Major low-energy trauma results in non-specific immunoglobulin generation without evidence for specific autoantibody production: A prospective cohort study.

Cellular debris resulting from large trauma might overwhelm the scavenger mechanisms and lead to autoimmune reactions. We analysed whether a major well-defined trauma in humans induces laboratory signs of transient autoimmunity in the months after the insult. We included 50 patients with pertrochanteric femur fracture undergoing intramedullary nail osteosynthesis in a prospective cohort study and followed them at 3-4 days, 6 weeks, 12 weeks and 12 months postoperatively. By standard techniques, we assessed levels of total immunoglobulins, anti-nuclear antibodies (ANA), anti-cardiolipin antibodies, anti-dsDNA antibodies and anti-C1q antibodies, as well as antibodies against cytomegalovirus (CMV) as a control. Blood leukocyte differential and lymphocyte subpopulations were determined at baseline and in the first two postoperative samples. The mean age of the patients reached 80.1 years, and 23 (46%) completed all visits. Serum concentrations of total IgG, IgM and IgA increased at all follow-up time points. The ANA fluorescence light intensity units increased at 12 weeks and 12 months postoperatively (p < 0.0001), but the proportion of ANA-positive patients did not change (35%). The values of anti-C1q mildly increased at all follow-up visits, but not the ratio to total IgG. Anti-dsDNA remained negative in all patients, and anti-cardiolipin IgG/IgM antibodies did not change. Anti-CMV IgG antibodies increased significantly at all follow-up visits, without change in the ratio to total IgG. Flow cytometry showed an increased proportion of B-cells 3-4 days postoperatively. In conclusion, major musculoskeletal trauma in elderly patients induces a generalized non-specific increase in immunoglobulin production without laboratory signs for enhanced systemic autoimmunity.

Analysis of the subcapital two-part humerus fracture by fluoroscopy: objective criteria for classification and decision making.

BACKGROUND: Surgical decision making in the treatment of proximal humerus fractures (PHFx) is primarily based on fracture classification using standard radiographs. Due to the lack of objective criteria, this classification process is associated with high interobserver variation. In this study, we investigate the fluoroscopic analysis of humerus fractures through the surgical neck using a semi-quantitative determination of distinct angulation patterns of the proximal humerus as they appear in the image intensifier. METHODS: Using a saw bone model, defined subcapital 2-part fracture configurations were generated and assessed radiographically. Anatomical landmarks-including the greater and lesser tuberosity as well as anatomical neck-were identified using an image converter, and the exact degree of fracture displacement with 10° up to 70° (in 10° increments) of posterior, varus or combined posterior-varus angulation was compared to nondisplaced controls. From the resultant series of radiographs, the appearance of these angulations in anteroposterior (AP) and scapular Y-views were also visualized and defined. RESULTS: An angulation of 50° or more of any given 2-part fracture through the surgical neck is present when the greater tuberosity becomes the most proximal point in AP view (varus and combined posterior-varus angulation) or a bimodal form is found for the superior contour of the head with the lesser tuberosity being the most proximal point in the Y-view (posterior angulation). CONCLUSION: The radiological appearance of various PHFx constellations can be well visualized using the saw bone shoulder model. The presence of angulation in accordance with the Neer classification for group III fractures can be adequately determined by analyzing the relative position of the greater or lesser tuberosity to the humeral head calotte. This can assist the surgeon's decision on whether to operate or opt for a conservative approach. LEVEL OF EVIDENCE: Basic Science, Anatomy Study, Imaging.

Acute Longus Colli Calcific Tendinitis: A Rare Cause of Neck Pain.

A 48-year-old man presented to our emergency department with neck pain without sensorimotor deficit and with a sore throat without signs of infection. Magnetic resonance imaging was performed because the patient had not responded to regular treatment and a blood test had showed inflammation. The images revealed cervical prevertebral fluid collection and calcification, compatible with acute calcific tendinitis of the longus colli muscle. Prednisolone 50 mg with pantoprazol 40 mg was administered for 5 days with rapid resolution of symptoms. Acute calcific tendinitis of the longus colli muscle is a rare and possibly underdiagnosed cause of atypical neck pain and sore throat. LEARNING POINTS: The signs and symptoms of acute calcific tendinitis of the longus colli muscle can easily be mistaken for serious disease such as spondylodiscitis or retropharyngeal abscess.Imaging with easily available modalities such as computed tomography can be used for diagnosis.Anti-inflammatory medication led to quick resolution of symptoms despite elevated signs of inflammation and delayed diagnosis in our patient.

Rationale and methods of an observational study to support the design of a nationwide surgical registry: the MIDAS study.

BACKGROUND Surgical registries are becoming increasingly popular. In addition, Swiss legislation requires data on therapeutic outcome quality. The Swiss Association of Surgeons (Schweizerische Gesellschaft Chirurgie, SGC-SCC) has already agreed on a first minimum data set. However, in the long run the scope and content of the registry should be evidence-based and not only accepted by professional stakeholders. The MIDAS study aims at providing such evidence for the example population of patients undergoing emergency or elective hip surgery. Five relevant aspects are considered: (1) choice of instruments for assessing health related quality of life (HRQoL); (2) optimal time-point for assessment; (3) use of proxy assessments; (4) choice of pre-surgery risk factors; and (5) assessment of peri- and postoperative variables. METHODS MIDAS is a longitudinal observational multicentre study. All patients suffering from a femoral neck fracture or from arthritis of the hip joint with an indication for prosthetic joint replacement surgery will be offered participation. The study is based on a combination of routine data from clinical standard practice with specifically documented data to be reported by the treating clinician and data to be collected in cooperation with the patient ­ in particular patient-reported outcome measures (PROMs). The latter include the Health Utility Index Mark 3 (HUI3) and Euro-Qol-5D (EQ-5D) as generic instruments, Hip Disability and Osteoarthritis Outcome Score (HOOS) as a disease specific instrument for the assessment of HRQoL, and two performance-based functional tests. Data will be collected at baseline, during hospitalisation/at discharge and at three routine follow-up visits. All patients will be asked to name a person for assessing proxy-perceived HRQoL. DISCUSSION To the best of our knowledge, this is the first study explicitly addressing questions about the design of a national surgical registry in an empirical manner. The study aims at providing a scientific base for decisions regarding scope and content of a potential national Swiss surgical registry. We designed a pragmatic study to envision data collection in a national registry with the option of specifying isolated research questions of interest. One focus of the study is the use of PROMs, and we hope that our study and their results will inspire also other surgical registries to take this important step forward. Trial registration Registered at the "Deutsches Register Klinischer Studien (DRKS)", the German Clinical Trials Registry, since this registry meets the scope and methodology of the proposed study. Registration no.: DRKS00012991

Minimally invasive anterior muscle-sparing versus a transgluteal approach for hemiarthroplasty in femoral neck fractures-a prospective randomised controlled trial including 190 elderly patients.

BACKGROUND: The relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients. METHODS: Four hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the "Timed up and go" test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality. RESULTS: A total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [- 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5-12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [- 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group. CONCLUSION: These results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population. TRIAL REGISTRATION: www.clinicaltrials.gov : NCT01408693 (registered August 3rd 2011).

Pubic rami fractures in the elderly--a neglected injury?

OBJECTIVE: To evaluate the patient characteristics and natural history of pubic rami fractures in geriatric patients, with a special focus on the frequency of concomitant posterior pelvic ring lesions and the percentage of secondarily operated patients as a result of conservative treatment failure. STUDY DESIGN: Retrospective cohort study. Patients were treated in a university hospital that is equivalent to a level I Trauma centre. PATIENTS AND METHODS: We analysed 132 consecutive patients (113 women, 19 men), >65 years old, presenting with low energy-trauma pubic rami fractures at our emergency department from January 2009 to December 2011. RESULTS: Mean age of patients was 84 years (range 66-100). Women were affected six times more frequently than men. Almost 30% of patients lost their previous independence permanently owing to the injury. Ninety eight percent of previously independent patients (community dwellers) required temporary hospital care for a median duration of 39 days (interquartile range [IQR] 28-52). One-year mortality was 18.5%. A concomitant posterior pelvic ring lesion was identified by computed tomography in 54% of patients. In 4% of the patients secondary operative fracture stabilisation was performed. DISCUSSION: Pubic rami fractures are frequently associated with concomitant posterior pelvic ring injuries, making these injuries more unstable than generally assumed. Based on this fact and the long duration of hospital stay, more aggressive management of these injuries may be considered. The principle aims in this patient population are satisfying pain management, early mobilisation, conservation of independence and return to previous place of residence.