medium; in certain cases MRI is indicated. The operative management depends on the extent and prognosis of the injury; a ventricular drain is probably indicated in most cases. Debridement of the bullet’s path and removal of the projectile are more controversial. Mortality is extremely high after such injuries; if the victim does survive the prognosis is comparable to that following closed cranial injuries.

Improved student preparation from implementing active learning sessions and a standardized curriculum in the surgical examination course

Students’ knowledge before and preparation for courses with practical skills training or bedside teaching may be insufficient and reduce efficiency of teaching time at the bedside and in skills training. To study the effect of a new curriculum on students’ preparation for courses, a quasi-randomized study was conducted. All medical students were included who participated in the surgical examination course during a period of four semesters. In the intervention group, specified topics for every session, a course book describing only those procedures relevant for the course and a foregoing case-based active learning session were introduced as compared to the traditional way of teaching the surgical examination course. For evaluation a questionnaire for the students was used. A total of 614 questionnaires (return rate 79.6%) were included in the analysis. Student as well as teacher preparation significantly improved in the intervention group from 34.8 to 73.6% and 46.1 to 73.0%, respectively. The case-based learning session and the course book were considered helpful by 77.7 and 96.4% of the students, respectively. The introduction of a timetable with specified topics for every session, a course book and a foregoing case-based learning session significantly improved student preparation for the surgical clinical examination course.

NCB-plating in the treatment of geriatric and periprosthetic femoral fractures

BACKGROUND The aim of this study is the presentation of the polyaxial locking NCB-plate in the treatment of femoral fractures, especially in elderly patients and in proximity of a prosthetic implant. The reduction and fixation of these fractures is a challenging surgical procedure with high complication rates reported up to 40%. PATIENTS AND METHODS A total of 72 patients with femoral fractures had polyaxial locking plate osteosynthesis. Indications included fractures of the shaft and around an implant. Concerning surgical procedures, three different standardized techniques were performed: (1) minimally invasive with percutaneous distal insertion using a targeting device; (2) mini-open with additional cerclage wire via the same approach and (3) a conventional open reduction and internal fixation. Data collection included intraoperative data and early complications at 6, 24 and 52 weeks. Fifty-two patients had an implant or prosthesis in situ. Thirty-three patients were treated by technique (1), 32 patients had mini-open surgery and seven patients conventional open surgery. RESULTS Thirty-nine patients attended clinical follow-up after 52 weeks. Twenty-two patients were interviewed by telephone, two were untraceable and nine patients had died. Bony consolidation without secondary loss of reduction was confirmed after 52 weeks in all patients but two. Plate breakage occurred in these two at 25 and 31 weeks after surgery due to non-union. Implant related complications (17% in total) lead to surgical revision in five other cases: two deep wound infections as well as three minor revisions. When itemizing complications according to surgical technique used, most major complications occurred following open surgery. CONCLUSION The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures. The advantages of the polyaxial locking implant combined with minimally invasive surgical technique contribute to successful management of this population category. Early revision rate is noticeably lower compared to similar procedures. LEVEL OF EVIDENCE IV retrospective series.