[Diagnostics of acute compartment syndrome : Current gold standard and the state of science of noninvasive assessment methods]. / Diagnostik des akuten Kompartmentsyndroms : Aktueller Goldstandard und Stand der Wissenschaft nichtinvasiver Messmethoden.

Acute compartment syndrome (ACS) is defined by a disorder of the microcirculation due to a persistent pathological pressure increase within a muscle compartment. The ischemia of the tissue leads to an initially reversible functional impairment and finally irreversible damage of the musculature, nerves and other structures. Based on the understanding of the pathophysiology, the current diagnostic concepts and treatment using the so-called dermatofasciotomy of the affected muscle compartments can be derived. In addition to the suspicion of a possible ACS based on the medical history of the patient, the findings of the clinical examination are decisive. This review article gives a summary of all the essential aspects of the diagnostics. In clinically uncertain cases and for monitoring, an objectification of the findings using instrument-based techniques is increasingly required. Nowadays, invasive needle pressure measurement is available; however, due to limited reliability, specificity and sensitivity, these measurements only represent an aid to decision guidance supporting or advising against the indications for dermatofasciotomy. The increasing demands on making a certain diagnosis and justification of a surgical intervention from a legal point of view, substantiate the numerous scientific efforts to develop noninvasive instrument-based diagnostics. These methods are based either on detection of increasing intracompartmental pressure or decreasing perfusion pressure and microcirculation. The various measurement principles are summarized in a lucid form.

Comparison of ALIF and PLIF in Isthmic Lumbosacral Spondylolisthesis. A Multicenter Surveillance Study of 602 cases from the German Spine Registry (DWG Register).

BACKGROUND: Isthmic spondylolisthesis most commonly occurs in the lumbosacral junction and can cause backpain and radicular pain as well as stiffness with progressive immobilization, with a negative impact on an individual's ability to work and quality of life. Multiple operative treatments are currently available. This study aims to compare complications, demography, and clinical features between anterior lumbar interbody fusion (ALIF) and posterior lumber body fusion (PLIF) in the operative treatment in isthmic spondylolisthesis. METHODS: An analysis of data from the German spine registry (Deutsche Wirbelsäulengesellschaft [DWG]-Register) of patients who underwent operative treatment (PLIF and ALIF) for isthmic spondylolisthesis in the sacrolumbar junction in 170 departments between January 2017 and May 2021 was performed. Age, gender, American Society of Anesthesiologists (ASA) score, surgical approach, smoker/nonsmoker, as well as severeness of the spondylolisthesis according to the Meyerding classification were evaluated. RESULTS: In total, 602 patients undergoing fusion in L5/S1 were identified in the registry, n = 570 PLIF (group 1) and n = 32 ALIF (group 2). A significant difference in the ASA score between the two groups was noted; group 1 had more patients suffering a more debilitating disease in comparison to group 2. There was no significant difference in gender, grade of spondylolisthesis, age, or smoking status. Significant differences were found in operative and postoperative variables and complications (fusion material, dura injury). CONCLUSION: No difference was found between the two procedures in terms of symptomatic benefit of patients who underwent either ALIF or PLIF. According to the DWG Register, PLIF was the preferred method to treat isthmic spondylolisthesis in the sacrolumbar junction in Germany. To compare these two spine fusion techniques, further studies with an adequate sample size and follow-up period are required.

Operative results of AO A3 and A4 traumatic injuries in the thoracic and lumbar spine. A multicenter surveillance study of 4230 patients from the German Spine Registry (DWG-Register).

BACKGROUND: The diagnosis, classification and treatment of thoracolumbar burst fractures, continue to be controversial. Surgery is generally the preferred treatment for unstable fractures while stable fractures are managed conservatively. This study aims to describe surgical procedures, outcomes, complications, demography, clinical features and differences between A3 and A4 fractures (AO classification) of the thoracolumbar region. A subgroup of patients <91 years with osteoporotic fractures is included and analyzed. METHODS: Analysis of data from the DWG-Register German spine registry on operative treatment for thoracolumbar AO A3 and A4 fractures out of 170 departments from January 2017 to May 2021. The evaluated variables included age, gender, surgical approach (posterior, anterior combined), and re-operation. RESULTS: In total, 4230 AO A3 and A4 thoracolumbar fractures were identified in the registry; 2898 A3 (group 1) and 1332 A4 (group 2). The preoperative ASIA-impairment scale score in group 1 was significantly different compared with group 2 (P=0.02). Surgical procedures such as decompression/stabilization with rod-screw system cemented/non-cemented, as well as an anterior approach, were statistically significant between the groups. Odds ratio was calculated for variables that could be influenced for the type of fracture (A3 or A4): decompression 4.89, OR time >2 hours 48.22, osteoporosis 6.46 and posterior access 9.85. CONCLUSIONS: This study provides multicenter results from a huge number of surgically treated AO A3 and A4 fractures. Anterior approaches are more often used in A4 type fractures, probably because of its inherent instability related to burst fractures, surprisingly, not associated with the occurrence of added perioperative complications. Nevertheless, A3 type fractures are presented with worse ASIA Impairment-Scale at admission, in comparison with A4 type fractures of the thoracolumbar region.

Open Posterior Reduction and Stabilization of AO Spine C3 Sacral Fractures.

AO Spine C3 sacral fractures are defined by separation of the spine including S1 from the pelvic ring and are usually result of a high-energy injury. Besides their high biomechanical instability and high rate of associated neurological impairment, these fractures are often extremely difficult to reduce due to severe bony impaction and dislocation. Additional difficulties in management of these fractures arise from only a thin-layer of soft-tissue coverage overlying the injured area.

Impact of Obesity on Perioperative Complications on Treatment of Spinal Metastases: A Multicenter Surveillance Study from the German Spine Registry (DWG-Register).

Background The spine is a common location for the development of primary and metastatic tumors, spinal metastases being the most common tumor in the spine. Spinal surgery in obesity is challenging due to difficulties with anesthesia, intravenous access, positioning, and physical access during surgery. The objective was to investigate the effect of obesity on perioperative complications by discharge in patients undergoing surgery for spinal metastases. Methods Retrospective analysis of data from the DWG-register on patients undergoing surgery for metastatic disease in the spine from January 2012 to December 2016. Preoperative variables included obesity (≥ 30 kg/m 2 ), age, gender, and smoking status. In addition, the influence of pre-existing medical comorbidity was determined, using the American Society of Anesthesiologists (ASA) score. Results In total, 528 decompressions with and without instrumentation undergoing tumor debulking, release of the neural structures, or tumor extirpation in metastatic disease of the spine were identified; 143 patients were obese (body mass index [BMI] ≥ 30 kg/m 2 ), and 385 patients had a BMI less than 30 kg/m 2 . The mean age in the group with BMI 30 kg/m 2 or higher (group 1) was 67 years (56.6%). In the group with BMI less than 30 kg/m 2 (group 2), the mean age was 64 years. Most of the patients had preoperatively an ASA score of 3 and 4 (patients with severe general disease). The likelihood of being obese in the logistic regression model seems to be protective by 47.5-fold for blood loss 500 mL or higher. Transfusions occurred in 321/528 (60.7%) patients (group 1, n = 122 and group 2, n = 299; p = 0.04). A total of 19 vertebroplasties with percutaneous stabilization (minimally invasive spine [MIS]), 6 vertebroplasties, and 31 MIS alone were identified. The variables between these groups, with exception of preoperative status (ASA-score; p = 0.02), remained nonsignificant. Conclusion Obese patients were predisposed to have blood loss more than 500 mL more often than nonobese patients undergoing surgery for spinal metastases but with perioperative blood transfusions, invasiveness, nor prolonged hospitalization. Early postoperative mobilization and a low threshold for perioperative venous thromboembolism (VTE) are important in obese patients to appropriately diagnose, treat complications, and minimize morbidity.

Challenging the dogma to "always operate" acute hip fractures: a proof-of-concept pilot study for nonoperative management of undisplaced femoral neck fractures.

BACKGROUND: The notion that all acute hip fractures are a surgical entity requiring either surgical fracture fixation or hip replacement represents a historic dogma, particularly within the orthopaedic community of the United States. The present study from a European regional trauma center was designed to challenge the notion that stable and undisplaced femoral neck fractures represent an absolute indication for surgical management. METHODS: The purpose of this study was to investigate the hypothesis that stable and undisplaced femoral neck fractures of the Garden types 1 and 2 can be safely managed nonoperatively. A retrospective observational cohort study was carried out at a regional orthopaedic trauma center in Germany from January 1, 2016 to June 30, 2021. The inclusion criteria specified patients older than 18 years suffering a < 24 h, traumatic, femoral neck fracture Garden types 1 and 2. Exclusion criteria included Garden types 3 and 4 femoral neck fractures, pregnancy, active infection or previous surgery, tumor-associated fractures, medical history of femoral neck necrosis, vascular injury associated with femoral neck fractures, nerve injury associated to a femoral neck fracture and ≥ 24 h femoral neck fracture. The primary intention of this research was to identify deterioration of fracture retention with an ensuing unplanned trip to the operating room in femoral neck fractures Garden types 1 and 2. Secondary were included unplanned readmissions and complications such as surgical site infection. RESULTS: A total of 41 undisplaced femoral neck fractures (Garden types 1 and 2) were included in this study; n = 20 were in the resulting admission operatively treated (group 1) and n = 21 were treated conservatively. The mean age in group 1 was 76 years; women (70%). In group 2 it was 81 years with a female dominance (71.4%). Admission status: Garden types 1 and 2, group 1 n = 13/7 and group 2 n = 15/6. Subsequent femoral neck fracture displacement (Y/N) (in case of operation, before operation) group 1 n = 14/6 and group 2 n = 6/15. CONCLUSION: According with our results, patients sustaining Garden type 1 femoral neck fractures, depending on age and comorbidities, should be treated conservatively with weight bearing and under physiotherapeutic instructions. In case of femoral neck fractures Garden type 2, a surgical treatment should be performed in order to avoid femoral neck fractures to slip after weight bearing by lacking of fracture impaction.

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries.

INTRODUCTION: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. METHODS: For this study based on the TraumaRegister DGU® (January 2002-December 2017), the inclusion criterion was an Injury Severity Score (ISS) ≥9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. RESULTS: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p ≤ 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57-3.45, p ≤ 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66-2.39, p ≤ 0.001), and suicide attempts (OR 1.36, 95% CI 1.06-1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. CONCLUSIONS: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients.

Intra- and postoperative complications in the treatment of spinal metastases . A multicenter surveillance study from the German Spinal Registry (DWG-Register).

BACKGROUND: The incidence of spinal column tumors is estimated to be 0.62 per 100,000 individuals in the USA. It is especially important to understand the incidence and predictive factors for adverse events of surgery in spinal oncology patients, as a single complication may be associated with morbidity, mortality, and costs. The aim of the study was to use a large national registry to evaluate the perioperative cumulative incidence and predictors of major complications, for metastatic spinal tumors. METHODS: This study is a retrospective analysis of data from the DWG registry on patients who have undergone decompression with and without instrumentation undergoing tumor debulking, release of the neural structures, spinal stabilization or tumor extirpation in metastatic disease of the spine in 124 departments from January 2017 to January 2020, as well as vertebroplasty and percutaneous instrumentation. The outcomes evaluated were major complications defined by Finkelstein et al. as: death; cerebral (new postoperative coma or stroke), cardiac, pulmonary or renal complication; symptomatic venous thromboembolism; surgical site infection. RESULTS: In total, 1617 decompressions with and without instrumentation undergoing tumor debulking, release of the neural structures, spinal stabilization or tumor extirpation in metastatic disease in the spine were identified in the registry; N.=266 developed a major complication (group 2), while N.=1351 had no complication (group 1). The mean age in group 1 was 65 years (58.5%), in group 2 69 years (63.5%). In group 2, most of the patients had preoperatively an ASA Score of 3 and 4 (patients with severe general disease): 202/266 (75.9%) being significant. The overall prevalence of a major postoperative complication was 16.5% and for an intraoperative complication remained 8%. The likelihood ratio for major complications by blood loss greater than 500 mL were as follows: cardiovascular event with a likelihood of 4.22 pulmonary insufficiency 4.18 and cerebral 5.47. CONCLUSIONS: This analysis provides predictive models for surgeons to identify patients who may benefit from transitional care programs. Preoperative status, invasiveness, blood loss >500 mL and blood transfusions are independent predictors associated with higher risk of complication.

There is no difference in perioperative results between posterior instrumentation with and without interbody cage and debridement in primary spondylodiscitis in adults: a multicenter surveillance study from the German Spine Registry (DWG Register).

BACKGROUND: Primary spondylodiscitis is a medically challenging disease that can lead to recurrent back pain, progressive kyphotic deformity, and neurologic deficits. The incidence rate of primary non-tuberculosis spondylodiscitis has been estimated from 2.2 to 2.4 cases per 100,000 person-years, and it has been reported to be increasing because of the aging population. The objectives were to determine the safety and efficacy of posterior instrumentation (PI) with and without interbody cage, bony attachment and debridement in the treatment of primary spondylodiscitis by comparing perioperative data, functional outcomes, and overall infection-free survival. METHODS: Analysis of data from the DWG Registry on patients who have undergone posterior instrumentation with and without interbody cage, bony attachment and debridement in primary spondylodiscitis from the thoracolumbar junction to S1 (Th10-S1) at 10 institutions from January 2012 to December 2016. RESULTS: In total, 420 posterior instrumentations with and without interbody cage, bony attachment and debridement in primary spondylodiscitis in the thoracolumbar junction to S1 were identified in the registry; N.=138 were exclusively percutaneous posterior instrumented (PPI), while N.=102 underwent open posterior instrumentation (OPI) without interbody cage, bony attachment and debridement and N.=180 OPI with interbody cage, bony attachment and debridement. Clinical evaluation after surgery did not show a significant difference between groups including improvement of the mobilization and infection-free survival. However, with PPI the duration of operation and blood loss was significantly less than OPI with and without interbody cage, bony attachment and debridement. CONCLUSIONS: The results suggest interbody cage, bony attachment and debridement as not indispensable for treatment in primary spondylodiscitis. Therefore, we encourage the use of posterior stabilization alone in the treatment of spondylodiscitis as less invasive procedure reducing costs in instrumentation.

Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons.

PURPOSE: Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons. METHODS: Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss' kappa (κ) statistics. RESULTS: We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%. CONCLUSION: We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.

Invasiveness has no influence on the rate of incidental durotomies in surgery for multisegmental lumbar spinal canal stenosis (≥3 levels) with and without fusion: analysis from the German Spine Registry data (DWG-Register).

BACKGROUND: Nowadays, perioperative complications as dural tear (DT) with subsequent neurological deficits are documented in independent registers. However, the relationship of these complications with the grade of invasiveness (≥3 levels) is still unclear. The aim of this study was to evaluate perioperative complications, particularly DT with subsequent neurological deficits, between patients undergoing laminotomy and decompression and decompression and fusion in ≥3 levels. METHODS: Retrospective analysis of the data pool of the DWG register based on cases described by 10 clinics between January 2012 and December 2016 was performed. Surgically treated LSS in ≥3 segments were divided into decompression with or without instrumentation and fusion. Cases with intraoperative DT in both subgroups were analysed for risk factor occurrence. The Surgical Invasive Index (SII) was used. RESULTS: DT occurred in 102/941 (10.8%) patients. Difference in DT between groups was non-significant. The likelihood of DT increased by 2.12-fold with previous spinal surgery at the same level and by 1.9-fold for BMI 30-34 and >35 in comparison with BMI 26-29, respectively. Postoperative deep wound infection was increased by 2.39-fold after DT than without. Significance in outcomes between patients with/without DT was not found. The invasiveness index explained 48% of the variation in blood loss and 51% of the variation in surgery duration. CONCLUSIONS: The rate of incidental DT during decompression for LSS with and without fusion in ≥3 levels was associated with BMI and previous surgery at the same spinal level. Invasivness (SII) is valid rather for variables proper to surgery such as bledding and Op-time but no with incidence for DT and subsequent CSF-leackage.

Convergence of scaffold-guided bone regeneration and RIA bone grafting for the treatment of a critical-sized bone defect of the femoral shaft.

BACKGROUND: Critical-sized bone defects, mainly from trauma, infection or tumor resection are a challenging condition, often resulting in prolonged, complicated course of treatment. Autografts are considered as the gold standard to replace lost bone. However, limited amount of bone graft volume and donor-site morbidity have established the need for the development of alternative methods such as scaffold-based tissue engineering (TE). The emerging market of additive manufacturing (3D-printing) has markedly influenced the manufacturing of scaffolds out of a variety of biodegradable materials. Particularly medical-grade polycaprolactone and tricalcium phosphate (mPCL-TCP) scaffolds show appropriate biocompatibility and osteoconduction with good biomechanical strength in large preclinical animal models. This case report aims to show first evidence of the feasibility, safety, and efficacy of mPCL-TCP scaffolds applied in a patient with a long bone segmental defect. CASE PRESENTATION: The presented case comprises a 29-year-old patient who has suffered a left-sided II° open femoral shaft fracture. After initial external fixation and subsequent conversion to reamed antegrade femoral nailing, the patient presented with an infection in the area of the formerly open fracture. Multiple revision surgeries followed to eradicate microbial colonization and attempt to achieve bone healing. However, 18 months after the index event, still insufficient diaphyseal bone formation was observed with circumferential bony defect measuring 6 cm at the medial and 11 cm at the lateral aspect of the femur. Therefore, the patient received a patient-specific mPCL-TCP scaffold, fitting the exact anatomical defect and the inserted nail, combined with autologous bone graft (ABG) harvested with the Reamer-Irrigator-Aspirator system (RIA-Synthes®) as well as bone morphogenetic protein-2 (BMP-2). Radiographic follow-up 12 months after implantation of the TE scaffold shows advanced bony fusion and bone formation inside and outside the fully interconnected scaffold architecture. CONCLUSION: This case report shows a promising translation of scaffold-based TE from bench to bedside. Preliminary evidence indicates that the use of medical-grade scaffolds is safe and has the potential to improve bone healing. Further, its synergistic effects when combined with ABG and BMP-2 show the potential of mPCL-TCP scaffolds to support new bone formation in segmental long bone defects.

[The coexistence of spinal canal stenosis in fragility fractures of the spine]. / Die Koexistenz der Spinalkanalstenose in der Alterstraumatologie.

BACKGROUND: In trauma care of fragility fractures of the spine, degenerative stenosis is often seen as an accompanying pathology. This may lead to a possible compression of neurogenic structures. The stenosis of the spinal canal can manifest itself with clinically significant complaints before the fracture occurs. This coexistence may have an impact on the injury itself or may provoke a complicated treatment of the fracture. AIM: The aim of this work is to differentiate these pathophysiologies and their merger in terms of clinical diagnostics and treatment options. DIFFERENTIAL DIAGNOSIS: The differential diagnosis is difficult and is often inadequately appreciated in everyday clinical life. The etiology and pathophysiology of both entities show, in several aspects, a congruence that enables joint treatment. If the indication is set for the decompression of a stenosing fracture, a pre-existing relevant stenosis can be addressed in the same session. Conversely, significant degenerative stenosis accompanying a fracture may lead to the indication of decompression.

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.

BACKGROUND: Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS: A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS: Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION: Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

Blunt Cerebrovascular Artery Injury and Stroke in Severely Injured Patients: An International Multicenter Analysis.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) is considered to be a rare entity in patients with high-energy trauma and is a potentially preventable cause of secondary brain damage. If it occurs, it may be fatal or associated with poor outcomes related to devastating complications. We hypothesized that analyses of epidemiology and concomitant injuries may predict the development of BCVI and associated complications. METHODS: The TraumaRegister DGU® (TR-DGU), a prospectively maintained database, was used for retrospective data analysis (01/2009-12/2015). INCLUSION CRITERIA: adult trauma patients (≥16 years) with severe injuries (ISS ≥ 16 points) with and without BCVI. Subgroups: carotid artery injury (CAI) and vertebral artery injury (VAI). The degree of vascular injury was classified according to the Abbreviated Injury Scale values. Demographic, injury, therapy and outcome characteristic data (length of stay, stroke, multiple organ failure and mortality) were collected and analyzed for each patient with SPSS statistics (Version 23, IBM Inc., Armonk, NY). RESULTS: Out of 76,480 individuals, a total of 786 patients with BCVI (1%) were identified. The 435 CAI patients included 263 dissections, 78 pseudoaneurysms and 94 bilateral injuries. The 383 VAI patients presented with 198 dissections, 43 pseudoaneurysms, 122 thrombotic occlusions and 20 bilateral injuries. The risk for stroke was excessive in BCVI patients versus controls (11.5 vs. 1.1%, p < 0.001) and increased with vascular injury severity, up to 24.1% in CAI patients and 30.0% in VAI patients. We confirmed that cervical spine injuries were a major BCVI predictor (OR 6.46, p < 0.001, 95% CI 5.34-7.81); furthermore, high-energy mechanisms (OR 1.79), facial fractures (OR 1.56) and general injury severity (OR 1.05) were identified as independent predictors. Basilar skull fractures (BSF) were found with comparable frequency (p = 0.63) in both groups, and the predictive value was found to be insignificant (OR 1.1, p = 0.36, 95% CI 0.89-1.37). Age ≥ 60 years was associated with a decreased risk for BCVI (OR 0.54, p < 0.001, 95% CI 0.45-0.65); however, in BCVI patients over 60 years of age, mortality was excessive (OR 4.33, p < 0.001, 95% CI 2.40-7.80). Even after adjusting for head injuries, BCVI-associated stroke remained a significant risk factor for mortality (OR 2.52, p < 0.001, 95% CI 1.13-5.62). CONCLUSION: Our data validated cervical spine injuries as a major predictor, but the predictive value of BSF must be scrutinized. Patient age appears to play a contradictory role in BCVI risk and BCVI-associated mortality. Predicting which patients will develop BCVI remains an ongoing challenge, especially since many patients do not present with concomitant injuries of the head or spine and therefore might not be captured by standard screening criteria.

Classification of soft-tissue injuries in open femur fractures: Relevant for systemic complications?

BACKGROUND: A broad range of systemic complications has been described to occur in patients with open major fractures. Various causes have been claimed to play a role. We therefore surveyed a nationwide trauma registry to assess risk factors associated with closed and various types of open femur fractures. METHODS: This was a cohort study in a nationwide population-based prospective database. Inclusion criteria for selection from database are as follows: individuals with femur fracture, age 16 years or older, and survival until primary admission. Main groups included closed and open femur fracture. Patient demographics, injury severity (New Injury Severity Score), surgical fracture management, length of stay, and systemic complications (e.g., multiple organ failure [MOF], sepsis, mortality) were collected and statistically analyzed using SPSS statistics. Multivariate regression analysis was performed to stratify subgroups for the degree of open soft-tissue injury according to Gustilo and Anderson. RESULTS: Among 32,582 documented trauma victims (January 1, 2002, to December 31, 2010), a total of 5,761 met the inclusion criteria. Main groups: 4,423 closed (76.8%) and 1,338 open femur fractures (23.2%). Open fractures subgroups were divided into I° (334, 28.1%), II° (526, 44.3%), and III° (328, 27.6%). Open fractures were associated with an increased risk of prehospital hemorrhagic shock (p = 0.01), higher resuscitation requirements (p < 0.001), MOF (p = 0.001), and longer in-hospital (p < 0.001) and intensive care stay (p = 0.001). While New Injury Severity Score values showed a minor increase per subgroup, the prevalence of MOF, sepsis, and mortality multiplied with the degree of open soft-tissue injury. Especially patients with Type III open femur fractures received mass transfusions (28.2%, p < 0.001), and mass transfusions were identified as independent predictor for sepsis (odds ratio [OR], 2.393; 95% confidence interval [CI], 1.821-3.143; p < 0.001) and MOF (OR, 2.966; 95% CI, 2.409-3.651; p < 0.001). Our data also indicate an increased mortality in patients with open femur managed outside Level I trauma centers (OR, 1.358; 95% CI, 1.018-1.812; p = 0.037). CONCLUSION: Open femur fractures are associated with higher in-hospital complications related to incidence of MOF, associated intensive care unit stay, and hospital days when compared with closed femur fractures. For prevention of in-hospital complications, prompt hemorrhage control, surgical fracture fixation, cautious blood management, and triage to a Level I trauma center must be considered. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level II.

The efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture.

INTRODUCTION: To evaluate the efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture. METHODS: Eighteen patients with recurrent Dupuytren's contracture of 22 fingers were retrospectively assessed with a mean follow-up time of 94 months (range: 70-114 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and subjective outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire). SURGICAL TECHNIQUE: Dissection with special regard to former skin incision and expected wound defect. Modified incisions after Bruner (Mini-Bruner incisions) were facilitated. Dissection started at the palm. Fibrous tissue was resected proximally within the palm including vertical fibrotic septae. Direct preparation of the neurovascular bundles (NVB) was facilitated from proximal to distal. If the anatomy of the neurovascular structures became unclear around the natatory ligament preparation of the NVB at the distal end of the fibrous cord was performed. After complete preparation of a NVB, dissection was continued from medial to lateral until the other bundle was completely released. Transposition flaps and skin transplants were often used for sufficient wound closure. RESULTS: Recurrence rate was 36 % applying the definition of van Rijssen et al. Fifteen patients had a grip strength of 90 % or higher in comparison to the contralateral side. Ten patients had a pinch strength of 90 % or higher in comparison to the contralateral side. All patients except for one had pain reduction or none postoperatively. Fifteen patients had a DASH score of 15 or lower (range: 0-47). An unrelated ray amputation was suffered due to wound healing complications. CONCLUSIONS: Open partial aponeurectomy performed by a board certified hand surgeon proved to be safe. The postoperative functional outcome seemed to be related to the individual course of the disease.

The Effect of Polymethyl Methacrylate Augmentation on the Primary Stability of Cannulated Bone Screws in an Anterolateral Plate in Osteoporotic Vertebrae: A Human Cadaver Study.

Study Design Cohort study. Objective Expandable anterolateral plates facilitate the reduction of posttraumatic deformities of thoracolumbar spine injuries and are commonly used in cases of unstable injuries or compromised bone quality. In this in vitro study, the craniocaudal yield load of the osseous fixation of an anterior angular stable plate fixation system and the effect of polymethyl methacrylate (PMMA) screw augmentation on the primary stability of the screw-bone interface during kyphosis reduction was evaluated in 12 osteoporotic human thoracolumbar vertebrae. Methods The anterolateral stabilization device used for this study is comprised of two swiveling flanges and an expandable midsection. It facilitates the controlled reduction of kyphotic deformities in situ with a geared distractor. Single flanges were attached to 12 thoracolumbar vertebrae. Six specimens were augmented with PMMA by means of cannulated bone screws. The constructs were subjected to static, displacement-controlled craniocaudal loading to failure in a servohydraulic testing machine. Results The uncemented screws cut out at a mean 393 ± 66 N, whereas the cemented screws showed significantly higher yield load of 966 ± 166 N (p < 0.02). We detected no significant correlation between bone mineral density and yield load in this setting. Conclusion Our results indicate that PMMA augmentation is an effective method to increase two- to threefold the primary stability of the screw-bone interface of an anterolateral spine stabilization system in osteoporotic bone. We recommend it in cases of severely compromised bone quality to reduce the risk of screw loosening during initial kyphosis correction and to increase long-term construct stability.

External fixation design evolution enhances biomechanical frame performance.

BACKGROUND: External fixation has become a quick and easy application for fracture stabilisation of the extremities and/or pelvis to maintain the reduction and provide stability while sparing the soft tissues. Over the last years, enhanced construct stiffness has become an essential requirement to preserve fracture reduction, particularly in active and overweight patients. This study was performed to determine whether the advancement of design features enhances the external fixation construct stiffness. The stiffness of the recently developed Hoffmann 3 external fixation system was determined and its characteristics compared with the widely clinically accepted Hoffmann II MRI fixation system. METHODS: A synthetic fracture model was used. Two carbon tubes with a fracture gap of 20 mm were appropriate to determine the stiffness of three different configurations: the basic frame configuration (group H 3, representing Hoffmann 3 with a rod diameter of 11 mm) using a double rod construction with 6 mm Apex pins, was compared with the Hoffmann II MRI fixation system using two 8.0 mm diameter rods with 6 mm (group H II-6 mm) and 5 mm (group H II-5 mm) Apex pins. Each group was tested five times under anterior-posterior bending (N/mm), medio-lateral bending (N/mm) and axial torsion loading directions (Nm/deg). The stiffness results of each construct were compared statistically. RESULTS: The basic frame construct (group H 3) showed consistently higher stiffness properties compared with the other configurations. The anterior-posterior-bending loads resulted in a mean value of 31 N/mm, which was significantly higher compared with the other groups (p=0.008) at 16 N/mm. The medio-lateral-bending test revealed a mean stiffness of 59 N/mm in the H3 group, compared with 43 N/mm in the H II-6 group and 31 N/mm in the H II-5 group. The axial torsion measurements of the Hoffmann 3 group yielded significantly higher results (1.03 Nm/°) compared with group H II-6 (0.61 Nm/°) and group H II-5 (0.56 Nm/°). CONCLUSIONS: The Hoffmann 3 construct showed the highest stiffness properties under bending and torsion loads. The enhanced stiffness of the Hoffmann 3 device may be helpful in maintaining fracture reduction and soft tissue compromise. This investigation showed the advancement of Hoffmann design features may be effective in enhancing frame stiffness.