[ATLS® and TDSC®: how it fits together : A treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios]. / ATLS® und TDSC®: How it fits together : Ein Behandlungskonzept für MANV und TerrorMANV, lebensbedrohliche oder besondere Lagen.

Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

[Vascular surgical training concept for military surgeons in Germany]. / Gefäßchirurgisches Ausbildungskonzept für Militärchirurgen in Deutschland.

BACKGROUND: Due to the increasing threat of terrorist attacks and assassinations even in Europe, the interest in management of severe vascular injuries, which, with an increased incidence of 10% are to be expected with such penetrating wounds, is also growing; however, with increasing subspecialization in surgery there is a threat that the know-how in vascular surgery will become lost among non-vascular surgical specialists. Therefore, the Germany military established an educational program, the so-called DUOplus concept, to ensure that future military surgeons acquire and retain the experience and skills to fulfill the demanding role of a deployed surgeon. OBJECTIVE: The DUOplus concept of the German Medical Forces is introduced with a special focus on vascular surgery training. RESULTS: All trainee German military surgeons attain a second specialization alongside general surgery. This residency includes several courses in various surgical specialties as well as a 12-month rotation in a vascular surgery department. The core elements of vascular trauma training are two practical courses on life-like models. In these courses, which were developed especially for the needs of non-vascular surgeons in hands-on training, open surgical techniques and damage control measures including resuscitative endovascular balloon occlusion of the aorta (REBOA) are taught on suitable models and intensively practiced. CONCLUSION: All surgeons potentially confronted with traumatic and iatrogenic vascular injuries should have some basic competence in the management of vascular trauma. Especially the courses in vascular surgery for non-vascular surgeons offer such a skill set for every surgeon. Next to the German military surgeons, the courses are attended more and more by civilian and military surgeons from different surgical specialties and nationalities.

[Update on gunshot wounds to extremities]. / Update zu Schussverletzungen der Extremitäten.

Due to recent rampage and terror attacks in Europe, gunshot wounds have become a focus of attention even though they are still rare in Europe. Approximately 50% of gunshot wounds affect the extremities and to understand the sequelae, a basic knowledge of wound ballistics is indispensable. The energy transmitted from the bullet to the tissue is responsible for the severity of the injury and is dependent on the type of weapon and ammunition. A differentiation is made between low-energy injuries caused, e.g. by pistols and high-energy injuries mostly caused by rifles. The higher energy transfer to the tissue in high-energy injuries, results in a temporary wound cavity in addition to the permanent wound channel with extensive soft tissue damage. High-energy gunshot fractures are also more extensive compared to those of low energy injuries. Debridement seems to be necessary for almost all gunshot wounds. Fractures should be temporarily stabilized with an external fixator due to contamination.

Antioxidative therapy in an ex vivo human cartilage trauma-model: attenuation of trauma-induced cell loss and ECM-destructive enzymes by N-acetyl cysteine.

OBJECTIVE: Mechanical trauma of articular cartilage results in cell loss and cytokine-driven inflammatory response. Subsequent accumulation of reactive oxygen (ROS) and nitrogen (RNS) species enhances the enzymatic degradation of the extracellular matrix (ECM). This study aims on the therapeutic potential of N-acetyl cysteine (NAC) in a human ex vivo cartilage trauma-model, focusing on cell- and chondroprotective features. DESIGN: Human full-thickness cartilage explants were subjected to a defined impact trauma (0.59 J) and treated with NAC. Efficiency of NAC administration was evaluated by following outcome parameters: cell viability, apoptosis rate, anabolic/catabolic gene expression, secretion and activity of matrix metalloproteinases (MMPs) and proteoglycan (PG) release. RESULTS: Continuous NAC administration increased cell viability and reduced the apoptosis rate after trauma. It also suppressed trauma-induced gene expression of ECM-destructive enzymes, such as ADAMTS-4, MMP-1, -2, -3 and -13 in a dosage- and time-depending manner. Subsequent suppression of MMP-2 and MMP-13 secretion reflected these findings on protein level. Moreover, NAC inhibited proteolytic activity of MMPs and reduced PG release. CONCLUSION: In the context of this ex vivo study, we showed not only remarkable cell- and chondroprotective features, but also revealed new encouraging findings concerning the therapeutically effective concentration and treatment-time regimen of NAC. Its defense against chondrocyte apoptosis and catabolic enzyme secretion recommends NAC as a multifunctional add-on reagent for pharmaceutical intervention after cartilage injury. Taken together, our data increase the knowledge on the therapeutic potential of NAC after cartilage trauma and presents a basis for future in vivo studies.

[Current state of medical care of polytrauma and mass casualty incidents in Germany. Are we well-prepared?]. / Aktueller Stand der Versorgung beim Polytrauma und MANV in Deutschland. Sind wir gut vorbereitet?

The white paper on the medical care of the severely injured published in 2006 is a collection of proposals and recommendations concerning structure, organization and equipment for the medical care of severely injured patients. Since its publication 50 networks ( http://www.dgu-traumanetzwerk.de/index ) have been established as part of the trauma network. This and the trauma register have helped to continuously improve the medical care of severely injured patients since 1993 [26]. Numerous studies have documented the progress made in measures required by the trauma network [4, 6]. For example, the mortality rate of severely injured patients has dropped from 25 % to approximately 10 % in the past 15 years. From the register and network data it is difficult to tell how each of these measures is implemented in the participating hospitals, who provides medical treatment to patients when, and how medical care is organized in detail. This is why a survey on medical care for polytrauma and in mass casualty situations was conducted among medical directors in German surgical hospitals who are members of the German Society for Trauma Surgery (DGU). Thanks to the 211 participants (most of whom specialize in orthopedic and trauma surgery) a detailed description of how medical treatment is currently organized and performed could be acquired. The survey showed that care of patients with polytrauma (i.e. medical treatment and management) is important irrespective of the level of training of physicians and of the level of patient treatment in hospitals. The central role of traumatologists was emphasized not only in terms of actual treatment but also as an administrator for organizational and management matters. Almost all hospitals have plans for a mass casualty situation; however, the levels of preparedness show considerable variation. A highly critical view is taken of the new surgical specialists with respect to interdisciplinary and comprehensive emergency medical treatment and casualty care. The survey also revealed the continual conflict between managing costs and maintaining quality and resources. It gives an overview of patient treatment in the transition from preclinical to clinical care and provides insights into the targets achieved, current problems and conflicts.

[Influence of anterior cruciate reconstruction on postural stability: A pre- and postoperative comparison]. / Der Einfluss einer VKB-Plastik auf die stabile Standfähigkeit: Ein prä- und postoperativer Vergleich.

BACKGROUND: Ruptures of the anterior cruciate ligament (ACL) lead to an anteromedial rotational instability in the knee joint and, thus, to a deterioration of the patient's ability to stand (postural control). It still remains unclear whether postural control can be restored by ACL reconstruction. The aim of this study was to investigate the effect of a unilateral ACL graft on the ability to stably stand on the injured leg using computer-aided dynamic posturography (CDP); the stability indices on standing on one leg were compared pre- and postoperatively. PATIENTS AND METHODS: A total of 25 patients were studied after unilateral ACL injury and subsequent ACL reconstruction using CDP. The average time of follow-up was 608 days (range 357-821 days). The ability to stably stand on the healthy and injured leg was compared and evaluated for significant differences. RESULTS: There was a significant improvement of postural control after ACL reconstruction. The Overall Stability Index (OSI) for the leg with ACL rupture was 3.7° ± 1.6° preoperatively and 3.0° ± 1.1° postoperatively (p < 0.05). In the postoperative comparison with the healthy leg, the value in the operated leg was 3.0° ± 1.1° and the healthy leg was 3.0° ± 1.4° (p = 0.99). CONCLUSIONS: ACL replacement can be improve stability compared to the preoperative value by about 21% and even the stability level of the contralateral healthy knee can be achieved.

Electromyography and range-of-motion measurements in German soldiers wearing different types of body armour while marching.

INTRODUCTION: In this study, we used surface electromyography (EMG) electrodes in order to measure and compare activity in the neck, back and thigh muscles of soldiers wearing two different types of body armour. A secondary objective was to analyse shoulder and hip ranges of motion using inertial motion sensors. METHODS: Fourteen male soldiers were instructed to march 6 km on a treadmill while wearing different types of body armour. All participants wore shorts and a T-shirt and the same size vest regardless of their body size. We measured back and thigh muscle activity as well as shoulder and hip ranges of motion at regular intervals during the march. RESULTS: Over the course of a 6 km march, muscle activity was already increased to 1.3 to 2.0 times after putting on the vest and increased by up to 13 times during the march with equipment. The new vest with hip belt required higher levels of muscle activity. CONCLUSIONS: Body armour with hip belt placed higher levels of stress on back and neck muscles during a 6 km march than without. There was no major difference between the two types of body armour in terms of thigh muscle activity. TRIAL REGISTRATION NUMBER: DRKS00016005.

[Anterior cruciate ligament ruptures and postural control: correlation of functional knee scores with computerized dynamic posturography]. / Verletzungen des vorderen Kreuzbandes und posturale Kontrolle: Korrelation von Kniescores und Klinik mit der computergestützten dynamischen Posturographie.

BACKGROUND: Quantification of postural stability deficits after anterior cruciate ligament (ACL) rupture requires a complex measurement process, the so-called computerized dynamic posturography (CDP). It would be desirable if the decrease in postural stability caused by ACL rupture could be estimated by simpler functional scores. The aim of this study was therefore to review the currently available standard knee scores for the suitability to assess postural stability. PATIENTS AND METHODS: In this study 58 patients with isolated unilateral ACL rupture were examined using CDP. The questionnaires used were Tegner, WOMAC, ADL-KOS, KOS-Sport, KSS and Lysholm scores. The values obtained were compared and correlated with the results of the CDP. In addition, a subgroup analysis of copers and non-copers was performed. RESULTS: There was no significant correlation with the postural stability deficit for any of the scores examined in this study. Only the subjectively perceived instability correlated appreciably with the CDP with r=0.423. CONCLUSIONS: All currently used scores for the investigation of patients with ACL rupture cannot give any information about the ability of postural balance. If patients complain about an increased subjective feeling of instability a close observation of postural stability using CDP is inevitable.

[Organizational redistribution of Ukrainian war wounded for care in Germany]. / Organisatorische Weiterverteilung ukrainischer Kriegsverletzter zur Versorgung in Deutschland.

Due to the war in Ukraine, which began on February 24th, 2022, countless people are injured every day, regardless of whether they are civilians or soldiers. This has led to the Ukrainian healthcare system being massively overburdened and for this reason these patients are brought to Germany, among other places, to be treated here. This article is intended to show the way and the organizational effort required to distribute the patients to the clinics in Germany.

[Necrotizing fasciitis. 2011 update]. / Nekrotisierende Fasziitis. Update 2011.

Necrotizing fasciitis belongs to a group of complicated soft tissue infections that can be even life threatening. Despite growing knowledge about its etiology, predictors, and the clinical progression, the mortality remains at a high level with 20%. A relevant reduction can be achieved only by an early diagnosis followed by consistent therapy. The clinical findings in about 75% of the cases are pain out of proportion, edema and tenderness, blisters, and erythema. It is elementary to differentiate a necrotizing or a non-necrotizing soft tissue infection early. In uncertain cases it can be necessary to perform a surgical exploration to confirm the diagnosis. The histopathologic characteristics are the fascial necrosis, vasculitis, thrombosis of perforating veins, the presence of the disease-causing bacteria as well as inflammatory cells like macrophages and polymorphonuclear granulocytes. Secondly, both the cutis and the muscle can be affected. In many cases there is a disproportion of the degree of local and systemic symptoms. Depending on the infectious agents there are two main types: type I is a polymicrobial infection and type II is a more invasive, serious, and fulminant monomicrobial infection mostly caused by group A Streptococcus pyogenes.Invasive, severe forms of streptococcal infections seem to occur more often in recent years. Multimodal and interdisciplinary therapy should be based on radical surgical débridement, systemic antibiotic therapy as well as enhanced intensive care therapy, which is sometimes combined with immunoglobulins (in streptococcal or staphylococcal infections) or hyperbaric oxygen therapy (HBOT, in clostridial infections). For wound care of extensive soft tissue defects vacuum-assisted closure has shown its benefit.

Non-resorbing osteoclasts induce migration and osteogenic differentiation of mesenchymal stem cells.

Osteoclast activity has traditionally been regarded as restricted to bone resorption but there is some evidence that also non-resorbing osteoclasts might influence osteoblast activity. The aim of the present study was to further investigate the hypothesis of an anabolic function of non-resorbing osteoclasts by investigating their capability to recruit mesenchymal stem cells (MSC) and to provoke their differentiation toward the osteogenic lineage. Bone-marrow-derived human MSC were exposed to conditioned media (CM) derived from non-resorbing osteoclast cultures, which were generated from human peripheral blood monocytes. Osteogenic marker genes (transcription factor Runx2, bone sialoprotein, alkaline phosphatase (AP), and osteopontin) were significantly increased. Osteogenic differentiation (OD) was also proved by von Kossa and AP staining occurred in the same range as in MSC cultures stimulated with osteogenic supplements. Chemotactic responses of MSC were measured with a modified Boyden chamber assay. CM from osteoclast cultures induced a strong migratory response in MSC, which was greatly reduced in the presence of an anti-human platelet-derived growth factor (PDGF) receptor beta antibody. Correspondingly, significantly increased PDGF-BB concentrations were measured in the CM using a PDGF-BB immunoassay. CM derived from mononuclear cell cultures did not provoke MSC differentiation and had a significantly lower migratory effect on MSC suggesting that the effects were specifically mediated by osteoclasts. In conclusion, it can be suggested that human non-resorbing osteoclasts induce migration and OD of MSC. While effects on MSC migration might be mainly due to PDGF-BB, the factors inducing OD remain to be elucidated.

Group I afferent pathway contributes to functional knee stability.

The hamstring reflex response has been suggested to play a substantial role in knee joint stabilization during anterior tibial translation. The present study was performed to determine which afferent pathways contribute to the hamstring reflex as well as the potential effects of specific afferent pathways on functional knee stability. Short- and medium-latency hamstring reflexes (SLR and MLR) were evoked by anterior tibial translation in 35 healthy subjects during standing with 30 degrees knee flexion. Nerve cooling, tizanidine, and ischemia were employed to differentiate afferent pathways. Two hours of thigh cooling (n = 10) resulted in a significant increase in MLR latency and, to a lesser extent, SLR latency. No significant changes were recorded in reflex sizes or maximum tibial translation. The ingestion of tizanidine (n = 10), a suppressor of group II afferents, strongly reduced the MLR size while SLR size or latency of both reflex responses was not significantly affected. Maximum tibial translation was unchanged [5.3 +/- 1.9 to 4.8 +/- 2 (SD) mm; P = 0.410]. Ischemia in the thigh (n = 15) led to a highly significant depression in SLR size (89 +/- 4%; P < 0.001) but only a slight and not significant decline of MLR size. In these subjects maximum tibial translation increased significantly (6.9 +/- 1.6 to 9.4 +/- 3.2 mm; P = 0.028). It is concluded that the hamstring SLR is mediated by Ia afferents, while group II afferents mainly contribute to the MLR. Suppression of SLR may increase maximum anterior tibial translation, thus indicating a possible functional role of Ia afferents in knee joint stabilization.

[Do meniscus injuries affect postural stability?]. / Beeinträchtigen Meniskusverletzungen den stabilen Stand?

BACKGROUND: Meniscal lesions are known to cause a loss of proprioception, which plays an important role in the regulation of postural stability. It is unclear, however, whether meniscus injuries adversely affect not only the sense of joint position but also postural control. The objective of this study was to investigate the influence of meniscal lesions on postural stability. MATERIAL AND METHODS: In this prospective study, postural stability was assessed by posturography in 27 patients with unilateral meniscal lesions. Both the injured and uninjured legs were tested and compared for significant differences using a t-test. RESULTS: Despite the presence of an arthroscopically confirmed meniscal lesion, none of the stability indexes that we calculated revealed significant differences in postural stability between the injured and uninjured sides. CONCLUSIONS: It was surprising to note that the loss of proprioception in patients with meniscus injuries did not influence postural stability. Patients with functional knee instability must therefore be examined for the presence of further injuries because a meniscal lesion alone cannot explain instability symptoms.

[The educational program for modern military surgeons]. / Weiterbildung zum modernen Militärchirurgen.

Casualties in military conflict produce patterns of injuries that are not seen in routine surgical practice at home. In an era of increasing surgical sub-specialization the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. Improvised explosive devices (IEDs) have become the modus operandi for terrorists and in the current global security situation these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries are relevant to both military and civilian surgeons. To create this kind of military surgeon the so-called "DUO-plus" model for the training of surgical officers (specialization general surgery plus a second specialization either in visceral surgery or orthopedics/trauma surgery) has been developed in the Joint Medical Service of the German Bundeswehr. Other relevant skills, such as emergency neurotraumatology, battlefield surgery with integrated oral and craniomaxillofacial surgery and emergency gynecology, are integrated into this concept and will be taught in courses. Log books will be kept in accordance with the training curricula. On successful completion of the program medical officers will be officially appointed as Medical Officer "Einsatzchirurg" by their commanding officers for a maximum of 5 years and it will be necessary to renew it after this period. These refresher programs will require participation in visiting physicians programs in the complementary surgical disciplines in order to retain the essential specific skills.

[Artificial intelligence, robotics and digitalization in the concept of military surgery of the German medical service]. / Künstliche Intelligenz, Robotik und Digitalisierung im Konzept der Einsatzchirurgie des deutschen Sanitätsdienstes.

BACKGROUND: As in other areas, military surgery is being transformed by developments in artificial intelligence, robotics and digitalization. Although the prospect of operating with a robot-assisted surgery system in the country of deployment while the responsible surgeon is in Germany is still a long way off, the training of military surgeons and the treatment of injured soldiers on deployment would nowadays be unimaginable without the digitalization of surgery in the armed forces. The structure of the medical environment in German clinics places restrictions on training that is close to operational reality. In the daily routine it is not possible to carry out the necessary numbers of deployment-relevant emergency surgical procedures under the expected conditions. Such procedures thus require the use of appropriate simulators or simulated scenarios that are as close to reality as possible. Although military surgeons are qualified in at least two specialist areas, the availability of telemedicine on deployment is helping to noticeably improve the treatment of injured soldiers. Telemedical consultation with colleagues in Germany makes it possible, for example, to reach joint decisions across different branches and disciplines. CONCLUSION: Until now it has not been possible to substitute the attending surgeon in the country of deployment with robot-assisted surgery systems or even robots for carrying out life-saving and stabilizing procedures; however, in order to provide surgeons with the necessary tools to successfully operate in situations where there is a shortage of personnel and materials in an inhospitable environment, use is made of the means that are currently available in the German medical services and constant efforts are made to explore the future possibilities of digital simulation. This article shows the reader the current status of digitalization in surgical training and deployments in the German armed forces.

In-vitro study of species-specific coagulation differences in animals and humans using rotational thromboelastometry (ROTEM).

Animal tests are conducted in all fields of trauma research, but transferability of these data to humans is limited. For example, it is still unclear which animal species is most similar to humans in terms of physiology of blood coagulation. To improve transferability and raise awareness of the existing differences, we compared human coagulation to coagulation of different animals. Rotational thromboelastometry was used to analyse the blood of pigs, sheep, rabbits and dogs. Animal data were compared with human coagulation based on the number of significant differences of the test parameters and on a descriptive comparison of the extent of relative deviation of the single values. All animal species showed significant differences in coagulation properties when compared with humans. Coagulation parameters of dogs and sheep were on average most similar to humans. However, there is no animal which is most similar to humans concerning all aspects of coagulation. Differences in coagulation between humans and animals are significant. This must be taken into account when transferring animal test data to humans.

Changes in trauma management following the implementation of the whole-body computed tomography: a retrospective multi-centre study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®).

OBJECTIVES: Whole-body computed tomography (WBCT) plays an increasingly important role in the diagnostic assessment of trauma room patients. It is still unclear whether its use has led to changes of trauma room procedures and patient outcomes. METHODS: In a retrospective multi-centric study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®), we analysed patients with an ISS ≥ 9 between 2002 and 2013. Two periods of time, i.e. up to 3 years preceding (pre-WBCT) and up to 3 years following the introduction of the WBCT (WBCT-group), were assessed separately for every hospital (TR-DGU Project ID 2014-020). RESULTS: 19,838 patients underwent treatment in 77 hospitals. Of these, 5621 were assigned to the pre-WBCT group and 11,307 to the WBCT group. Basic data did not differ relevantly. The time spent in the trauma room decreased from 77.9 min (pre-WBCT) to 63.3 min (WBCT). Following the introduction of the trauma scan, the number of diagnoses per patient increased from 4.6 to 5.1. The percentage of patients who underwent surgery immediately after the completion of trauma room procedures decreased from 44.5 to 39.1%. There was an increase in mortality from 15.7 to 15.9%. CONCLUSIONS: Routine use of WBCT is not superior to a combination of conventional radiography, ultrasound and focused CT in terms of mortality. The entire process involving the introduction of the trauma scan and the further development of algorithms has caused changes that can be observed in the trauma room setting.

[Treatment strategies for mass casualty incidents and terrorist attacks in trauma and vascular surgery : Presentation of a treatment concept]. / Versorgungsstrategien beim MANV/TerrorMANV in der Unfall- und Gefäßchirurgie : Darstellung eines Versorgungskonzeptes.

The treatment of patients in the context of mass casualty incidents (MCI) represents a great challenge for the participating rescue workers and clinics. Due to the increase in terrorist activities it is necessary to become familiar with this new kind of threat to civilization with respect to the medical treatment of victims of terrorist attacks. There are substantial differences between a "normal" MCI and a terrorist MCI with respect to injury patterns (blunt trauma vs. penetrating/perforating trauma), the type and form of the incident (MCI=static situation vs. terrorist attack MCI= dynamic situation) and the different security positions (rescue services vs. police services). This article is concerned with question of which changes in the surgical treatment of patients are made necessary by these new challenges. In this case it is necessary that physicians are familiar with the different injury patterns, whereby priority must be given to gunshot and explosion (blast) injuries. Furthermore, altered strategic and tactical approaches (damage control surgery vs. tactical abbreviated surgical care) are necessary to ensure survival for as many victims of terrorist attacks as possible and also to achieve the best possible functional results. It is only possible to successfully counter these new challenges by changing the mindset in the treatment of terrorist MCI compared to MCI incidents. An essential component of this mindset is the acquisition of a maximum of flexibility. This article would like to make a contribution to this problem.