Steven C. Herath

Predictors of mortality for complex fractures of the pelvic ring in the elderly: a twelve-year review from a German level I trauma center.

STUDY OBJECTIVE To document mortality rate and predictors of mortality in elderly patients with complex pelvic fractures. METHODS We reviewed a total of 84 subjects whose ages were above 70 years with complex pelvic fractures, admitted to our hospital from January 2001 to December 2012. A multivariate linear regression model was used to determine the predictors of mortality in the study population. The median age of the patients was 80.4 years (range 70-94 years). 65 of 84 (77%) patients were females. There were 72 Tile Type B fractures (86%) and 12 Type C fractures (14%). The most common associated injuries were thoracic, extremity and head injuries, with incidence of 13 (15%), 11 (13%), and 9 (11%), respectively. RESULTS The mortality rate was 10% in our study population. The initial haemoglobin on admission (p<0.01), the presence of blood vessel injuries (p<0.01) and the number of PRBCs transfused within the first six hours after admission (p<0.01) independently predicted mortality in elderly patients with complex pelvic fractures. CONCLUSION Although there is a downward trend in mortality in elderly patients with complex pelvic fractures, haemodynamic instability still has a significant impact on survival of those patients.

[Fractures of the acetabulum: complications and joint replacement].

Acetabular fractures assume a special role amongst the fractures of the pelvis, because they involve a major weight-bearing joint. As those fractures mostly result from exposure to great force, and because of their location in an anatomically complex region, a high rate of complications has to be anticipated. Besides general and perioperative complications long-term consequences, especially post-traumatic arthrosis, are relevant problems when it comes to treating fractures of the acetabulum. The primary reconstruction of the acetabulum, as well as a possibly necessary prosthetic replacement of the hip joint, makes high demands on the diagnostic and operative capabilities of the attending physician. Exact knowledge of the specific risks and pitfalls for each type of fracture and for the specific surgical techniques is crucial for a successful treatment. Due to the much worse long-term outcome when compared to primary total hip replacement in patients with osteoarthritis, acetabular fractures should, regardless of the patients age, whenever possible be treated by operative reconstruction.

Effect of Stabilization on the Healing Process of Femur Fractures in Aged Mice

ABSTRACT Background: The influence of mechanical stability on fracture healing has previously been studied in adult mice, but is poorly understood in aged animals. Therefore, we herein studied the effect of stabilization on the healing process of femur fractures in aged mice. Methods: Twenty-four 18-month-old CD-1 mice were stabilized after midshaft fracture of the femur with an intramedullary screw. In another 24 18-month-old mice, the femur fractures were left unstabilized. Bone healing was studied by radiological, biomechanical, histomorphometric, and protein expression analyses. Results: After 2 and 5 weeks of healing, the callus of nonstabilized fractures compared to stabilized fractures was significantly larger, containing a significantly smaller amount of osseous tissue and a higher amount of cartilaginous tissue. This was associated with a significantly lower biomechanical stiffness during the early phase of healing. However, during the late phase of fracture healing both nonstabilized and stabilized fractures showed a biomechanical stiffness of ∼40%. Of interest, Western blot analyses of callus tissue demonstrated that the expression of proteins related to angiogenesis, bone formation and remodeling, i.e. VEGF, CYR61, BMP-2, BMP-4, Col-2, Col-10, RANKL, OPG, did not differ between nonstabilized and stabilized fractures. Conclusion: Nonstabilized fractures in aged mice show delayed healing and remodeling. This is not caused by an altered protein expression in the callus but rather by the excessive interfragmentary movements.

Pelvic ring fractures in the elderly now and then – a pelvic registry study

OBJECTIVES To analyze the changes in demographic data stratified for age, sex and type of injury of elderly patients suffering from pelvic ring fractures over a 22-year observation period. DESIGN/SETTING Data has been collected prospectively, multi-centrically in hospitals participating in the German Pelvic Trauma Registry. PATIENTS We analyzed the data of 5665 patients with an age ≥60years included in the German Pelvic Trauma Registry from 1991 to 2013. KEY RESULTS Over the 22-year study period the frequency of type A fractures decreased significantly from 84.8% to 43.9%, while type C and, in particular, type B fractures significantly increased from 7.0% and 8.2% to 14.3% and 41.8%. In patients between 60 and 70 years of age the frequency of type B and C fractures was higher compared to patients >70years. The proportion of female patients, who represent the majority of the cohort (75%), was stable over the entire observation period. Interestingly, type A fractures were found more frequently in females, while type B and C fractures were found more frequently in males. CONCLUSIONS With the predicted demographic change and a shift toward more severe injury patterns (type B and C pelvic fractures) in the elderly population, trauma departments will need to develop specific surgical concepts for geriatric patients with pelvic ring fractures.

Stimulation of angiogenesis by cilostazol accelerates fracture healing in mice

Cilostazol, a selective phosphodiesterase‐3 inhibitor, is known to control cyclic adenosine monophosphate (c‐AMP) and to stimulate angiogenesis through upregulation of pro‐angiogenic factors. There is no information, however, whether cilostazol affects fracture healing. We, therefore, studied the effect of cilostazol on callus formation and biomechanics during fracture repair. Bone healing was analyzed in a murine femur fracture stabilized with an intramedullary screw. Radiological, biomechanical, histomorphometric, histochemical, and protein biochemical analyses were performed at 2 and 5 weeks after fracture. Twenty‐five mice received 30 mg/kg body weight cilostazol p.o. daily. Controls (n = 24) received equivalent amounts of vehicle. In cilostazol‐treated animals radiological analysis at 2 weeks showed an improved healing with an accelerated osseous bridging compared to controls. This was associated with a significantly higher amount of bony tissue and a smaller amount of cartilage tissue within the callus. Western blot analysis showed a higher expression of cysteine‐rich protein 61 (CYR61), bone morphogenetic protein (BMP)‐4, and receptor activator of NF‐kappaB ligand (RANKL). At 5 weeks, improved fracture healing after cilostazol treatment was indicated by biomechanical analyses, demonstrating a significant higher bending stiffness compared to controls. Thus, cilostazol improves fracture healing by accelerating both bone formation and callus remodeling.

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

Should I Stay or Should I Go? A Prospective, Blinded Study Comparing the Diagnostic Capability of Dynamic and Stationary Pedobarography in Plantar Fasciitis

ABSTRACT The aim of this study was to determine the diagnostic capability of a dynamic gait analysis insole and compare its ability to detect clinical correlations to a common stationary analysis tool. Twenty‐five patients with chronic plantar fasciitis were included in this prospective, blinded, diagnostic study. Conventional, stationary gait analysis on a force plate on an even surface and continuous dynamic pedobarography on a standardized course consisting of different gait tasks were performed and correlated to the disease severity. Mean patient age was 53.6 (range 41 to 68) years, with a mean pain level of 6.1 (range 4 to 10) on the Visual Analogue Scale and a calcaneodynia score of 48.7 (range 33 to 66). Significant correlations were seen between several dynamic gait values and clinical scoring: cadence (rs = 0.56, p = .004), stance time (rs = –0.6, p = .002), center‐of‐pressure velocity (rs = 0.44, p = .046), and double support time (rs = 0.42, p = .042). No significant correlations were seen between any force plate gait analysis values and clinical scoring. In this study setting, dynamic gait analysis was able to identify clinically relevant correlations to plantar fasciitis disease severity that standard force plate measurements could not. &NA; Level of Clinical Evidence: 3

Polytrauma in the elderly: a review

Although the field of geriatric trauma is – ironically – young, care for the elderly trauma patient is increasingly recognised as an important challenge, considering the worldwide trend towards increasing longevity. Increasing age is associated with physiological changes and resulting comorbidities that present multiple challenges to the treating physician. Even though polytrauma is less likely with increasing age, lower-energy trauma can also result in life-threatening injuries due to the reduced physiological reserve. Mechanisms of injury and resulting injury patterns are markedly changed in the elderly population and new management strategies are needed. From initial triage to long-term rehabilitation, these patients require care that differs from the everyday standard. In the current review, the special requirements of this increasing patient population are reviewed and management options discussed. With the increase in orthogeriatrics as a speciality, the current status quo will almost certainly shift towards a more tailored treatment approach for the elderly patient. Further research expanding our current knowledge is needed to reduce the high morbidity and mortality rate. Cite this article: Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev 2016;1:146-151. DOI: 10.1302/2058-5241.1.160002.

Penetrierende 2-Höhlen-Verletzung mit einer 20 cm langen dolchartigen Scherbe nach Sturz in eine Glastür@@@Penetrating injury of two body cavities with a 20 cm long dagger-like sliver after falling into a glass door

In Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.ZusammenfassungZwei-Höhlen-Verletzungen gehören in Deutschland im Vergleich zu angloamerikanischen Ländern zu den selteneren Entitäten. Jedoch steigt diese Zahl aufgrund zunehmender Gewaltbereitschaft stetig. Im hier folgenden Fall soll von einer Patientin berichtet werden, die sich akzidentiell nach häuslichem Sturz eine große thorakale Penetrationsverletzung mit erheblicher Begleitverletzung zuzog. Sie wurde entsprechend den gängigen Behandlungsalgorithmen operativ versorgt und zeigte entgegen der Ersteinschätzung des erstbehandelnden Notarztes eine erheblich größere Verletzungsschwere.AbstractIn Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.

Penetrierende 2-Höhlen-Verletzung mit einer 20 cm langen dolchartigen Scherbe nach Sturz in eine Glastür

In Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.ZusammenfassungZwei-Höhlen-Verletzungen gehören in Deutschland im Vergleich zu angloamerikanischen Ländern zu den selteneren Entitäten. Jedoch steigt diese Zahl aufgrund zunehmender Gewaltbereitschaft stetig. Im hier folgenden Fall soll von einer Patientin berichtet werden, die sich akzidentiell nach häuslichem Sturz eine große thorakale Penetrationsverletzung mit erheblicher Begleitverletzung zuzog. Sie wurde entsprechend den gängigen Behandlungsalgorithmen operativ versorgt und zeigte entgegen der Ersteinschätzung des erstbehandelnden Notarztes eine erheblich größere Verletzungsschwere.AbstractIn Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.