Clinical Profile, Treatment Details and Survival of Trauma Patients Treated at Intensive Care Unit in a Level II Trauma Center.

OBJECTIVE: This retrospective study evaluated all trauma patients who were admitted to intensive care unit in Turku University Central Hospital, Finland in 2000-2004. METHODS: We reviewed details of demographic factors, injury mechanism, treatment details, and the overall recovery of patients after the hospital episode. RESULTS: A total of 427 trauma patients were identified, 66% of these were severely injured (ISS > 15). 79% of patients were men. The median age of 44 years. The most frequent injury type was road traffic accidents, leisure-time accidents and injury mechanism a high-energy blunt trauma. Head injuries were the most frequently diagnosed severe injury and 59% of the patients were multiple traumatized. CONCLUSIONS: Current results suggest that the overall survival of these patients is satisfactory, although, the head and cervical spine injuries are still often related to compromised prognosis. Despite the improvements in morbidity and mortality of these patients during last decades, still almost every tenth of trauma patient treated in the ICU dies to the complications of the injury.

Perioperative myocardial infarctions are common and often unrecognized in patients undergoing hip fracture surgery.

BACKGROUND: The aim of this prospective cohort study was to assess the incidence and characteristics of acute myocardial infarction in patients undergoing surgery for acute hip fracture. METHODS: A consecutive cohort of patients (n = 200, 68 men) referred to acute surgical correction of hip fracture was studied. Troponin T (TnT) measurements and electrocardiographic (ECG) recordings were performed at admission, before operation, and on the first and 2nd postoperative days, which were used for diagnosis. RESULTS: The age of the patients ranged from 32 to 98 years (mean, 80.8 years), and 65 patients had a history of coronary artery disease. A significant rise in TnT as a sign of myocardial infarction was observed in 71 patients (35.5%), and 25 of them had a TnT elevation exceeding five times the upper normal limit. TnT elevation was observed in 36 patients (51%) already before surgery. Seven patients (10%) had ST elevation myocardial infarction, 23 patients (32%) had new ST depressions, and 21 patients (30%) had no new ST segment changes in the serial electrocardiographic recordings. In 40 patients (56%), the perioperative myocardial infarction was the first manifestation of coronary artery disease. Multivariate logistic regression revealed that old age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; p = 0.002), earlier revascularization (OR, 3.29; 95% CI 1.12-9.73; p = 0.03), and heart failure (OR, 2.42; 95% CI 1.04-5.61; p = 0.04) were independent predictors of TnT elevation. Majority of myocardial infarctions were asymptomatic or unrecognized. Evidence-based medications of myocardial infarction were seldom started and cardiologist was consulted in 12 patients (16.9%). CONCLUSION: Patients with hip fracture often develop asymptomatic and clinically unrecognized perioperative myocardial infarctions. Earlier diagnosis and appropriate treatment of cardiac infarction may improve survival of hip fracture patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Instrumented spondylodesis in degenerative spondylolisthesis with bioactive glass and autologous bone: a prospective 11-year follow-up.

A prospective long-term follow-up study of bioactive glass (BAG)-S53P4 and autogenous bone (AB) used as bone graft substitutes for posterolateral spondylodesis in treatment of degenerative spondylolisthesis during 1996 to 1998 was conducted. The surgical procedure was a standardized instrumented posterolateral fusion that used USS/VAS. BAG was implanted on the left side of the fusion bed and AB on the right side. The operative outcome was evaluated on x-rays and computed tomography scans, and a clinical examination was also performed. Seventeen patients (12 women, 5 men) participated in the 11-year follow-up. The mean Oswestry Disability Index score at the follow-up was 21 (range 0 to 52), compared with 49 (range 32 to 64) at the preoperative time. A solid bony fusion was seen on computed tomography scans on the AB side in all patients and on the BAG side in 12 patients. The fusion rate of all fusion sites (n=41) for BAG as a bone substitute was 88% at the L4/5 level and 88% at the L5/S1 level. The use of BAG as a bone graft extender can be considered as a good alternative in spinal surgery in the future.

Similar central hemodynamics but increased postoperative oxygen consumption in unreamed versus reamed intramedullary nailing of femoral fractures.

BACKGROUND: Patients undergoing intramedullary nailing of long bone fractures have pathologically altered pulmonary vascular tone, right heart strain, and transient impairment of pulmonary gas exchange. The purpose of this study was to examine the acute differences in cardiopulmonary variables between reamed and unreamed nailing techniques in 18 (9 + 9) healthy patients with unilateral femoral shaft fractures. METHODS: Intramedullary nailing was performed under general anesthesia within 12 hours after the trauma. For blood sampling, recording, and measurements, the patients were cannulated with radial artery and pulmonary artery catheters. Changes in central hemodynamics and oxygenation were studied pre-, peri-, and postoperatively for 16 to 20 hours. RESULTS: Abnormally high pulmonary shunting (23 +/- 12% in the reamed and 27 +/- 11% in the unreamed group) was observed before the operation. The trends of all variables were very similar in both groups except for the last phase in which the mixed venous oxygen saturation tended to be lower (65 +/- 8 vs. 70 +/- 5%) and the oxygen consumption index was higher (186 +/- 21 vs. 151 +/- 20 mL/min/m) in the unreamed group than in the reamed group (p < 0.05). The timepoints most strenuous to the heart were at the end of operation and in the recovery room. CONCLUSIONS: The unreamed intramedullary nailing technique does not offer any advantage in cardiopulmonary variables over the reamed technique. In both groups, there was considerable deviation in over 10 cardiopulmonary variables from normal reference values during the study. We suggest the use of invasive monitoring on patients with a long bone fracture and poor preoperative oxygenation or a history of cardiopulmonary or cardiac disease.

Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study.

BACKGROUND: It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies. METHODS: A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively. RESULTS: Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films. CONCLUSION: A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

Similar central hemodynamics and oxygenation in reamed and unreamed intramedullary nailing of tibial fractures.

BACKGROUND: Reamed intramedullary nailing of a long bone fracture is considered to be of crucial importance in the genesis of pulmonary disturbances. Use of unreamed nailing technique has been encouraged to avoid temporary deterioration in lung functions. METHODS: Central hemodynamic changes were recorded in 20 healthy adults with a unilateral simple tibial fracture undergoing reamed or unreamed intramedullary nailing. The patients were cannulated with a pulmonary artery catheter. Intramedullary nailing was performed during general anesthesia. Pre- and immediate postoperative hemodynamic variables were compared. RESULTS: Unchanged cardiac performance but pathologically altered pulmonary vascular tone were unrelated to the type of nailing technique. Increased oxygen consumption was observed as well. CONCLUSION: Changes in cardiac and pulmonary hemodynamics are already present after the trauma and before the intramedullary nailing procedure.