Implementation of health-related quality of life in the German TraumaRegister DGU® - first results of a pilot study.

BACKGROUND: Approximately 30,000 people are affected by severe injuries in Germany each year. Continuous progress in prehospital and hospital care has significantly reduced the mortality of polytrauma patients. With increasing survival rates, the functional outcome, health-related quality (hrQoL) of life and ability to work are now gaining importance. Aim of the study is, the presentation of the response behavior of seriously injured patients on the one hand and the examination of the factors influencing the quality of life and ability to work 12 months after major trauma on the other hand. Building on these initial results, a standard outcome tool shall be integrated in the established TraumaRegister DGU® in the future. METHODS: In 2018, patients [Injury Severity Score (ISS) ≥ 16; age:18-75 years] underwent multicenter one-year posttraumatic follow-up in six study hospitals. In addition to assessing hrQoL by using the Short-Form Health Survey (SF-12), five additional questions (treatment satisfaction; ability to work; trauma-related medical treatment; relevant physical disability, hrQoL as compared with the prior to injury status) were applied. RESULTS: Of the 1,162 patients contacted, 594 responded and were included in the analysis. The post-injury hrQoL does not show statistically significant differences between the sexes. Regarding age, however, the younger the patient at injury, the better the SF-12 physical sum score. Furthermore, the physically perceived quality of life decreases statistically significantly in relation to the severity of the trauma as measured by the ISS, whereas the mentally perceived quality of life shows no differences in terms of injury severity. A large proportion of severely injured patients were very satisfied (42.2%) or satisfied (39.9%) with the treatment outcome. It should be emphasized that patients with a high injury severity (ISS > 50) were on average more often very satisfied with the treatment outcome (46.7%). A total of 429 patients provided information on their ability to work 12 months post-injury. Here, 194 (45.2%) patients had a full employment, and 58 (13.5%) patients were had a restricted employment. CONCLUSION: The present results show the importance of a structured assessment of the postinjury hrQoL and the ability to work after polytrauma. Further studies on the detection of influenceable risk factors on hrQoL and ability to work in the intersectoral course of treatment should follow to enable the best possible outcome of polytrauma survivors.

Musculus psoas major morphology - a novel predictor of mortality in elderly polytraumatized patients.

INTRODUCTION: Numerous papers in different fields have already shown that CT imaging of the Musculus Psoas Major (MPM) can be used to predict patient outcome. Unfortunately, most of the methods presented in the literature are very complex and not easy to perform in the clinic. Therefore, the objectives of the study were to introduce a novel and convenient method for measuring the MPM to trauma surgeons and to prove the association between MPM morphology and mortality in elderly polytraumatized patients. MATERIAL AND METHODS: The retrospective outcome study was conducted at our level I trauma center. All patients admitted from 2006 to 2020 were included if they (1) presented with multiple injuries (≥2 body regions) and an Injury Severity Score (ISS) ≥16, (2) were at least 65 years of age, and (3) were diagnosed using a whole-body computed tomography. Subsequently, the ratios of short-axis to long-axis of both MPM were measured, and their mean value was evaluated as a candidate predictor of 31-day mortality. RESULTS: Our study group consisted of 158 patients (63.3% male; median age, 76 years; median ISS, 25). In the survivors (55.7%), the mean MPM score was significantly higher compared to the fatalities (0.57 versus 0.48; p < 0.0001). Multivariate binary logistic regression analysis identified the MPM score as a protective predictor of 31 day-mortality (OR = 0.92, p < 0.001), whereas age (OR 1.08, p = 0.002 and ISS (OR 1.06, p = 0.006) revealed as significant risk factors for mortality. ROC statistics provided an AUC = 0.724 (p < 0.0001) and a cut-off level of 0,48 (sensitivity, 80.7%; specificity, 54.3%). CONCLUSION: The present study demonstrated that MPM score levels lower than 0.48 might be considered an additional tool to identify elderly patients at high risk of death following major trauma. In our opinion, the assessment of the MPM score is an easy, convenient, and intuitive method to gain additional information quickly after admission to the hospital that could be implemented without great effort into daily clinical practice.

25-Year experience with adult polytraumatized patients in a European level 1 trauma center: polytrauma between 1995 and 2019. What has changed? A retrospective cohort study.

PURPOSE: To analyze the changes of the clinical characteristics, injury patterns, and mortality rates of polytraumatized patients within the past 25 years in a European Level I trauma center. METHODS: 953 consecutive polytraumatized patients treated at a single-level 1 trauma center between January 1995 and December 2019 were enrolled retrospectively. Polytrauma was defined as AIS ≥ 3 points in at least two different body regions. Retrospective data analysis on changes of clinical characteristics and mortality rates over time. RESULTS: A significant increase of the average age by 2 years per year of the study could be seen with a significant increase of geriatric patients over time. No changes of the median Injury Severity Score (ISS) could be seen over time, whereas the ISS significantly decreased by patient's year. The rates of concomitant severe traumatic brain injury (TBI) remained constant over time, and did not increase with rising age of the patients. Although, the mortality rate remained constant over time the relative risk of overall in-hospital mortality increased by 1.7% and the relative risk of late-phase mortality increased by 2.2% per patient's year. CONCLUSION: The number of polytraumatized patients remained constant over the 25-year study period. Also, the mortality rates remained stable over time, although a significant increase of the average age of polytraumatized patients could be seen with stable injury severity scores. Severe TBI and age beyond 65 years remained independent prognostic factors on the late-phase survival of polytraumatized patients. TRIAL REGISTRATION: NCT04723992. LEVEL OF EVIDENCE: Prognostic study, level III.

Circulating Myostatin Levels Decrease Transiently after Implantation of a Hip Hemi-Arthroplasty.

INTRODUCTION: Muscle and bone metabolism are both important for the healing of fractures and the regeneration of injured muscle tissue. The aim of this investigation was to evaluate myostatin and other regulating factors in patients with hip fractures who underwent hemi-arthroplasty. METHODS: Serum levels of myostatin (MSTN), follistatin (FSTN), dickkopf-1 (Dkk1), and periostin (PSTN) as well as markers of bone turnover were evaluated in patients with hip fractures before surgery and twice in the 2 weeks after surgery. These parameters were also evaluated in age- and gender-matched subjects without major musculoskeletal injury. RESULTS: MSTN was transiently reduced; its opponent FSTN was transiently increased. Dkk1, the negative regulator of bone mass, and PSTN, a marker of subperiosteal bone formation, increased after surgery. With regard to markers of bone turnover, resorption was elevated during the entire period of observation whereas the early bone formation marker N-terminal propeptide of type I collagen was elevated 12 days after surgery. CONCLUSIONS: Unexpectedly, MSTN, a negative regulator of muscle growth, was reduced after surgery compared with before surgery. As musculoskeletal markers are altered during bone healing, they do not reflect general bone metabolism after fracture or joint arthroplasty. This is important because many elderly patients receive treatment for osteoporosis.

Acetabular Revision With Intramedullary and Extramedullary Iliac Fixation for Pelvic Discontinuity.

BACKGROUND: Parallel to the increase in revision hip procedures surgeons face more and more complex anatomical challenges with pelvic discontinuity (PD) being one of the worst-case scenarios. Here we report on our clinical results using an asymmetric acetabular component for the treatment of PD. The implant is armed in a monoblock fashion with an extramedullary iliac flange and provides the possibility to augment it with an intramedullary iliac press-fit stem. METHODS: In a single-center retrospective cohort study we analyzed prospectively collected data of 49 patients (35 female, 14 male) suffering from unilateral periprosthetic PD treated with an asymmetric acetabular component between 2009 and 2017. The mean follow-up was 71 months (21-114). Complications were documented and radiographic and functional outcomes were assessed. RESULTS: Kaplan-Meier analysis revealed a 5-year implant survival of 91% (confidence interval 77%-96%). The 5-year survival with revision for any cause was 87% (CI 74%-94%). The overall revision rate was 16% (n = 8). Two patients required acetabular component revision due to aseptic loosening. Four patients (8%) suffered from periprosthetic infection: one patient was treated with a 2-stage revision, and another one with resection arthroplasty. The other 2 patients were treated with debridement, irrigation, and exchange of the mobile parts. Of 6 patients (12%) suffering from hip dislocation, 2 required implantation of a dual mobility acetabular component. The mean Harris Hip Score improved from 41 preoperatively to 79 at the latest follow-up (P < .001). CONCLUSION: Our findings demonstrate that an asymmetric acetabular component with extramedullary and optional intramedullary iliac fixation is a reliable and safe treatment method for periprosthetic PD resulting in good clinical and radiographic mid-term results.

Failed Two-Stage Exchange: Factors Leading to Unachievable Endoprosthetic Reconstruction After Multiple Revision Surgeries.

BACKGROUND: Information about the outcome after failed 2-stage exchange is scarce. The aim of this study is to determine possible influencing factors leading to multiple revisions, resulting in a failed endoprosthetic joint reconstruction. METHODS: Medical records of patients (15 hip and 29 knee joints) who had undergone additional revision surgeries due to a failed 2-stage exchange were reviewed concerning infection parameters, number and type of procedure(s), current state of the revised joint, and whether failure of endoprosthetic reconstruction had occurred. RESULTS: Endoprosthetic reconstruction was achieved in 52.3% (n = 23) of the patients. About 36.4% (n = 16) of patients successfully reached the second stage of the initial 2-stage exchange. Half of the patients (n = 22) had to undergo spacer exchange in the initial interstage period. Five or more revision surgeries significantly increased the odds of failure of endoprosthetic reconstruction compared to patients with <5 revision surgeries (odds ratio 4.98, 95% confidence interval 1.34-18.4, P = .016). Patients with initial culture-negative revision surgery showed no significant differences in the odds of failure of endoprosthetic reconstruction (odds ratio 0.69, 95% confidence interval 0.20-2.43, P = .567). CONCLUSION: Patients undergoing re-revision surgery due to a failed 2-stage exchange are very likely to ultimately experience a failed endoprosthetic reconstruction. The identification of the underlying pathogen does not influence the likelihood of a better outcome in terms of a successful endoprosthetic reconstruction.

Periprosthetic femoral fractures--incidence, classification problems and the proposal of a modified classification scheme.

INTRODUCTION: The increasing incidence of periprosthetic fractures correlates directly with the year-after-year increasing frequency of primary joint replacement surgery. The most common fracture localisation is the femur. The undisputed leader in frequency is the fracture that occurs around a total hip arthroplasty. Unfortunately, no general epidemiologic data exist dealing with exact fracture incidence numbers. Furthermore, existing classifications are lacking important information like time point of fracture occurrence, type of the implanted prosthesis and implantation technique (cemented vs. cementless). Additionally, information about mechanical quality of the bone structure and the fracture type are also missing in part. METHODS: We scanned the literature for adequate and widely used classifications in the field of hip and knee arthroplasty. In a next step we analyzed those classification systems in order to find out to what extent they are able to describe the specific aspects of the fracture event. Therefore we compared the existing classifications and presented their most relevant emphasis. Furthermore, we looked at our own patient population to evaluate incidence of fracture occurrence over time and percentage of loosened components. RESULTS: The existing classification systems address themselves specifically to the task of describing fracture localization and to some extent fracture type, or combine these two in order to calculate the possibility of loosening of the implanted prosthesis. Some of the important criteria like mechanical quality of the bone stock, primary implantation technique or time point of the prosthesis loosening (prior to or because of the fracture) remain ignored. The incidence of periprosthetic femur fractures at our department increased approximately 2.5 fold over the past two decades. The risk of suffering from a periprosthetic fracture was substantially higher after THA than after TKA. We observed a loose femoral component of the THA in about 45 % of the cases. Finally, we postulate the application of a modified classification for periprosthetic fractures as an alternative to the already published ones; not only for the femur, but also universally for all joints with an arthroplasty. CONCLUSION: The classification that is introduced in this study allows, in our opinion, a differentiated reflection of the given post-traumatic pathologic changes and enables the description of the fracture itself according to a generally accepted fracture classification scheme.

Surgical site infection after trochanteric and subtrochanteric fractures: a single centre retrospective analysis.

Surgical site infection (SSI) following osteosynthesis of trochanteric or subtrochanteric fractures is a rare but serious complication with incidence rate ranging from 1 to 3%. SSIs are associated with higher mortality and increased length of hospital stay resulting in higher healthcare costs and loss of life quality. In this retrospective analysis all patients with SSI following osteosynthesis of trochanteric or subtrochanteric fractures at the Department of Trauma Surgery were identified. We included all surgical procedures performed from 1992 to 2018, using data from electronic health records and SSI-Trauma-Registry. The aim was to describe epidemiological data, as well as to identify parameters correlating with the occurrence of SSI and mortality. Of 2753 patients, 53 (1.9%) developed SSI. Longer operative time was demonstrated among patients with SSI (P = 0.008). Mortality during the first postoperative year was significantly higher in the SSI group (32.1% vs. 19.1%; P = 0.018), with detection of methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA; HR 4.13, CI 95% 1.24-13.80; P = 0.021) or Enterococcus spp. (HR 5.58, CI 95% 1.67-18.65; P = 0.005) being independent risk factors. Male sex (HR 2.25, 95% CI 1.86-2.73; P < 0.001) and higher mean age (HR 1.05, 95% CI 1.04-1.06; P < 0.001) were found to be predictors for 1-year mortality in non-infected patients. SSI rate was low with 1.9% and longer duration of surgery was associated with infection. Patients with SSI had a higher 1-year mortality, with detection of MSSA, MRSA and enterococci significantly increasing the risk of dying. Male sex and higher age were risk factors for one-year mortality in patients without SSI.

Red blood cell distribution width and Charlson comorbidity index help to identify frail polytraumatized patients : Experiences from a level I trauma center.

INTRODUCTION: Little is known about the potential impact of the red blood cell distribution width (RDW) and pre-existing comorbidities on the late-phase survival of polytraumatized patients. METHODS: A total of 173 polytraumatized patients were included retrospectively in this cohort study in a level I trauma center from January 2012 to December 2015. The Charlson comorbidity index (CCI) scores and RDW values were evaluated. RESULTS: Out of all polytraumatized patients (n = 173), 72.8% (n = 126) were male, the mean ISS was 31.7 points (range 17-75) and the mean age was 45.1 years (range 18-93 years). Significantly higher RDW values (13.90 vs. 13.37; p = 0.006) and higher CCI scores (3.38 vs. 0.49; p < 0.001) were seen in elderly polytraumatized patients (age > 55 years). RDW values > 13.75% (p = 0.033) and CCI scores > 2 points (p = 0.001) were found to have a significant influence on the late-phase survival of polytraumatized patients. Age > 55 years (p = 0.009, HR 0.312; 95% confidence interval (CI) 0.130-0.749) and the presence of severe traumatic brain injury (TBI) (p = 0.007; HR 0.185; 95% CI 0.054-0.635) remained as independent prognostic factors on the late-phase survival after multivariate analysis. CONCLUSION: Even younger elderly polytraumatized patients (> 55 years of age) showed significant higher RDW values and higher CCI scores. In addition to the presence of severe TBI and age > 55 years, RDW value > 13.75% on admission and CCI score > 2 might help to identify the "younger" frail polytraumatized patient at risk.

Custom Made Monoflange Acetabular Components for the Treatment of Paprosky Type III Defects.

PURPOSE: Patient-specific, flanged acetabular components are used for the treatment of Paprosky type III defects during revision total hip arthroplasty (THA). This monocentric retrospective cohort study analyzes the outcome of patients treated with custom made monoflanged acetabular components (CMACs) with intra- and extramedullary iliac fixation. METHODS: 14 patients were included who underwent revision THA with CMACs for the treatment of Paprosky type III defects. Mechanism of THA failure was infection in 4 and aseptic loosening in 10 patients. Seven patients underwent no previous revision, the other seven patients underwent three or more previous revisions. RESULTS: At a mean follow-up of 35.4 months (14-94), the revision rate of the implant was 28.3%. Additionally, one perioperative dislocation and one superficial wound infection occurred. At one year postoperatively, we found a significant improvement of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (p = 0.015). Postoperative radiographic analysis revealed good hip joint reconstruction with a mean leg length discrepancy of 3 mm (-8-20), a mean lateralization of the horizontal hip center of rotation of 8 mm (-8-35), and a mean proximalization of the vertical hip center of rotation of 6 mm (13-26). Radiolucency lines were present in 30%. CONCLUSION: CMACs can be considered an option for the treatment of acetabular bone loss in revision THA. Iliac intra- and extramedullary fixation allows soft tissue-adjusted hip joint reconstruction and improves hip function. However, failure rates are high, with periprosthetic infection being the main threat to successful outcome.

Does the applied polytrauma definition notably influence outcome and patient population? - a retrospective analysis.

BACKGROUND: Although the term "polytrauma" has been in use for decades, no generally accepted definition exists. The aim of this study was to demonstrate that different polytrauma definitions applied to a specific patient population result in diverse subgroups of individuals, who in turn present a varying outcome. METHODS: All patients (≥18 years) treated at our level I trauma center within a time period of three years were classified according to 11 selected polytrauma definitions and included in our study, if they were rated "polytraumatized" by at least one of these definitions. All patients, who met the criteria of a certain definition, were combined to the relevant definition-positive group, thus resulting in 11 patient subgroups. Their demographic data (number of patients, mean patient age, mean Injury Severity Score value, median number of ventilator days, median length of stay at the intensive care unit and at the hospital, mortality rate and odds ratio) were statistically compared. RESULTS: Three hundred seventy-five patients (73% male) with a mean age of 47 years met the inclusion criteria and were allocated to the relevant subgroups; their patient number varied from 55 to 346 and their mean Injury Severity Score value ranged from 4 to 75. Not surprisingly, all examined parameters were subject to variations. Whereas most definition-positive groups showed a mortality rate of about 21% to 30%, 18% of the individuals, who met the criteria according to Blacker, and 40% of the polytrauma victims according to Schalamon died. The Pape 1-, Schalamon-, and Berlin-positive groups presented a significant odds ratio with regard to mortality that considerably exceeded 1. DISCUSSION: A polytrauma definition can only be a reliable tool in classifying trauma victims if it provides a significant odds ratio with regard to mortality that considerably exceeds 1 and if it succeeds in capturing patients with multiple severe injuries and a higher mortality rate without reducing the number of polytraumatized patients to a not representatively small number. CONCLUSIONS: Solely the Berlin definition resulted in a patient number reflecting clinical reality, thus enabling a transparent evaluation of treatment results provided by different institutions and allowing objective comparison of published studies.