Stefan Rammelt

Impact of helicopter transport and hospital level on mortality of polytrauma patients.

BACKGROUND Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identified unequivocally. METHODS Four possible pathways in 403 polytrauma patients (Injury Severity Score [ISS] > 16) who were in reach of the helicopter emergency medical service (HEMS) Dresden were analyzed as follows: HEMS-UNI group (n = 140), transfer by HEMS into a university hospital; AMB-REG group (n = 102), transfer by ground ambulance into a regional (Level II or III) hospital; AMB-UNI group (n = 70), transfer by ground ambulance into the university hospital; and INTER group (n = 91), transfer by ground ambulance into a regional hospital, followed by transfer to the university hospital. Scores used were the ISS and the TRISS. Tests used for statistical analysis included chi2 and Fishers tests. Statistical significance was set at p > 0.05. RESULTS Age, gender, and mean ISS (range, 33.3-35.6) revealed extensive homogeneity of the groups. Mortality of the AMB-REG group was almost doubled (41.2%) compared with HEMS-UNI (22.1%) patients (p = 0.002). The AMB-UNI group displayed the lowest mortality (15.7%, p = not significant). TRISS analysis (PRE-Chart) revealed identical outcome for AMB-UNI and HEMS-UNI patients. Rescue time averaged 90 +/- 29 minutes for HEMS-UNI patients, 68 +/- 25 minutes for AMB-UNI patients, and 69 +/- 26 minutes for the AMB-REG group. CONCLUSION Primary transfer by HEMS into a Level I trauma center reduces mortality markedly. In principle, this benefit can be attributed to superior preclinical therapy, primary admission to a Level I trauma center, or both. However, the identical probability of survival of the AMB-UNI and HEMS-UNI groups in this and comparable studies does not confirm generally better survival rates on account of a more aggressive on-site approach.

Talar neck and body fractures

Fractures of the talar neck and body are rare and serious injuries. The vast majority are either intra-articular or lead indirectly to an intra-articular incongruity through a dislocation at the talar neck. Because of the high energy needed to produce talar fractures, they are frequently seen in multiply injured and polytraumatised patients. Open fractures and fracture-dislocations are treated as emergencies. Preoperative planning of definite internal fixation requires CT scanning. To obtain a complete intra-operative overview allowing for anatomical reconstruction of the articular surfaces and the axial deviation bilateral approaches are usually necessary. Internal fixation is achieved with screws or mini-plates supplemented by temporary K-wire transfixation in cases of marked additional ligamentous instability. The clinical outcome after talar neck and body fractures is determined by the severity of the injury and the quality of reduction and internal fixation. The timing of definite internal fixation does not appear to affect the final result. The rates of avascular necrosis (AVN) correlate with the degree of initial dislocation. Only total AVN with collapse of the talar body leads to inferior results with the need for further surgery whilst prolonged immobilisation or offloading of the affected foot is not indicated for partial AVN. Talar malunions and non-unions after inadequate treatment of displaced fractures are debiliating conditions that should be treated by surgical correction. Treatment options include corrective osteotomy by recreating the former fracture with secondary fixation, free or vascularised bone grafting and salvage by realignment and fusion of the affected joint(s).

Foot function after subtalar distraction bone-block arthrodesis: A PROSPECTIVE STUDY

Subtalar distraction bone-block arthrodesis for malunited calcaneal fractures was performed in 31 patients (26 men, five women), with a mean age of 38.5 years. The mean time from injury to arthrodesis was 36 months. There were no cases of nonunion. One patient had an early dislocation of the bone block requiring a repeat arthrodesis, and one had a soft-tissue infection. The mean AOFAS hindfoot score improved significantly from 23.5 before operation to 73.2 at a mean follow-up of 33 months (p > 0.001). Compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Dynamic pedobarography revealed a return to normal of the pressure distribution during roll-over and a more energetic gait. The distribution of local transfer of load correlated well with the AOFAS score. The amount of correction of the heel height correlated with a normal pattern of pressure transfer on the heel (p < 0.05).

Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis.

The distal tibiofibular syndesmosmotic ligament complex is important for dynamic stability and congruency of the ankle joint. Syndesmotic lesions in the ankle fracture-dislocations are well recognized and classified systematically. Chronic insufficiency of the syndesmosis leads to a lateral shift of the talus and under eversion stress permits a pathological rotation of the talus. There is also retroversion of the distal fibula representing a painful deformity. Little experience exists with surgical reconstruction of the syndesmosis. This article describes a new ligamentoplasty with a split peroneus longus tendon graft that mimics the normal anatomic conditions of the syndesmotic complex in 16 patients with symptomatic chronic syndesmotic insufficiency after pronation-external rotation and pronation abduction injuries to the ankle joint. Postoperatively, no infections or hematomas were seen. One patient had asymptomatic breakage of the syndesmosis screw; one patient had a 10° decrease of dorsiflexion at the ankle because of a partial anterior tibiofibular synostosis. Fifteen of 16 patients had pain relief at a mean follow-up period of 16.4 months (range, 13–29 months); all patients had relief of the chronic swelling of the ankle and the giving way. The mean Karlsson score at follow-up was 88 (range, 70–100) points. It may be concluded that peroneus longus ligamentoplasty in a preliminary series resulted in reliable ankle stability and considerable pain relief in patients with chronic syndesmotic instability.

The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures.

A wealth of clinical and experimental data suggests, that anatomical restoration of the posterior calcaneal facet is a major predictor of outcome after intra-articular calcaneus fractures. The value of subtalar arthroscopy was examined in three clinical study groups (I–III). Materials and Methods: (I) The subtalar joint was inspected arthroscopically in 28 patients during hardware removal one year after open reduction and internal fixation (ORIF). This procedure was accompanied by subtalar arthrolysis in all cases. (II) Open subtalar arthroscopy was performed to evaluate the quality of reduction after ORIF of intra-articular calcaneus fractures in 59 cases. Arthroscopy was performed after seemingly exact reconstruction of the posterior facet as judged visually and fluoroscopically. (III) Arthroscopically assisted percutaneous reduction and screw fixation (PRSF) was performed in 18 patients with Sanders II fractures. Reduction was achieved with a Schanz screw introduced percutaneously into the tuberosity fragment and controlled fluoroscopically, while fine corrections were made under arthroscopic guidance. Results: (I) Clinical results after ORIF of intra-articular calcaneus fractures were highly correlated to the degree of residual incongruities and chondromalacia of the posterior facet as seen arthroscopically during hardware removal (P<0.01). (II) In 13 of 59 cases (22.0%) during ORIF despite seemingly accurate reduction, steps between 1–2 mm were detected arthroscopically in the posterior calcaneal facet and reduction was repeated subsequently in these cases. (III) Fifteen patients who underwent arthroscopically guided PRSF were re-evaluated after a minimum of one year with excellent clinical results (94.1 pts. with the AOFAS scales). No wound complications were seen. Conclusions: Subtalar arthroscopy provides a most precise and thorough view of the posterior facet of the calcaneus both in assessing the quality of initial reduction as well as evaluation during hardware removal after intra-articular calcaneus fractures. It is more precise than intra-operative fluoroscopy and less time consuming than standard Brodén views during surgery. The use of arthroscopy allows anatomical percutaneous reduction and screw fixation of Sanders II fractures. It therefore provides a useful additional tool in treating intra-articular calcaneus fractures.

Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation

Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion. In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031). We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.

Delayed bone regeneration and low bone mass in a rat model of insulin-resistant type 2 diabetes mellitus is due to impaired osteoblast function

Patients with diabetes mellitus have an impaired bone metabolism; however, the underlying mechanisms are poorly understood. Here, we analyzed the impact of type 2 diabetes mellitus on bone physiology and regeneration using Zucker diabetic fatty (ZDF) rats, an established rat model of insulin-resistant type 2 diabetes mellitus. ZDF rats develop diabetes with vascular complications when fed a Western diet. In 21-wk-old diabetic rats, bone mineral density (BMD) was 22.5% (total) and 54.6% (trabecular) lower at the distal femur and 17.2% (total) and 20.4% (trabecular) lower at the lumbar spine, respectively, compared with nondiabetic animals. BMD distribution measured by backscattered electron imaging postmortem was not different between diabetic and nondiabetic rats, but evaluation of histomorphometric indexes revealed lower mineralized bone volume/tissue volume, trabecular thickness, and trabecular number. Osteoblast differentiation of diabetic rats was impaired based on lower alkaline phosphatase activity (-20%) and mineralized matrix formation (-55%). In addition, the expression of the osteoblast-specific genes bone morphogenetic protein-2, RUNX2, osteocalcin, and osteopontin was reduced by 40-80%. Osteoclast biology was not affected based on tartrate-resistant acidic phosphatase staining, pit formation assay, and gene profiling. To validate the implications of these molecular and cellular findings in a clinically relevant model, a subcritical bone defect of 3 mm was created at the left femur after stabilization with a four-hole plate, and bone regeneration was monitored by X-ray and microcomputed tomography analyses over 12 wk. While nondiabetic rats filled the defects by 57%, diabetic rats showed delayed bone regeneration with only 21% defect filling. In conclusion, we identified suppressed osteoblastogenesis as a cause and mechanism for low bone mass and impaired bone regeneration in a rat model of type 2 diabetes mellitus.

NADPH oxidase 4 limits bone mass by promoting osteoclastogenesis

ROS are implicated in bone diseases. NADPH oxidase 4 (NOX4), a constitutively active enzymatic source of ROS, may contribute to the development of such disorders. Therefore, we studied the role of NOX4 in bone homeostasis. Nox4(-/-) mice displayed higher bone density and reduced numbers and markers of osteoclasts. Ex vivo, differentiation of monocytes into osteoclasts with RANKL and M-CSF induced Nox4 expression. Loss of NOX4 activity attenuated osteoclastogenesis, which was accompanied by impaired activation of RANKL-induced NFATc1 and c-JUN. In an in vivo model of murine ovariectomy–induced osteoporosis, pharmacological inhibition or acute genetic knockdown of Nox4 mitigated loss of trabecular bone. Human bone obtained from patients with increased osteoclast activity exhibited increased NOX4 expression. Moreover, a SNP of NOX4 was associated with elevated circulating markers of bone turnover and reduced bone density in women. Thus, NOX4 is involved in bone loss and represents a potential therapeutic target for the treatment of osteoporosis.

The use of subtalar arthroscopy in open reduction and internal fixation of intra-articular calcaneal fractures

Congruency of the subtalar joint is a major predictor of outcome after intra-articular calcaneal fractures. Because of the irregular shape of the posterior joint facet, minor steps may be overlooked with direct vision or intra-operative fluoroscopy during open reduction and internal fixation (ORIF). In a preliminary series of 15 subtalar arthroscopies during hardware removal after ORIF of intra-articular calcaneal fractures, patients with visible steps of 1 mm or more had significantly inferior functional results compared to those with an intact subtalar joint (117 vs. 158 points with the 200-point score, 71.3 vs. 91.2 points with the Maryland Foot Score, P<0.01). Congruency of the posterior facet was controlled arthroscopically in 47 intra-articular calcaneus fractures after open reduction and temporary K-wire-fixation. In 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated, temporarily removing the K-wires. After anatomical reduction a standard AO calcaneal plate was fixed to the lateral wall. Intra-operative arthroscopy appears to be useful in detecting minor incongruencies after ORIF of intra-articular calcaneus fractures. In the hands of an experienced surgeon it is less time demanding than intra-operative X-rays and more precise than fluoroscopy.

Tibiotalocalcaneal Fusion Using the Hindfoot Arthrodesis Nail A Multicenter Study

Background: Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. Methods: Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons—Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. Results: The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. Conclusions: The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. Level of Evidence: Level IV, retrospective case series.