Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Patient satisfaction after elective implant removal of the lower extremity - a retrospective cohort study.

PURPOSE: The topic of elective implant removal (IR) in healed fractures of the lower extremity remains controversial, particularly when unspecific symptoms of discomfort, which cannot be quantified, are the primary indication. This study aims to assess indications and outcomes of elective IR of the lower extremity, focusing on unspecific symptoms of discomfort and patient satisfaction postoperatively. MATERIALS AND METHODS: The retrospective cohort study was conducted at a single level I academic trauma center. We included patients who underwent elective IR for healed fractures of the ankle, foot, patella, and proximal tibia from 2016 to 2021. All patients were followed-up for a minimum of 6 weeks after IR. Our outcomes of interest were patient satisfaction, complications, and alleviation of complaints. RESULTS: A total of 167 patients were included in the study. Unspecific symptoms of discomfort were the most common reason for IR in all investigated anatomical regions of the lower extremity (47.9%), followed by pain (43.1%) and limited range of motion (4.2%). 4.8% of patients experienced a combination of pain and range of motion limitation. Among all patients, 47.9% reported subjective improvement after IR. IRs based on unspecific symptoms of discomfort were significantly less likely to show alleviation of complaints after IR (27.5%, OR 0.19, p ≤ 0.01). Patients who reported limited range of motion (OR 1.7, p = 0.41) or pain (OR 6.0, p = 0) were significantly more likely to be satisfied after IR. Patients who reported sensitivity to cold weather also showed a decrease of complaints after IR (OR 3.6, p = 0.03). Major complications occurred in 2.1% of cases. The minor complication rate was 8.4% (predominantly impaired wound healing). Smoking patients showed a significantly higher risk of complications after IR (OR 5.2, p = 0.006). Persistent pain postoperatively was detected in 14.7%. CONCLUSION: When elective IR for consolidated fractures of the lower extremity is primarily motivated by patients' subjective symptoms of discomfort, the risk for postoperative dissatisfaction significantly increases. Objective symptoms on the other hand are associated with higher satisfaction after IR. While the procedure is generally safe, minor complications such as wound healing disorders can occur, especially in smokers. Patient education and well-documented informed consent are critical.

Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients.

PURPOSE: Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma-specific assessment of the lower extremities for injuries. This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase. METHODS: This diagnostic, prognostic observational cohort study was performed on trauma patient treated at one level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g., open fracture), active elevation of the leg, and cautious elevation of the lower extremity from the heel. SILENT was considered positive when obvious fracture was present and painful or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity, and receiver operating characteristic testing. RESULTS: 403 trauma bay patients were included, mean age 51.6 (SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity was 75% (95%CI 64 to 84%), and overall specificity was 99% (95%CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. AUC was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99). CONCLUSION: The SILENT test is a clinical applicable and feasible rule-out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging. Further large-scale prospective studies might be required to corroborate the beneficial effects of the SILENT test.

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND: The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS: In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS: Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION: Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The impact of fasciotomy on inpatient outcomes in lower leg fracture management.

BACKGROUND: While lower extremity fractures are common injuries, concomitant compartment syndrome can lead to significant implications and surgical release (fasciotomy) is essential. The aim of this study was to identify potential predictors of compartment release and risk factors related to complications. Using a large nationwide cohort, this study compared patients suffering from lower extremity fractures with and without compartment syndrome during their primary in-hospital stay following trauma. METHODS: A retrospective analysis was conducted using the prospective surgical registry of the working group for quality assurance in surgery in Switzerland, which collects data from nearly 85% of all institutions involved in trauma surgery. Inclusion criteria Patients who underwent surgical treatment for tibia and/or fibula fractures between January 2012 and December 2022 were included in the study. Statistics Statistical analysis was performed using Chi-square, Fisher's exact test, and t test. Furthermore, a regression analysis was conducted to determine the independent risk factors for fasciotomy and related complications. In the present study, a p value less than 0.001 was determined to indicate statistical significance due to the large sample size. RESULTS: The total number of cases analyzed was 1784, of which 98 underwent fasciotomies and 1686 did not undergo the procedure. Patients with fasciotomies were identified as significantly younger (39 vs. 43 years old) and mostly male (85% vs. 64%), with a significantly higher American Society of Anesthesiologists (ASA) score (ASA III 10% vs. 6%) and significantly more comorbidities (30% vs. 20%). These patients had significantly longer duration of surgeries (136 vs. 102 min). Furthermore, the total number of surgical interventions, the rate of antibiotic treatment, and related complications were significantly higher in the fasciotomy group. Sex, age, comorbidities, and fracture type (both bones fractured) were identified as relevant predictors for fasciotomy, while ASA class was the only predictor for in-hospital complications. Outcomes Patients who underwent fasciotomy had a significantly longer hospital stay (18 vs. 9 days) and a higher complication rate (42% vs. 6%) compared to those without fasciotomy. While fasciotomy may have played a role, other factors such as variations in patient characteristics and injury mechanisms may also contribute. Additionally, in-house mortality was found to be 0.17%, with no patient death recorded for the fasciotomy group. CONCLUSIONS: Fasciotomy is vital. The knowledge about the further course is, however, helpful in resource allocation. We found significant differences between patients with and without fasciotomy in terms of age, sex, complication rate, length of stay, comorbidities, duration of operations, and use of antibiotics during their primary in-hospital stay. While the severity of the underlying trauma could not be modulated, awareness of the most relevant predictors for fasciotomy and related complications might help mitigate severe consequences and avoid adverse outcomes.

Elective implant removal in the upper extremity: only symptomatic patients benefit.

PURPOSE: Elective implant removal (IR) in the upper extremity remains controversial. Implants in the olecranon and clavicle are commonly removed for prominence, unlike in the distal radius. Patient-reported symptomatic cannot be verified, and nonspecific discomfort remains unquantified. In this study, indications and outcomes of IR at the clavicle, olecranon and distal radius were evaluated, with a focus on postoperative patient satisfaction. MATERIALS AND METHODS: In this retrospective, single-center cohort study, patients, who received elective IR of the clavicle, olecranon and distal radius were included. Patients were followed up at least six weeks after IR. Outcomes included patient satisfaction, symptom resolution, and complications. RESULTS: One hundred and eighty-nine patients were included. Unspecific symptoms of discomfort were the most prevalent indication for IR (48.7%), followed by pain (29.6%) and objective limited range of motion (ROM) (7%). Pain and limited ROM combined was observed in 13.8%. Subjective benefit following IR was described in 54%. Patients with limited ROM (OR 4.7, p < 0.001) or pain (OR 4.1, p < 0.001) were more likely to experience alleviation of complaints. Patients with unspecific symptoms of discomfort, often did not report improvement. Major complications occurred in 2%. Refractures were detected at the clavicle (3.7%) and at the olecranon (2.5%). Minor complication rate was 5%. CONCLUSION: IR is a safe procedure in the upper extremity. Indications based on unspecific symptoms of discomfort have a significant lower rate of patient satisfaction postoperatively. Elective IR should be considered cautiously, if it is driven primarily by unspecific symptoms of discomfort. Patient education is relevant to prevent dissatisfying outcome.

Cost-effectiveness analysis of surgical proximal femur fracture prevention in elderly: a Markov cohort simulation model.

BACKGROUND: Hip fractures are a common and costly health problem, resulting in significant morbidity and mortality, as well as high costs for healthcare systems, especially for the elderly. Implementing surgical preventive strategies has the potential to improve the quality of life and reduce the burden on healthcare resources, particularly in the long term. However, there are currently limited guidelines for standardizing hip fracture prophylaxis practices. METHODS: This study used a cost-effectiveness analysis with a finite-state Markov model and cohort simulation to evaluate the primary and secondary surgical prevention of hip fractures in the elderly. Patients aged 60 to 90 years were simulated in two different models (A and B) to assess prevention at different levels. Model A assumed prophylaxis was performed during the fracture operation on the contralateral side, while Model B included individuals with high fracture risk factors. Costs were obtained from the Centers for Medicare & Medicaid Services, and transition probabilities and health state utilities were derived from available literature. The baseline assumption was a 10% reduction in fracture risk after prophylaxis. A sensitivity analysis was also conducted to assess the reliability and variability of the results. RESULTS: With a 10% fracture risk reduction, model A costs between $8,850 and $46,940 per quality-adjusted life-year ($/QALY). Additionally, it proved most cost-effective in the age range between 61 and 81 years. The sensitivity analysis established that a reduction of ≥ 2.8% is needed for prophylaxis to be definitely cost-effective. The cost-effectiveness at the secondary prevention level was most sensitive to the cost of the contralateral side's prophylaxis, the patient's age, and fracture treatment cost. For high-risk patients with no fracture history, the cost-effectiveness of a preventive strategy depends on their risk profile. In the baseline analysis, the incremental cost-effectiveness ratio at the primary prevention level varied between $11,000/QALY and $74,000/QALY, which is below the defined willingness to pay threshold. CONCLUSION: Due to the high cost of hip fracture treatment and its increased morbidity, surgical prophylaxis strategies have demonstrated that they can significantly relieve the healthcare system. Various key assumptions facilitated the modeling, allowing for adequate room for uncertainty. Further research is needed to evaluate health-state-associated risks.

[Bilateral thoracic trauma-"double the trouble"?] / Beidseitiges Thoraxtrauma ­ "double the trouble"?

BACKGROUND: Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma. OBJECTIVE: The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two. MATERIAL AND METHODS: In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome. RESULTS: A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors. CONCLUSION: Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Pre-hospital and Hospital Trauma Care during the Covid-19 Lockdown - Experience in a Metropolitan European Level 1 Trauma Centre.

BACKGROUND: Trauma case load is said to have declined during the Covid-19 pandemic, especially during the national lockdowns. Due to the altered frequency and changes in daily life, pre-hospital care (altered personal protective measurements) as well as mechanisms of trauma and initial trauma treatment may have changed. The purpose of this study was to assess differences in pre-hospital as well as initial treatment of trauma victims and trauma mechanisms during a national lockdown compared to the year before. MATERIAL AND METHODS: Pre-hospital as well as clinical data from all trauma patients admitted to our metropolitan level 1 trauma center resuscitation room during the hard lockdown in Switzerland (March 17 to April 26, 2020) and the same time period in 2019 were analyzed retrospectively. RESULTS: In total, we assessed 91 patients (51 lockdown cohort, 40 control cohort) with a mean age of 50.7 years. Significantly more trauma was sustained in the household environment during the lockdown (p = 0.015). Pre-hospital treatment remained similar between the two assessed groups. No difference was found in length of stay or mortality. In severely injured patients (ISS > 15), we found significantly fewer motor vehicle accidents (p = 0.018) and fewer horizontal decelerations (p = 0.006), but insignificantly more falls (p = 0.092) in the lockdown cohort. None of the patients in the lockdown cohort had a positive PCR test for Covid-19 on admission. CONCLUSION: Trauma systems seem not to have changed during hard lockdowns in terms of pre-hospital treatment. Fewer severely injured patients due to motor vehicle accidents and horizontal decelerations, but more household-related injuries were seen in the lockdown cohort than in the control cohort. A qualitative analysis of treatment during the hard lockdown is needed to gain further insights into the effect of the pandemic on trauma care.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients.

PURPOSE: The impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization. METHODS: We analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied. RESULTS: In total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders. CONCLUSION: Type of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

The number of beds occupied is an independent risk factor for discharge of trauma patients.

Reducing the burden of limited capacity on medical practitioners and public health systems requires a time-dependent characterization of hospitalization rates, such that inferences can be drawn about the underlying causes for hospitalization and patient discharge. The aim of this study was to analyze non-medical risk factors that lead to the discharge of trauma patients. This retrospective cohort study includes trauma patients who were treated in Switzerland between 2011 and 2018. The national Swiss database for quality assurance in surgery (AQC) was reviewed for trauma diagnoses according to the ICD-10 code. Non-medical risk factors include seasonal changes, daily changes, holidays, and number of beds occupied by trauma patients across Switzerland. Individual patient information was aggregated into counts per day of total patients, as well as counts per day of levels of each categorical variable of interest. The ARIMA-modeling was utilized to model the number of discharges per day as a function of auto aggressive function of all previously mentioned risk factors. This study includes 226,708 patients, 118,059 male (age 48.18, standard deviation (SD) 22.34 years) and 108,649 female (age 62.57, SD 22.89 years) trauma patients. The mean length of stay was 7.16 (SD 14.84) days and most patients were discharged home (n = 168,582, 74.8%). A weekly and yearly seasonality trend can be observed in admission trends. The mean number of occupied trauma beds ranges from 3700 to 4000 per day. The number of occupied beds increases on weekdays and decreases on holidays. The number of occupied beds is a positive, independent risk factor for discharge in trauma patients; as the number of occupied beds increases at any given time, so does the risk for discharge. The number of beds occupied represents an independent non-medical risk factor for discharge. Capacity determines triage of hospitalized patients and therefore might increase the risk of premature discharge.

Impact of the first COVID-19 shutdown on traumatological patient volumes in Switzerland.

Background: The coronavirus has caused a worldwide pandemic with serious impacts on our healthcare systems. Many countries experienced a decline in traumatological patient volume. The aim of this study is to evaluate the impact of the first lockdown on traumatological patient volume in Switzerland. Methods: We retrospectively used a prospective national quality measurement database. We compared the period of the first lockdown in Switzerland from March 17 to April 26, 2020 to the same period in the years 2018 and 2019. Included were all adult patients with any S-code (trauma) according to the International Classification of Diseases. Results: In total, we assessed 3874 patients (1779 in the year 2018, 1303 in the year 2019, and 792 in the year 2020) with a mean age of 61 ± 21 years. The patients during the lockdown period had significantly more injuries to the hip and forearm, had more comorbidities, and were more likely to have statutory insurance. During the lockdown period, more thromboembolism prophylaxis or anticoagulation was applied, and more patients needed antibiotic treatment. Conclusions: The present study demonstrated a 40-55% reduction in patient volume during the lockdown period in Switzerland compared to the previous years. The in-hospital mortality and complication rate during the lockdown period remained stable. This study suggests that in-hospital care for trauma patients in Switzerland was not substantially affected by the first lockdown.

Are the rib fracture score and different computed tomography measures of obesity predictors for mortality in patients with rib fractures? A retrospective cohort study.

BACKGROUND: There is missing knowledge about the association of obesity and mortality in patients with rib fractures. Since the global measure of obesity (body mass index [BMI]) is often unknown in trauma patients, it would be convenient to use local computed tomography (CT)-based measures (e.g., umbilical outer abdominal fat) as a surrogate. The purpose of this study was to assess (1) whether local measures of obesity and rib fractures are associated with mortality and abdominal injuries and to evaluate (2) the correlation between local and global measures of obesity. MATERIALS AND METHODS: A retrospective cohort study included all inpatients with rib fractures in 2013. The main exposure variable was the rib fracture score (RFS) (number of rib fractures, uni- or bilateral, age). Other exposure variables were CT-based measures of obesity and BMI. The primary outcome (endpoint) was in-hospital mortality. The secondary outcome consisted of abdominal injuries. Sex and comorbidities were adjusted for with logistic regression. RESULTS: Two hundred and fifty-nine patients (median age 55.0 [IQR 44.0-72.0] years) were analyzed. Mortality was 8.5%. RFS > 4 was associated with 490% increased mortality (ORadjusted = 5.9, 95% CI 1.9-16.6, p = 0.002). CT-based measures and BMI were not associated with mortality, rib fractures or injury of the liver. CT-based measures of obesity showed moderate correlations with BMI (e.g., umbilical outer abdominal fat: r = 0.59, p < 0.001). CONCLUSIONS: RFS > 4 was an independent risk factors for increased mortality. Local and global measures of obesity were not associated with mortality, rib fractures or liver injuries. If the BMI is not available in trauma patients, CT-based measures of obesity may be considered as a surrogate.

Prevalence and outcome of contrast-induced nephropathy in major trauma patients.

BACKGROUND: Contrast-induced nephropathy (CIN) has been well investigated in patients undergoing coronary angiography, but not in trauma patients. The main aim of this study was to determine the prevalence and to investigate independent risk factors for the development of CIN. METHODS: Between 2008 and 2014, all pre-hospital intubated major trauma patients with documented serum creatinine levels (SCr) undergoing a contrast-enhanced whole-body CT at admission were retrospectively analyzed. CIN was defined as a relative increase in SCr > 25% over the baseline value or an absolute SCr increase of > 44 µmol/l within 72 h. Univariate and multivariable regression analyses were performed to identify significant risk factors. A p value of < 0.01 was considered statistically significant and a p value of 0.01-0.049 suggested evidence. RESULTS: Of 284 analyzed patients, 41 (14%) met the criteria for CIN. There is suggestive evidence that age and lactate level influenced the development of CIN. Six patients (15%) had hemodialysis in the CIN-group and eight (3.3%) in the group without CIN. Complication and mortality rate was higher in patients with CIN (71% vs. 56% and 32% vs. 23%, respectively). CIN was not an independent risk factor for complications or mortality while controlling for age, gender, injury severity score, and lactate level. The length of stay was not affected by CIN. CONCLUSION: CIN occurs frequently in trauma patients, but is not an independent risk factor for complications or mortality. Therefore, contrast enhanced whole-body CT can safely be performed in trauma patients.

Short-term outcome of isolated lateral malleolar fracture treatment is independent of hospital trauma volume or teaching status: a nationwide retrospective cohort study.

INTRODUCTION: In light of current discussions about centralisation and teaching in medicine, we wanted to investigate the differences in in-hospital outcomes after surgical treatment of isolated ankle fractures, taking into account high-volume centres (HVCs) and low-volume centres (LVCs) and teaching procedures. METHODS: A retrospective analysis of malleolar fractures recorded in a National Quality Assurance Database (AQC) from the period 01-01-1998 to 31-12-2018 was carried out. Inclusion criteria were isolated, and operatively treated lateral malleolar fractures (ICD-10 Code S82.6 and corresponding procedure codes). Variables were sought in bivariate and multivariate analyses. A total of 6760 cases were included. By dividing the total cases arbitrarily in half, 12 HVCs (n = 3327, 49%) and 56 LVCs (n = 3433, 51%) were identified. RESULTS: Patients in HVCs were younger (48 vs. 50 years old), had more comorbidities (26% vs. 19%) and had more open fractures (0.48% vs. 0.15%). Open reduction and internal fixation was the most common operative treatment at HVCs and LVCs (95% vs. 98%). A more frequent use of external fixation (2.5% vs. 0.55%) was reported at HVCs. There was no difference in mortality between treatment at HVCs and LVCs. A longer hospitalisation of 7.2 ± 5 days at HVCs vs. 6.3 ± 4.8 days at LVCs was observed. In addition, a higher rate of complications of 3.2% was found at HVCs compared to 1.9% at LVCs. The frequency of teaching operations was significantly higher at HVCs (30% vs. 26%). Teaching status had no influence on mortality or complications but was associated with a prolonged length of stay and operating time. CONCLUSION: We found significant differences between HVCs and LVCs in terms of in-hospital outcomes for ankle fractures. These differences could be explained due to a more severely ill patient population and more complex (also open) fracture patterns with resulting use of external fixation and longer duration of surgery. However, structural and organisational differences, such as an extended preoperative stays at HVCs and a higher teaching rate, were also apparent. No difference in mortality could be detected.

The effect of Covid-19 on the willingness to use video consultations among orthopedic and trauma outpatients: a multi-center survey in 1400 outpatients.

INTRODUCTION: Due to the Covid-19 pandemic, making more use of remote medical solutions has been advertised. The purpose of this study was to assess the willingness of orthopedic trauma patients to conduct an online video consultation (OVC) during the coronavirus pandemic compared to before. METHODS: A survey amongst orthopedic and trauma outpatients from three European trauma centers was conducted via paper-based questionnaires, composed of participants' demographics and five open and closed questions between June and November 2019 and between April and July 2020 during Covid-19. The main outcome was the difference between the cohorts regarding the willingness to use an OVC, reasons for and against usage as well as advantages and disadvantages. Sub-analysis was performed for gender, participants' occupation and three age groups (≤ 30 years; 31-55 years; > 55 years). RESULTS: 1400 participants (780 preCovid-19 and 620 Covid-19) were included. There was no difference in willingness to conduct an OVC between the cohorts (57.6% versus 63.9%; p = 0.053). The highest disposition towards an OVC in both cohorts was seen in patients below 30 years of age, followed by 31-55 years and over 55 years. Women were significantly more likely in the Covid-19-group than in the preCovid-19-group to conduct an OVC (p = 0.032). Use of the OVC for "personal questions to the physician" was more often stated in the Covid-19-cohort (p = 0.007). "No danger of an infection" (p = 0.001) and "availability from anywhere" (p = 0.032) as advantages of an OVC were more often stated in the Covid-19-cohort. "No direct contact with the doctor" (p = 0.001) and "relationship to the doctor could change" (p = 0.024) as disadvantages of the OVC were less often stated in the Covid-19-cohort. CONCLUSION: The majority of the assessed outpatients would use an OVC. Fear of infections have increased, and direct physical contact is less important since the Covid-19 pandemic, but have not increased the disposition for an OVC significantly.

Long-term experience with a collagen-elastin scaffold in combination with split-thickness skin grafts for the treatment of full-thickness soft tissue defects: improvements in outcome-a retrospective cohort study and case report.

PURPOSE: The management of severe soft tissue injuries to the extremities with full-thickness wounds poses a challenge to the patient and surgeon. Dermal substitutes are used increasingly in these defects. The aim of this study was to investigate the impact of the type of injury on the success rate of Matriderm® (MD)-augmented split-thickness skin grafting, as well as the role of negative pressure wound therapy (NPWT) in preconditioning of the wounds, with a special focus on the reduction of the bioburden. METHODS: In this study, 45 wounds (44 affecting lower extremities (97.7%)), resulting from different types of injuries: soft tissue (ST), soft tissue complications from closed fracture (F), and open fracture (OF) in 43 patients (age 55.0 ± 18.2 years, 46.7% female), were treated with the simultaneous application of MD and split-thickness skin grafting. The study was designed as a retrospective cohort study from March 2013 to March 2020. Patients were stratified into three groups: ST, F, and OF. Outcome variables were defined as the recurrence of treated wound defects, which required revision surgery, and the reduction of bioburden in terms of reduction of number of different bacterial strains. For statistical analysis, Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, and Pearson's chi-squared test were used. RESULTS: There was no significant difference in the rate of recurrence in the different groups (F: 0%; OF: 11.1%; ST: 9.5%). The duration of VAC therapy significantly differed between the groups (F: 10.8 days; OF: 22.7 days; ST: 12.6 days (p < 0.05)). A clinically significant reduction of bioburden was achieved with NPWT (bacterial shift (mean (SD), F: - 2.25 (1.89); OF: - 1.9 (1.37); ST: - 2.6 (2.2)). CONCLUSION: MD-augmented split-thickness skin grafting is an appropriate treatment option for full-thickness wounds with take rates of about 90%. The complexity of an injury significantly impacts the duration of the soft tissue treatment but does not have an influence on the take rate. NPWT leads to a relevant reduction of bioburden and is therefore an important part in the preconditioning of full-thickness wounds.

Does the insurance status influence in-hospital outcome? A retrospective assessment in 30,175 surgical trauma patients in Switzerland.

INTRODUCTION: There has been growing evidence in trauma literature that differences in insurance status lead to inequality in treatment and outcome. Most studies comparing uninsured to insured patients were done in the USA. We sought to gain further insights into differences in the outcomes of trauma patients in a healthcare system with mandatory public health coverage by comparing publicly versus privately insured patients. METHODS: We used a prospective national quality assessment database from the Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC). More than 80 surgical departments in Switzerland are part of this quality program. We included all patients in the AQC database with any S- or T-code diagnosis according to the International Classification of Diseases ICD-10 (any injuries) who were treated during the 11-year period of 2004-2014. Missing insurance status information was an exclusion criterion. In total, 30,175 patients were included for analysis. The primary outcome was in-hospital mortality. Secondary outcomes included overall and intra- and postoperative complications. Bi- and multivariate analyses were performed, adjusted for insurance status, age, sex, American Society of Anesthesiologists (ASA) physical status category, type of injury, and surgeon's level of experience. RESULTS: In total, 76.8% (n = 23,196) of the patients were publicly insured. Patients with public insurance were significantly younger (p < 0.001), more often male (p < 0.001), and in better general health according to the ASA physical status category (p < 0.001). Length of pre- and postoperative stay and the number of operations per case were similar in the two groups. Patients with public insurance had a lower mortality rate (1.3% vs. 1.9%, p < 0.001), but after adjusting for confounders, insurance status was not a predictor of mortality. Overall complication rates were significantly higher for publicly insured patients (8.4% vs. 6.2%, p < 0.001), and after adjusting for confounders, insurance status was identified as an independent risk factor for overall complications (p < 0.001). CONCLUSION: Differences exist with respect to patient and procedural characteristics: publicly insured patients were younger, more often male, and scored better on ASA physical status. Insurance status seems not to be a predictor for fatal outcome after trauma, although it is associated with complications.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients.

There has been an ongoing discussion as to which interventions should be carried out by an "organ specialist" (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.

Chylomicronemia Mimicking an Infection During Emergent Fracture Surgery: A Case Report.

CASE: A 36-year-old patient with chronic alcohol abuse and previous medical history of total hip arthroplasty suffered a fracture of the femoral shaft. During osteosynthesis, a milky fluid similar to purulent discharge emerged at multiple locations. Immediate Gram stains were negative, and the surgery was performed as planned. Laboratory tests showed massive elevated levels of triglycerides. During further workup, chylomicronemia syndrome was diagnosed. CONCLUSION: This case report shows that chylomicronemia syndrome can have an appearance during surgery similar to a purulent infection. Immediate Gram stains and laboratory work can identify the reason.