Safe drilling zones for anteriorly, central, and posteriorly angulated syndesmotic stabilization devices.

PURPOSE: The purposes of the study were to (1) analyze the shape of the distal fibula at the location of syndesmotic stabilization and to (2) define safe zones at the distal-lateral fibula for three different drilling tunnel orientations: anteriorly-, posteriorly angulated and center-center. METHODS: Postoperative, bilateral CT images of adult patients that underwent syndesmotic stabilization (suture-button system) for an acute, unilateral ankle injury were analyzed. Manual axial CT reconstructions of the uninjured side were generated. First, the axial shape of the distal fibula was classified. The aspect ratio between the anterio-lateral and the posterior-lateral surfaces of the fibula was calculated to assess symmetry. Second, the same axial planes were used to define the safe zones. Each drilling-tunnel orientation (anterior, central, posterior) comprised a fixed medial tibial anchor point and a safe zone on the lateral fibula. For each of the three orientations, the most anteriorly and posteriorly drilling tunnel location was simulated. Next to a cumulative visual analysis, a quantitative analysis of the most anterior and posterior point on the anterio- and posterior-lateral surfaces was calculated. RESULTS: A total of 96 CT datasets were analyzed. (1) 81% of fibulae revealed a triangular convex-, 10% an irregular-, and 8% a quadrilateral shape. The lateral surface ratio was 1.0 ± 0.2 (range: 0.7-1.5), not differing between the fibula types (n.s.). (2) The safe corridor on the lateral surface of the fibula for an anteriorly angulated drilling tunnel was - 8% to - 41%, for a posteriorly angulated drilling tunnel was 0% to 46%, and for a center-center alignment - 7 ± 11% (range: - 28 to 18%). CONCLUSION: The meta-diaphyseal region of the distal fibula revealed a homogeneous crosssectional shape. The lateral apex of the fibula can serve as a landmark defining safe zones to place the drilling tunnels correctly. Applying these safe zones in clinical practice could help to avoid the misplacement of the syndesmotic fixation device. LEVEL OF EVIDENCE: Level III, retrospective radiographic study.

Pedobarographic evaluation of five commonly used orthoses for the lower extremity.

INTRODUCTION: Orthoses are designed to achieve immobilization or off-loading of certain regions of the foot. Yet, their off-loading capacity for the specific regions has not yet been studied. Therefore, the aim of this study was to analyze the plantar pressure distribution of five commonly applied orthoses for foot and ankle in a healthy population. MATERIALS AND METHODS: Five orthoses (postoperative shoe, forefoot relief shoe, short walker boot, high walker boot, and calcaneus fracture orthosis) were compared pedobarographically using insoles on a treadmill to a ready-made running shoe in eleven healthy subjects (median age 29 years). Peak pressure, maximum force, force-time integral, contact time, and contact area were evaluated separately for the forefoot, midfoot, and hindfoot. RESULTS: The forefoot relief shoe, the short- and high walker boot significantly reduced the peak pressure at the forefoot with no significant differences between these orthoses. None of the five orthoses off-loaded the midfoot, but the calcaneus fracture orthosis and the short walker boot instead increased midfoot load. For the hindfoot, the calcaneus fracture orthosis was the only device to significantly reduce the peak pressure. CONCLUSIONS: This is the first study to investigate the specific off-loading capacities of different orthoses for specific foot regions in a healthy collective. The knowledge of absolute and relative load shifts for the different orthoses is of fundamental interest for targeted clinical decision-making of physicians.

Immediate weight bearing without immobilization for operatively treated ankle fractures is safe - A systematic review.

BACKGROUND: This systematic literature review compared weight bearing (WB) vs. partial- / non-weight bearing (NWB) and mobilization (MB) vs. immobilization (IMB) for surgically treated ankle fractures. METHODS: Five databases were searched. Eligible were (quasi-)randomized controlled trials comparing at least two different postoperative treatment protocols. The risk of bias was assessed using the RoB-2 toolkit. The primary outcome was complication rate, secondary outcome Olerud and Molander Ankle Score (OMAS), range of motion (ROM), and return to work (RTW). RESULTS: Out of 10,345 studies, 24 papers were eligible. Thirteen studies (n = 853) compared WB/NWB, 13 studies (n = 706) MB/IMB with a moderate study quality. WB did not increase the risk for complications but resulted in superior short-term outcomes for OMAS, ROM, RTW. 12 studies found no inferior results for MB compared to IMB. CONCLUSION: Early and immediate WB and MB do not increase the complication rates but result in superior short term outcome scores. LEVEL OF EVIDENCE: Level I Systematic Review.

Pain levels during distraction osteogenesis with lengthening nails in 168 cases.

PURPOSE: To firstly examine the pain levels during distraction osteogenesis (DO) with lengthening nails (LN) in a large sample. METHODS: A total of 168 cases underwent DO of the tibia or femur with five different models of LN. Under a standardized medical regime, daily pain levels were noted as nominal rating scale (NRS) score (0-10) during the distraction phase. NRS scores and several potential influence factors (LN model, bone, approach, side, age, gender) were evaluated. RESULTS: The mean distraction length was 39.1 ± 14.4 mm. The average NRS score decreased from postoperative day 1 with 2.84 nonlinearly by 1.03 points (36.3%) over the course of 62 days to an average score of 1.81. The mean decrease during the first thirty days was 0.67(23.6%). Subgroup analysis did not reveal any influence factors. CONCLUSION: Pain levels during the distraction phase are overall low, continuously decreasing, and well manageable with mostly non-opioid analgesics.

High prevalence of missed information related on bone health in orthogeriatric patients with fragility fractures of the pelvis-an institutional register-based analysis.

This is the first study that highlighted the amount of missed information related on bone health in orthogeriatric patients suffering fragility fractures of the pelvis and also evaluated its prevalence and differing etiology in the assessed patients, regarding osteoporosis and/or osteomalacia, based on laboratory and instrumental measurements. This evaluation should become a standardized procedure in the treatment of orthogeriatric patients presenting with a FFP. INTRODUCTION: Fragility fractures of the pelvis (FFP) are common in orthogeriatric patients. Secondary fracture prevention regarding evaluation and treatment of an underlying osteoporosis or osteomalacia is still often neglected. The purpose of this study was to evaluate the amount of missed information related on bone health in older adult FFP patients, the prevalence of vitamin D deficiency in assessed patients, and if fracture type-dependent distribution patterns could be observed. METHODS: A retrospective analysis of prospectively collected data of an institutional register was performed. Patients aged 80 years and older (n = 456) admitted with a FFP from 01/2003 until 12/2019 to a level I trauma center were included. RESULTS: In 456 patients, FFP type II were leading (66.7%). Diagnostics were conducted in 37.1% of the patients regarding measurement of vitamin D levels and 21.7% regarding DXA measurements; vitamin D deficiency was observed in 62.7%, indicators for an underlying osteomalacia in 45.8%, and an osteoporosis in 46.5% of the assessed patients. CONCLUSION: Although FFP are common and will increase, there is still a lack of secondary fracture prevention, starting with information related on bone health. In the assessed patients, a high prevalence of vitamin D deficiency was present, but no significant correlation between vitamin D level and type of fracture was observed. Ongoing education for varying etiology and specific treatment of these fractures is necessary, as surgical treatment was unified, but drug therapy remains different.

Functional outcomes before and after implant removal in patients with posttraumatic shoulder stiffness and healed proximal humerus fractures: does implant material (PEEK vs. titanium) have an impact? - a pilot study.

BACKGROUND: Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR). METHODS: 16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR. RESULTS: In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%. CONCLUSION: There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material. LEVEL OF EVIDENCE: II.

[Transverse distraction osteogenesis : New chances for limb salvage?] / Transverse Kallusdistraktion : Neue Chancen für den Extremitätenerhalt?

Distraction osteogenesis (DO) is a technique that can be successfully used to treat leg length discrepancies and to reconstruct long defects of bone. By gradual distraction of the bone fragments by approximately 1 mm per day, hypervascularization and an increased bone healing potential (growth stimulus) occur. So far, DO has almost exclusively been used longitudinally to generate new biologically active bone. Chronic wounds, ulcers and osteitis, especially in the region of the foot, are always a challenge for the treating surgeon, since treatment is tedious, the outcome uncertain and associated with possible loss of the extremity. Transverse distraction osteogenesis (tDO) now uses the growth stimulus of the DO translationally to treat distally located, chronic wounds and thus leads to accelerated wound healing. At the end of the 5­week treatment, the transversely distracted fragment, located far proximal to the chronic wound, is back in its original location. The biological stimulus has a long-lasting effect, longer than the tDO itself. Further investigations into the mechanisms of action and treatment outcomes of tDO are required. If the previous results are confirmed, tDO may become a game changer and enable the limb salvage for a large proportion of findings that previously required amputation.

[Salvage options following failed total ankle arthroplasty]. / Revisionsmöglichkeiten nach gescheiterter Sprunggelenkprothese.

The number of patients with osteoarthritis of the ankle, which are treated by arthroplasty, has continuously increased in recent years. The survival time of these implants is far below the results following hip and knee arthroplasty. In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain. For the revision of an ankle prosthesis there are basically two treatment options. For a long time, ankle arthrodesis was considered the gold standard after a failed prosthesis. In recent years, there has been an increasing trend towards re-implantation of an ankle prosthesis, as this preserves the functionality and mobility of the ankle joint as far as possible. Depending on the reason for failure and the size of the bony defect, a decision must be made regarding a one-stage and a two-stage procedure with bone augmentation. This article presents the advantages and disadvantages of arthrodesis and revision arthroplasty after failed primary ankle arthroplasty and highlights the special features of surgery.

[Aftercare following surgical treatment of ankle fractures : What is the current state of knowledge?] / Nachbehandlung von operativ versorgten Sprunggelenkfrakturen : Was ist der aktuelle Wissensstand?

BACKGROUND: Ankle fractures are among the most common fractures in adults but often with unsatisfactory long-term results. In recent years several new surgical treatment approaches have been developed but little has changed regarding the aftercare. The postoperative treatment can be divided into two main components, weight bearing and mobilization. In Germany most patients are still recommended to be immobilized with partial weight bearing for 6 weeks after surgery. OBJECTIVE: The aim of this review is to present the current evidence on postoperative treatment based on an extensive literature search. MATERIAL AND METHODS: A total of seven prospective randomized controlled trials (RCT) compared early and delayed full weight bearing and six RCTs compared ankle mobilization with a form of immobilization. RESULTS: In none of these studies did early full weight bearing lead to an increased complication rate but some studies found a shortened time before return to work and, at least in the short term, better clinical results. Immediate mobilization led to an increased complication rate in only one out of six studies. It also appeared that mobilization led to a reduced time before return to work and, in the short term, to better clinical outcomes. The comparability of the studies was limited as in most cases different clinical scores and parameters were collated. In addition, information on patient age, fracture type, bone quality, comorbidities, and the implants used was often inadequate and post-treatment regimens sometimes differed significantly. CONCLUSION: The early functional therapy following surgically treated ankle fractures increased the rate of wound healing complications in only one of 13 studies, otherwise there were no significant differences in complication rates; however, early functional therapy partly shortened the time to return to work and led to better clinical results in the short term. For future studies, standardization of the parameters assessed would be important to provide clear evidence-based guidelines on follow-up treatment for specific fractures and patient populations.

[Reconstruction of large osteochondral defects of the distal femur and proximal tibia : Adaptation of fresh frozen allografts using 3D-printed models]. / Rekonstruktion großer osteochondraler Defekte des distalen Femurs und der proximalen Tibia : Anpassung frisch gefrorener Allografts unter Zuhilfenahme 3D-gedruckter Kunststoffmodelle.

The reconstruction of large osteochondral defects is still a challenge in musculoskeletal surgery. Fresh frozen allografts are a frequently used resource for the treatment of such tissue defects. Furthermore, 3D-printed models enable multiple options in the preoperative planning and intraoperative adaptation of the allografts, so that healing is optimal and the best functional outcome for the patient is achieved.

[Rotator cuff tear : Indications and pathology-specific reconstructive procedures]. / Rotatorenmanschettenruptur : Indikationen und pathologiespezifische rekonstruktive Verfahren.

Rotator cuff (RC) tears comprise a broad spectrum of lesions ranging from partial to full thickness tears of a single tendon and massive cuff tears. Both glenohumeral trauma as well as degenerative processes can result in tearing of the RC. Treatment therefore requires a meticulous diagnosis as well as a differentiated approach by careful consideration of morphological and patient-specific factors. The pathogenesis, tear morphology, clinical symptoms and functional demands of the patient determine the therapeutic approach. Despite pathological and individual patient-related factors, early surgical repair is generally recommended for traumatic RC tears in young patients and in patients with high functional demands due to the high risk of tear progression. The results of RC repair are negatively correlated with the size of the lesion, the number of tendons involved, the degree of tendon retraction, muscular alteration and patient age. This article provides an overview of the various pathogenesis, indications and surgical repair of RC tears with respect to modern pathology-specific reconstructive procedures.

[Unguis incarnatus-conservative or operative treatment? A practical treatment algorithm]. / Unguis incarnatus ­ konservative oder operative Therapie? Ein praktischer Behandlungsalgorithmus.

Unguis incarnatus, an ingrown toenail, is a common condition in primary care, which is encountered by various medical professions. Inconsistent conservative treatment and nonindicated surgical treatment often result in complications and recurrence of the disease. Patients must be thoroughly informed about the complexity of the nail organ. This is a prerequisite to prevent trivialization of the disease and to achieve appropriate patient compliance for treatment. In this article a practical diagnostic and treatment algorithm for unguis incarnatus is presented. In mild cases of acute unguis incarnatus a consistent conservative treatment is the first-line strategy showing promising results. In cases of moderate to severe forms of acute unguis incarnatus, surgical procedures that preserve the nail matrix should be applied. For cases of chronic unguis incarnatus without an acute infection, elective partial matrixectomy can be indicated. Prior to any surgical intervention, detailed informed consent must be obtained from the patients.

[Locking plate fixation of distal periprosthetic femoral fractures : Clinical outcome and mortality]. / Winkelstabile Plattenosteosynthese bei distalen periprothetischen Femurfrakturen : Klinisches Outcome und Mortalität.

BACKGROUND: The care of distal periprosthetic femoral fractures (PFF) is becoming a major interdisciplinary challenge due to demographic developments. The operative treatment is often performed (depending on the type of fracture) by means of locking plate fixation (LPF), although little data on the clinical outcome exist by now. The aim of the study is to identify risk factors for a poor outcome and increased mortality METHODS: In this retrospective study, 36 cases with distal PFF were examined. Exclusively treatment with LPF were included. Relevant previous illnesses (ASA score, Charlson index), fracture morphology and major complications were recorded as well as 1- and 3- year mortality. The clinical outcome was detected by using the Lysholm score. RESULTS: The 1- and 3- year mortality were 9% and 26% - exclusively affecting ASA 3 and 4 patients. The Lysholm Score showed a high variability (65 ± 27 points) with higher values in the ASA 1-2 subgroup (82 vs. 63 points) but independent of fracture type. The preoperative ASA score, the Charlson comorbidity index, and the patient age were determined to be decisive for 3-year mortality. CONCLUSION: This case series displayed a high absolute mortality even if the rate was slightly lower compared to previously published data. The rate of secondary dislocations, lack of fracture healing or follow-up operations were also low. The LPF therefore appears to be a suitable treatment for fractures with a stable prosthesis. However, there is a high variability in the clinical outcome regardless of the type of fracture and significantly increased mortality rates in previously ill patients.

Incidence of fractures in patients with type 1 diabetes mellitus-a retrospective study with 4420 patients.

This retrospective study investigated the incidence of fracture in 4420 type 1 diabetes (T1DM) patients. Our findings indicate that patients with T1DM have an increased incidence of fractures. Further studies and preventive measures are urgently needed. INTRODUCTION: The aim of this study was to investigate the incidence of fracture in patients with type 1 diabetes mellitus (T1DM). METHODS: This study is based on the German Disease Analyzer database and included 4258 adult individuals with a T1DM diagnosis documented between January 2000 and December 2015 in 1203 general practices in Germany. Individual matching of T1DM and non-diabetic patients was performed. The cumulative incidence of new fractures was shown for up to 10 years after the index date using Kaplan-Meier curves. Cox proportional hazard models (dependent variable: incident fracture) were used to estimate the effect of T1DM on fracture incidence, as well as the effect of predefined variables on fracture incidence. RESULTS: After 10 years of follow-up, the cumulative fracture incidence was 18.4% for T1DM patients and 9.9% for non-diabetic patients (p < 0.001). A strong association between T1DM and fractures was found (HR, 2.01 (95% CI, 1.70-2.38) p < 0.001) in both female and male patients. Significant differences between T1DM and non-diabetes patients were found in lower leg/ankle, foot and toe, shoulder/upper arm, and rib(s), sternum and thoracic spine fractures. A significant association between higher age and fracture incidence was observed in T1DM patients. CONCLUSIONS: In summary, we found that patients with T1DM have a twofold increased fracture rate compared with healthy controls. Furthermore, fractures were associated with increased age and high HbA1c values.

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery.

OBJECTIVES: Patients with recurrent instability after anterior cruciate ligament (ACL) reconstruction often present with enlarged or misplaced tunnels and bone grafting is required prior to the actual revision reconstruction. Autologous bone grafting features limited quantity and donor site morbidity. These problems may be eliminated utilizing cancellous bone allografts, but their efficiency and reliability have not been investigated systematically. The aim of the present study was to compare tunnel filling rates attained by utilizing either allogenic or autologous cancellous bone grafts. MATERIALS AND METHODS: A total of 103 consecutive patients were enrolled retrospectively. All patients suffered from recurrent instability and underwent either allogenic or autologous cancellous bone grafting. Computed tomography (CT) was carried out before and after the bone grafting procedure. Based on preoperative CT scans, positioning and maximum diameter of the femoral and tibial tunnels were determined. Tunnel filling rates were calculated as a ratio of pre- and postoperative tunnel volumes. Primary outcome was the tibial tunnel filling rate. Femoral filling rates and density of the grafted bone were assessed secondarily. RESULTS: Preoperative CT scans revealed no significant differences between the two groups regarding distribution of misplacement and widening of the femoral or tibial tunnel. Postoperative CT scans were conducted after an interval of 5.2 months. Tunnel filling rates of 74.5% (± 14.3) femoral and 85.3% (± 10.3) tibial were achieved in the allogenic compared to 74.3% (± 15.9) femoral and 84.9% (± 9.4) tibial in the autologous group. With p values of 0.85 at the femur and 0.83 at the tibia, there were no significant differences between the groups. The density of the grafted bone revealed significantly higher values in the allogenic group. CONCLUSIONS: Utilizing cancellous bone allografts in two-staged revision ACL surgery provides for sufficient and reproducible filling of enlarged or misplaced tunnels. The filling rates are comparable to those achieved with autologous bone grafting. Advantages of allografts are the unrestricted quantity and the absence of any harvesting procedure.

[Arthroscopically assisted fracture treatment and open reduction of the posterior malleolus : New strategies for management of complex ankle fractures. Video article]. / Arthroskopisch assistierte Frakturversorgung und offene Reposition des posterioren Malleolus : Neue Strategien zur Versorgung komplexer Sprunggelenksfrakturen. Videobeitrag.

OBJECTIVE: Identification and treatment of intra-articular injuries, stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus (PM). INDICATIONS: Bimalleolar and trimalleolar fractures, patients with functional demands. CONTRAINDICATIONS: Soft tissue injuries/infections in the area of the surgical approach, higher grade circulatory disorders, diabetes mellitus. SURGICAL TECHNIQUE: The video exemplarily depicts the arthroscopically assisted treatment (AORIF) of a trimalleolar fracture and ORIF of the PM via the dorsolateral approach. Positioning in an unstable lateral position, arthroscopy via standard ventral portals in external rotation, resection of interposing capsular ligamentous structures, removal of loose bodies, diagnosis and treatment of cartilage lesions. Dorsolateral approach dorsal to the peroneal tendons and incision of the fascia of the lateral and deep lower leg compartments, retraction of the flexor hallucis longus muscle medially, visualization of the PM, reduction and fixation with an antiglide plate. Development of a full thickness flap above the superficial fascia to visualize the lateral malleolus, fixation according to AO principles. Repositioning to the supine position without changing the sterile covers, medial approach for fixation of the medial malleolus, stability testing of the distal tibiofibular joint, final arthroscopy, and wound closure. FOLLOW-UP: Cooling and elevation, 6 weeks of partial weight-bearing (20 kg), early functional exercises, full weight-bearing after clinical radiological follow-up at 6 weeks postoperatively. RESULTS: It is known that relevant chondral injuries frequently occur in complex ankle fractures and that ORIF of the PM leads to stabilization of the distal tibiofibular joint. So far only few clinical results have been published regarding AORIF and ORIF of the PM; however, the majority of the studies available found significantly better results for AORIF and ORIF of the posterior malleolus compared to conventional treatment.

[Gluteal compartment syndrome after immobilization following opioid abuse]. / Gluteales Kompartmentsyndrom nach Liegetrauma bei Opiatabusus.

This article reports the case of a 42-year-old male patient, who sustained a gluteal compartment syndrome after drug-induced immobilization with subsequent rhabdomyolysis and sciatic nerve palsy. Unlike compartment syndrome of the forearm or lower leg, this is a rare condition. After immediate surgical decompression and installation of negative pressure wound treatment, hemofiltration in acute renal failure could be averted using forced diuresis. The sensorimotor function of the lower extremity improved already after the first treatment and secondary wound closure was possible after 1 week. The patient was discharged 11 days after admission with complete recovery of sensorimotor and renal functions.

On-the-Scene Hyaluronan and Syndecan-1 Serum Concentrations and Outcome after Cardiac Arrest and Resuscitation.

BACKGROUND: It is not predictable which patients will develop a severe inflammatory response after successful cardiopulmonary resuscitation (CPR), also known as "postcardiac arrest syndrome." This pathology affects only a subgroup of cardiac arrest victims. Whole body ischemia/reperfusion and prolonged shock states after return of spontaneous circulation (ROSC) may both contribute to this devastating condition. The vascular endothelium with its glycocalyx is especially susceptible to initial ischemic damage and may play a detrimental role in the initiation of postischemic inflammatory reactions. It is not known to date if an immediate early damage to the endothelial glycocalyx, detected by on-the-scene blood sampling and measurement of soluble components (hyaluronan and syndecan-1), precedes and predicts multiple organ failure (MOF) and survival after ROSC. METHODS: 15 patients after prehospital resuscitation were included in the study. Serum samples were collected on the scene immediately after ROSC and after 6 h, 12 h, 24 h, and 48 h. Hyaluronan and syndecan-1 were measured by ELISA. We associated the development of multiple organ failure and 30-day survival rates with these serum markers of early glycocalyx damage. RESULTS: Immediate serum hyaluronan concentrations show significant differences depending on 30-day survival. Further, the hyaluronan level is significantly higher in patients developing MOF during the initial and intermediate resuscitation period. Also, the syndecan-1 levels are significantly different according to MOF occurrence. CONCLUSION: Serum markers of glycocalyx shedding taken immediately on the scene after ROSC can predict the occurrence of multiple organ failure and adverse clinical outcome in patients after cardiac arrest.

[Influence of massive blood transfusion and traumatic brain injury on TIMP­1 and MMP­9 serum levels in polytraumatized patients]. / Der Einfluss von Massentransfusion und Schädel-Hirn-Trauma auf die Seruminflammationsmarker TIMP­1 und MMP­9 bei polytraumatisierten Patienten.

BACKGROUND: The morbidity and mortality of polytrauma patients are substantially influenced by the extent of the posttraumatic inflammatory reaction. Studies have shown that TIMP­1 and MMP­9 play a major role in posttraumatic immune disorder in genome-wide mRNA microarray analyses. Furthermore, both showed differential gene expression profiles depending on the clinical parameters massive blood transfusion and traumatic brain injury. OBJECTIVE: The aim of this study was to evaluate TIMP­1 and MMP­9 serum concentrations in polytraumatized patients depending on the clinical parameters massive blood transfusion and traumatic brain injury in the early posttraumatic phase. MATERIAL AND METHODS: Polytrauma patients (≥18 years) with an "Injury Severity Score" (ISS) ≥ 16 points were enrolled in this prospective study. Serum levels of TIMP­1 and MMP­9 were quantified (at 0 h, 6 h, 12 h, 24 h, 48 h and 72 h) using an enzyme-linked immunosorbent assay (ELISA). Groups were divided according to the clinical parameter massive blood transfusion (≥10 red blood cell units [RBC units] in the first 24-hour posttrauma) and traumatic brain injury (CCT postive [cranial computed tomography]). RESULTS: Following massive blood transfusion (n = 21; 50 ± 15.7 years; ISS 39 ± 12.8 points) patients showed overall significantly increased TIMP­1 levels (p = 0.003) and significantly higher TIMP­1 values after 12-72 h. Traumatic brain injury patients (n = 28; 44 ± 19 years; ISS 42 ± 10 points) showed significantly higher MMP­9 levels (p = 0.049) in the posttraumatic period. CONCLUSION: Polytraumatized patients who received massive blood transfusions following major trauma showed significantly higher TIMP­1 levels than patients who did not receive massive transfusions. This seems to be an expression of a massively excessive inflammatory reaction and therefore represents a substantial factor in the pathogenesis of severe posttraumatic immune dysfunction in this collective. Furthermore, the significant increase in MMP­9 with accompanying traumatic brain injury reflects the pivotal role of matrix metalloproteinases in the pathophysiology of traumatic brain injury.

[Minimally invasive treatment of serial metatarsal fractures by antegrade intramedullary K­wire osteosynthesis]. / Minimal-invasive Versorgung von Metatarsale-Serienfrakturen durch antegrade intramedulläre K­Draht-Osteosynthesen.

Serial fractures of metatarsal bones are rare and usually caused by direct or indirect high-energy trauma; however, in cases of pre-existing diseases, such as diabetes mellitus, they also can occur spontaneously or as insidious fractures. Due to the substantial soft tissue swelling mostly associated with such injuries, minimally invasive osteosynthesis with intramedullary Kirschner-wires (K­wires) is recommended. The antegrade technique for placement of the K­wires is preferred as the technically simpler retrograde procedure has several significant disadvantages. The preferred operative approach is described in detail exemplified by two clinical cases.