[Evaluation of the current research structures in trauma surgery : A survey of the scientific committee of the German Society for Trauma Surgery]. / Erhebung der Forschungsstrukturen in der Unfallchirurgie : Eine Umfrage des Wissenschaftsausschusses der DGU.

BACKGROUND: To improve research in orthopedics and traumatology (O&T) in Germany, the implementation of comprehensive research collaborations and enhanced communication pathways among different institutions are necessary. This survey was initiated to collect data regarding the current research structures in O&T. MATERIAL AND METHODS: A subject-specific questionnaire was sent via email to collect data regarding demographics, on-going and past research activities and the funding. Naming of current and future research topics and problems regarding realization of projects were determined. All results were submitted electronically, anonymously and voluntarily. RESULTS: Of 229 participants, 83% worked as clinicians and 59.6% of the participants were working in departments with joint structures (O&T). Industry and universities were found to be the essential funding sources. Future research topics tend to concentrate on digital health issues (artificial intelligence, big data, 3D-printing). Resource scarcity in time and staff as well as administrative barriers but also insufficient funding were identified as major impediments of research activity. CONCLUSION: Future research development in O&T will cause an expansion of techniques and methods. At the same time aggravated personnel, financial, administrative and legal framework conditions can only be managed with an intensively increased effort. Cooperation projects and collaborative research structures might be a solution to these challenges.

Hematological and Chemical Profiles in a Porcine Model of Severe Multiple Trauma.

BACKGROUND: Clinical chemistry and hematological tests are widely used to monitor the clinical course of several diseases. However, these parameters are sparse in large-animal models of multiple trauma (MT). Thus, we aimed to provide these missing data to improve future experimental setups in trauma research. METHODS: Male pigs (German Landrace pigs) were randomized into either an MT group (n = 8) including blunt thoracic trauma, tibial fracture, and controlled hemorrhage or a sham group (n = 8) without any trauma. After trauma induction, all animals received intensive care treatment for 72 h under anesthesia, including mechanical ventilation and volume resuscitation. Blood and urine samples were obtained to measure common hematological and chemical parameters before trauma (0 h), after trauma (1.5 h), during resuscitation (2.5 h), after fracture stabilization (3.5 h), and at 12, 24, 48, and 72 h. Statistical analyses were performed using a linear mixed model (group × time) and Welch's ANOVA. RESULTS: MT led to a perceptible immunological reaction. Between groups, significantly different time courses of leukocyte counts (p = 0.034) and lymphocyte proportions (p = 0.001) were observed. Moreover, MT changed the time course of total protein (p = 0.006). Significantly lower concentrations compared to sham were found in MT at each single time point starting at 1.5 h to the end of the observation period (all p < 0.05). CONCLUSIONS: Our results indicate that a traumatic insult leads to significant alterations in the immune system already shortly after trauma. Together with the additional catabolic reactions observed, these alterations might contribute to the occurrence of later complications. The presented data provide valid references for further experimental setups with prolonged observation times, especially in similar porcine models of MT.

Geriatric Polytrauma-Cardiovascular and Immunologic Response in a Murine Two-Hit Model of Trauma.

BACKGROUND: The aims of the present study were to establish a clinically relevant two-hit model with trauma/hemorrhage followed by sepsis in older mice and investigate age-dependent cardiovascular and immunologic specificities under these conditions. MATERIALS AND METHODS: In aged mice (12, 18, and 24 mo old), a femur fracture followed by hemorrhage was induced. After resuscitation, animals were monitored for 72 h before sepsis was induced. Vital signs were monitored during shock. Systemic interleukin (IL)-6 levels were measured daily. Expression of sarcoplasmic or endoplasmic reticulum calcium ATPase (SERCA) and IL-6 receptor were analyzed in heart, lung, and liver tissues. RESULTS: After induction of shock, mean arterial pressure decreased significantly in all groups (12 mo, P < 0.001; 18 mo, P < 0.001; 24 mo, P = 0.013). Compared with younger animals, 24-mo old mice were not able to adequately compensate for hypovolemia by an increase of heart rate (P = 0.711). Expression of SERCA2 (P = 0.002) and IL-6 receptor on myocytes (P = 0.037), lung (P = 0.005), and liver (P = 0.009) tissues were also lowest in this group. Systemic IL-6 values showed the most distinct posttraumatic response in 24-mo-old mice (P = 0.016). Survival rate decreased significantly with increased age (P = 0.005). CONCLUSIONS: The increased mortality rate in older animals was associated with a limited compensatory physiological response and a more distinct immunologic reaction after trauma and sepsis. A decreased SERCA2 expression and missing feedback loops due to a reduced density of organ bound immune receptors might represent possible explanations for the observed age-dependent differences.

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

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

Muscular changes after minimally invasive versus open spinal stabilization of thoracolumbar fractures: A literature review.

PURPOSE: This review addressed the question of whether minimally invasive surgery after traumatic thoracolumbar spine fractures can reduce paraspinal muscle injury, limit changes in muscular structure and function, and lead to better functional outcome. Special emphasis was given to studies using imaging techniques or electromyography to evaluate the lumbar multifidus muscle structure and function. METHODS: The authors searched the literature in the PubMed/Medline, EMBASE, by cross-referencing and additional hand search. Included were comparative studies between conventional open and minimally invasive or percutaneous surgical approaches. Twelve studies were included. RESULTS AND CONCLUSIONS: The literature review supports the assumption that minimally invasive surgery preserves muscles for the early post-operative period, even though the level of evidence is still low. The correlation of changes in muscular structure to pain, strength, disability, and quality of life remains ambiguous and should be addressed in further studies with a focus on the surgical approach.

Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation.

OBJECTIVES: To reduce mechanical complications after osteosynthesis of femoral neck fractures, improved fixation techniques have been developed including blade or screw-anchor devices. This biomechanical study compares different fixation systems used for treatment of unstable femoral neck fractures with evaluation of failure mode, load to failure, stiffness, femoral head rotation, femoral neck shortening and femoral head migration. METHODS: Standardized Pauwels type 3 fractures (AO/OTA 31-B2) with comminution were created in 18 biomechanical sawbones using a custom-made sawguide. Fractures were stabilized using either SHS-Screw, SHS-Blade or Rotationally Stable Screw-Anchor (RoSA). Femurs were positioned in 25 degrees adduction and ten degrees posterior flexion and were cyclically loaded with an axial sinusoidal loading pattern of 0.5 Hz, starting with 300 N, with an increase by 300 N every 2000 cycles until bone-implant failure occurred. RESULTS: Mean failure load for the Screw-Anchor fixation (RoSA) was 5100 N (IQR 750 N), 3900 N (IQR 75 N) for SHS-Blade and 3000 N (IQR 675 N; p = 0.002) for SHS-Screw. For SHS-Screw and SHS-Blade we observed fracture displacement with consecutive fracture collapse as the main reason for failure, whereas RoSA mainly showed a cut-out under high loadings. Mean stiffness at 1800 N was 826 (IQR 431) N/mm for SHS-Screw, 1328 (IQR 441) N/mm for SHS-Blade and 1953 (IQR 617) N/mm for RoSA (p = 0.003). With a load of 1800 N (SHS-Screw 12° vs. SHS-Blade 7° vs. RoSA 2°; p = 0.003) and with 2700 N (24° vs. 15° vs. 3°; p = 0.002) the RoSA implants demonstrated a higher rotational stability and had the lowest femoral neck shortening (p = 0.002), compared with the SHS groups. At the 2700 N load point, RoSA systems showed a lower axial (p = 0.019) and cranial (p = 0.031) femoral head migration compared to the SHS-Screw. CONCLUSIONS: In our study, the new Screw-Anchor fixation (RoSA) was superior to the comparable SHS implants regarding rotational stability and femoral neck shortening. Failure load, stiffness, femoral head migration, and resistance to fracture displacement were in RoSA implants higher than in SHS-Screws, but without significance in comparison to SHS-Blades.

Evaluation of severe and fatal injuries in extreme and contact sports: an international multicenter analysis.

PURPOSE: The participation in extreme and contact sports has grown internationally, despite the significant risk for major and multiple injuries. We conducted this multicenter study to evaluate sport-specific injury patterns and mechanisms, to characterize individuals at risk and to identify possible approaches for prevention. METHODS: We compared demographic data, severity and patterns of injuries; and the pre- and in-hospital management from an international population-based prospective trauma database (TraumaRegister DGU®). The registry was screened for sport-related injuries, and only patients with major injuries [Injury Severity Score (ISS) ≥ 9 points] related to extreme or contact sports activities were included (January 1, 2002, to December 31, 2012). Parameters were compared for different types of sports activities: (1) Airborne sports, (2) Climbing, (3) Skateboarding/Skating, (4) Contact sports. The following countries participated: Germany, Austria, Switzerland, Finland, Slovenia, Belgium, Luxembourg, and The Netherlands. Statistical analyses were performed with SPSS (Version 22, IBM Inc., Armonk, New York). RESULTS: A total of 278 athletes were identified within the study period and classified into four groups: Airborne sports (n = 105) were associated with the highest injury severity (ISS 22.4 ± 14.6), followed by climbing (n = 35, ISS 16.5 ± 12), skating (n = 67, ISS 15.2 ± 10.3) and contact sports (n = 71, ISS 10.4 ± 9.2). Especially high falls resulted in a significant rate of spinal injuries in airborne activities (68.6%, p < 0.001) and in climbing accidents (45.7%). Skating was associated with the highest rate of loss of consciousness (LOC) at scene (27.1%), the highest pre-hospital intubation rate (33.3%), and also the highest in-hospital mortality (15.2%, p < 0.001), related to major head injuries. CONCLUSIONS: Extreme and contact sports related major injuries predominantly affect young male athletes. Especially skaters are at risk for debilitating and lethal head injuries. Individuals recognizing sport-specific hazards might modify their risk behavior. LEVEL OF EVIDENCE: Descriptive Epidemiologic Study, Level II.

Return to Sports After Multiple Trauma: Which Factors Are Responsible?-Results From a 17-Year Follow-up.

OBJECTIVE: We hypothesize that the majority of polytraumatised patients are unable to maintain their preinjury level of sporting activity, and that musculoskeletal injuries are a major contributing factor. We assessed the impact of such injuries on sporting prowess, with a focus on isolating, particularly debilitating musculoskeletal trauma. METHODS: We conducted a cohort study of 637 patients at a level 1 trauma centre, to assess the long-term outcome of severe trauma on return to sporting activities (RTS). Data collated on the multiply injured patient included preinjury physical activity, standardized outcome scores (SF-12, GOS, HASPOC), and clinical follow-up of at least 10 years duration. The return to preinjury sports participation was defined as a primary outcome parameter. Regression analyses were performed to identify specific injuries interfering with the RTS. STUDY DESIGN: Prognostic study; Level of evidence, II. RESULTS: Mean follow-up was 17 ± 5 years. We included 465 patients, including 207 athletic and 258 nonathletic individuals. Mean age at the time of injury was 26 ± 11.5 years and injury severity was comparable between the 2 cohorts. The deleterious effects on quality of life and the total duration of the rehabilitation process were also similar in athletes and nonathletes. Athletes were more likely to be unable to return to preinjury activities, or to return to a lower level of sporting prowess posttrauma. We identified knee injuries as the type of musculoskeletal trauma most likely to be career ending for the athlete (odds ratio 3.4, 95% confidence interval, 1.4-8.3; P = 0.008). CONCLUSION: Our results demonstrate an enforced shift from high-impact and team sports to low-impact activities after multiple trauma. Injuries of the lower extremities, especially around the knee joint, seem to have the highest lifechanging potential, preventing individuals from returning to their previous sporting activities.

Prehospital identification of trauma patients requiring transfusion: results of a retrospective study evaluating the use of the trauma induced coagulopathy clinical score (TICCS) in 33,385 patients from the TraumaRegister DGU®.

BACKGROUND: Identifying trauma patients that need emergent blood product transfusion is crucial. The Trauma Induced Coagulopathy Clinical Score (TICCS) is an easy-to-measure score developed to meet this medical need. We hypothesized that TICCS would assist in identifying patients that need a transfusion in a large cohort of severe trauma patients from the TraumaRegister DGU® (TR-DGU). MATERIALS AND METHODS: A total of 33,385 severe trauma patients were extracted from the TR-DGU for retrospective analysis. The TICCS was adapted for the registry structure. Blood transfusion was defined as the use of at least one unit of red blood cells (RBC) during acute hospital treatment. RESULTS: With an area under the receiving operating curve (AUC) of 0.700 (95% CI: 0.691-0.709), the TICCS appeared to be moderately discriminant for determining the need for RBC transfusion in the trauma population of the TR-DGU. A TICCS cut-off value of ≥12 yielded the best trade-off between true positives and false positives. The corresponding positive predictive value and negative predictive values were 48.4% and 89.1%, respectively. CONCLUSION: This retrospective study confirms that the TICCS is a useful and simple score for discriminating between trauma patients with and without the need for emergent blood product transfusion.

Peyton's four-step approach for teaching complex spinal manipulation techniques - a prospective randomized trial.

BACKGROUND: The objectives of this prospective randomized trial were to assess the impact of Peyton's four-step approach on the acquisition of complex psychomotor skills and to examine the influence of gender on learning outcomes. METHODS: We randomly assigned 95 third to fifth year medical students to an intervention group which received instructions according to Peyton (PG) or a control group, which received conventional teaching (CG). Both groups attended four sessions on the principles of manual therapy and specific manipulative and diagnostic techniques for the spine. We assessed differences in theoretical knowledge (multiple choice (MC) exam) and practical skills (Objective Structured Practical Examination (OSPE)) with respect to type of intervention and gender. Participants took a second OSPE 6 months after completion of the course. RESULTS: There were no differences between groups with respect to the MC exam. Students in the PG group scored significantly higher in the OSPE. Gender had no additional impact. Results of the second OSPE showed a significant decline in competency regardless of gender and type of intervention. CONCLUSIONS: Peyton's approach is superior to standard instruction for teaching complex spinal manipulation skills regardless of gender. Skills retention was equally low for both techniques.

Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany?

INTRODUCTION: Open reduction in displaced intra-articular calcaneal fractures entails a high rate of wound healing deficits and infections as well as an uncertain outcome, which leads to remaining ambiguity in treatment preferences. METHODS: Between January and July 2011, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 31-question web-based survey regarding three broad domains: fracture classification, surgical treatment algorithms and risk factors for wound healing deficits. RESULTS: The response rate was 47 %. With an incidence of 77 %, open reduction via an extended lateral approach and plate fixation was the main treatment option for displaced intra-articular fractures of the joint-depression-type (Sanders II or III). Percutaneous techniques were only preferred in individual cases, with mainly precarious wound situations (59 %) as well as in patients with a reduced general health condition (ASA 3 and 4; 41 %). The re-operation rate due to infections and wound healing deficits after an extended lateral approach was reported with a percentage of 0-5 % by 88 % of the respondents. Participants stated that especially a poor microcirculation of the foot, disregard of soft tissue conserving techniques, overall condition of the patient, smoking, long time-to-surgery and operation time are the main reasons for wound healing deficits. CONCLUSION: Given the extended lateral approach as the preferred treatment option, we found minimally invasive techniques and primary arthrodesis of the lower ankle joint play a minor role in treating intra-articular calcaneal fractures in Germany. Ninety percent of our respondents stated less than 5 % of patients required re-operations due to infections and wound healing deficits. Level of Evidence Level V, expert opinion.

Detecting severe injuries of the upper body in multiple trauma patients.

BACKGROUND: The clavicle limits the upper thoracic cage and connects the body and upper extremities. The clavicle is easy to examine and is visible on standard emergency room radiographs. We hypothesized that clavicular fracture in polytrauma patients would indicate the presence of further injuries of the upper extremities, head, neck, and thorax. METHODS: A population-based trauma registry was used. All patients were documented between 2002 and 2013. Inclusion criteria were age ≥16 y and injury severity score (ISS) ≥16. Patients were divided into two groups according to the presence or absence of a clavicular fracture (group C+ and group C-). Scoring was based on the abbreviated injury scale, ISS, and new injury severity score. Trauma mechanisms, demographics, and the posttraumatic clinical course were compared. RESULTS: In total, 4790 patients with clavicular fracture (C+) and 41,775 without (C-) were included; the mean ISS was 30 ± 11 (C+) versus 28 ± 12 (C-). Patients with clavicular fracture had a longer stay on the intensive care unit with 12 ± 14 versus 10 ± 13 d. Injuries to the thoracic wall, severe lung injuries as well as injuries to the cervical spine were significantly increased in C+ patients. Thoracic injuries as well as injuries of the shoulder girdle and/or arm showed an increased abbreviated injury scale in the C+ group. CONCLUSIONS: A clinically relevant coincidence of clavicular fractures with injuries of the chest and upper extremity was found. As clavicular fractures can be diagnosed easily, it might also help to reduce the incidence of missed injuries of the chest and upper extremity. Therefore, special attention should be paid on thoracic as well as upper extremity injures during the second and tertiary surveys in case of clavicular fractures.

Development of a standardized trauma-related lung injury model.

BACKGROUND: The pathophysiology of acute lung injury is multifactorial, and the mechanisms are difficult to prove. We have devised a study of two known and standardized animal models (hemorrhagic shock [HS] and oleic acid [OA]) to more closely reproduce the pathophysiology of posttraumatic acute lung injury. MATERIAL AND METHODS: Pressure-controlled HS (group HS) was performed by withdrawing blood over 15-min until mean arterial pressure reached 35 mm Hg for 90 min. In an additional group, HS and standardized lung injury induced by OA were combined (group lung injury [HS + OA]). After the shock period, both groups were resuscitated over 15 min by transfusion of the removed blood and an equal volume of lactate Ringer solution. The end point was 6 h. Plasma interleukin (IL)-6, keratinocyte chemoattractant (KC), IL-10, monocyte chemoattractant protein-1 (MCP-1), and lung histology were carried out. RESULTS: The posttraumatic lung injury group demonstrated significantly higher IL-6 levels when compared with HS group (744.8 ± 104 versus 297.7 ± 134 pg/mL; P = 0.004). Histologic analysis confirmed diffuse alveolar congestion and moderate-to-severe lung edema in animals with HS + OA. Lung injury was mild in mice with isolated HS or OA injection. CONCLUSIONS: We established a posttraumatic lung injury model combining two different standardized protocols (HS and OA). This model leads to pronounced inflammation and lung injury. This model allows the analysis of the dynamics of sterile lung injury and associated organ dysfunction.

Partial rupture of the hamstring muscle complex: a literature review on treatment options.

Injuries of the hamstring muscle complex (HMC) often affect athletes participating in specific sporting activities. Mild injuries that constitute a mere strain of the muscle can be managed symptomatically, while severe injuries often require surgical intervention to precipitate a return to function. Neglected injuries usually result in a long-term functional impairment. Therefore, surgical reconstruction of the HMC is advised for both partial and complete lesions. Without acute repair, a chronic lesion referred to as hamstring syndrome can result due to dysfunction of the HMC. Surgical intervention is usually recommended. A case of a chronic severe partial injury to the HMC managed conservatively in a 49-year old female is presented to illustrate the level of function that can be achieved after non-operative management. The clinical and radiological findings are presented 18 months post-injury along with a review of the current literature. There are no previous reports in the literature describing this scenario. This case indicates the need for re-evaluation in treatment options in partial hamstring muscle ruptures. A surgical treatment of partial rupture should be considered more often as an adequate treatment option and cofactors that influence the prognosis must be revealed. The indication of surgical intervention should be re-evaluated within the first months in case of conservative treatment.

[Treatment of proximal femoral fractures : Principles, tips and tricks]. / Therapie proximaler Femurfrakturen : Grundlagen, Tipps und Tricks.

Proximal femoral fractures occur at an annual incidence of approximately 200/100,000 inhabitants and mortality rates range up to 30% especially in geriatric patients where complications are not necessarily associated to surgery. In nearly all cases surgical treatment is required. Procedures to preserve the femoral head have to be performed as early as possible (as specified by the Federal Joint Committee, GBA, within 24 h). For joint-preserving approaches in medial femoral neck fractures a time to surgery within 6 h is considered to be advantageous. Perioperative patient care is of high importance regarding the prevention of pneumonia, renal failure, delirium and further complications. Postoperatively full weight bearing enables for early mobilization and prevention of surgery-related complications. Nonunions, avascular necrosis of the femoral head, cut-out and prosthetic dislocation must be avoided by the selection of the appropriate procedure. Minimally displaced femoral neck fractures are primarily treated by osteosynthesis and conservative management is only considered in isolated cases. For displaced femoral neck fractures, factors such as a young biological age with high activity levels, the absence of arthritis and good bone quality with a successful reduction favor for a femoral head-preserving osteosynthesis. Otherwise, (hybrid) total hip replacement (THR) is the preferred method for unstable and displaced fractures, whereby hemiarthroplasty should only be considered for very old and patients with pre-existing diseases. Fractures in the trochanteric region are treated with a proximal femoral nail and subtrochanteric fractures are managed using a long proximal femoral nail. To avoid secondary complications, the choice of optimal treatment should be based on a good understanding of the injury pattern, biomechanical and technical aspects of each procedure.

Lactate dehydrogenase can be used for differential diagnosis to identify patients with severe polytrauma with or without chest injury-A retrospective study.

BACKGROUND: Chest injury is an important factor regarding the prognosis of patients with polytrauma (PT), and the rapid diagnosis of chest injury is of utmost importance. Therefore, the current study focused on patients' physiology and laboratory findings to quickly identify PT patients with chest injury. METHOD: Data on 64 PT patients treated at a trauma center level I between June 2020 and August 2021 were retrospectively collected. The patients were divided into a PT group without chest injury (Group A) and a PT group including chest injury (Group B). The relationship between chest injury and the patients' baseline characteristics and biochemical markers was analyzed. RESULTS: Heart rate, respiration rate, Sequential Organ Failure Assessment (SOFA) score, glutamate oxaloacetate aminotransferase (GOT), glutamate pyruvate transaminase (GPT), creatine kinase MB (CK-MB), leucocytes, hemoglobin (Hb), platelets, urine output, lactate, and lactate dehydrogenase (LDH) in groups A and B exhibited statistically significant differences at certain time points. Multifactorial analysis showed that blood LDH levels at admission were associated with chest injury (P = 0.039, CI 95% 1.001, 1.022). CONCLUSION: LDH may be a promising indicator for screening for the presence of chest injury in patients with severe polytrauma.

Porcine Mandibular Bone Marrow-Derived Mesenchymal Stem Cell (BMSC)-Derived Extracellular Vesicles Can Promote the Osteogenic Differentiation Capacity of Porcine Tibial-Derived BMSCs.

OBJECTIVE: Existing research suggests that bone marrow-derived mesenchymal stem cells (BMSCs) may promote endogenous bone repair. This may be through the secretion of factors that stimulate repair processes or directly through differentiation into osteoblast-progenitor cells. However, the osteogenic potential of BMSCs varies among different tissue sources (e.g., mandibular versus long BMSCs). The main aim of this study was to investigate the difference in osteogenic differentiation capacity between mandibular BMSCs (mBMSCs) and tibial BMSCs (tBMSCs). MATERIALS AND METHODS: Bioinformatics analysis of the GSE81430 dataset taken from the Gene Expression Omnibus (GEO) database was performed using GEO2R. BMSCs were isolated from mandibular and tibial bone marrow tissue samples. Healthy pigs (n = 3) (registered at the State Office for Nature, Environment, and Consumer Protection, North Rhine-Westphalia (LANUV) 81-02.04.2020.A215) were used for this purpose. Cell morphology and osteogenic differentiation were evaluated in mBMSCs and tBMSCs. The expression levels of toll-like receptor 4 (TLR4) and nuclear transcription factor κB (NF-κB) were analyzed using quantitative polymerase chain reaction (qPCR) and Western blot (WB), respectively. In addition, mBMSC-derived extracellular vesicles (mBMSC-EVs) were gained and used as osteogenic stimuli for tBMSCs. Cell morphology and osteogenic differentiation capacity were assessed after mBMSC-EV stimulation. RESULTS: Bioinformatic analysis indicated that the difference in the activation of the TLR4/NF-κB pathway was more pronounced compared to all other examined genes. Specifically, this demonstrated significant downregulation, whereas only 5-7 upregulated genes displayed significant variances. The mBMSC group showed stronger osteogenic differentiation capacity compared to the tBMSC group, confirmed via ALP, ARS, and von Kossa staining. Furthermore, qPCR and WB analysis revealed a significant decrease in the expression of the TLR4/NF-κB pathway in the mBMSC group compared to the tBMSC group (TLR4 fold changes: mBMSCs vs. tBMSCs p < 0.05; NF-κB fold changes: mBMSCs vs. tBMSCs p < 0.05). The osteogenic differentiation capacity was enhanced, and qPCR and WB analysis revealed a significant decrease in the expression of TLR4 and NF-κB in the tBMSC group with mBMSC-EVs added compared to tBMSCs alone (TLR4 fold changes: p < 0.05; NF-κB fold changes: p < 0.05). CONCLUSION: Our results indicate that mBMSC-EVs can promote the osteogenic differentiation of tBMSCs in vitro. The results also provide insights into the osteogenic mechanism of mBMSCs via TLR4/NF-κB signaling pathway activation. This discovery promises a fresh perspective on the treatment of bone fractures or malunions, potentially offering a novel therapeutic method.

Radiographic changes in the operative treatment of acute acromioclavicular joint dislocation - tight rope technique vs. K-wire fixation.

BACKGROUND: Operative treatment of higher degree acromioclavicular joint luxation is common. A new option is made available by the tight rope technique. It claims to provide adequate outcome with the use of a minimally invasive technique. First clinical studies justified its medical use, but the equivalence to established surgical methods remains unclear. We therefore analyzed radiographic data from patients that were treated with the tight rope system (TR) and compared them to those treated with K-wires (KW) fixation. MATERIAL/METHODS: RETROSPECTIVE STUDY WITH INCLUSION CRITERIA: surgery for acromioclavicular joint luxation between 2004 and 2011, classified as Rockwood type III, no concomitant injury, first event injury. We compared pre- and post-operative X-rays with those taken at the end of treatment. Clinical data from follow-ups and radiographic data were evaluated. The main outcome variable was the remaining distance between the acromion and clavicle (ACD), as well as the coracoid process and clavicle (CCD). RESULTS: 27 patients (TR: n=16; KW: n=11) with comparable demographics and injury severity were included. Surgery reduced ACD (TR: p=0.002; KW: p<0.001) and CCD (TR: p=0.001; KW: p=0.003). Heterotopic ossification or postoperative osteolysis was not significantly associated with either one of the procedures. Three patients (18.75%) in the TR group showed impaired wound healing, migrating K-wires were recorded in 2 patients (18.2%) and impingement syndrome occurred in 1 patient (9.1%) with K-wires. Posttraumatic arthritis was not seen. There was a loss of reduction in 2 cases within the TR-group (12.51%) and 1 in the KW-group (9.1%). At last follow up, ACD and CCD were wider in both groups compared to the healthy side. CONCLUSIONS: This study shows that the Tight rope system is an effective alternative in the treatment of higher degree acromioclavicular luxation and comparable to the established methods.

["Stop the bleeding"-Acute bleeding control in injuries to the trunk and extremities]. / "Stop the bleeding" ­ akute Blutungskontrolle bei Verletzungen von Körperstamm und Extremitäten.

Trauma-related blood loss is still associated with a high mortality and is a major factor in the development of a deadly triad consisting of acidosis, hypothermia and coagulopathy. Sources of bleeding occur particularly in the thoracic, abdominal and pelvic regions as well as in the extremities. For control of bleeding a timely identification of the source of bleeding and the initiation of a targeted treatment are essential. The principles are to stop the blood loss as soon as possible and to restore the lost volume to avoid the complications associated with traumatic hemorrhage. Surgical treatment in the acute situation is especially important due to its efficiency. The present article focuses on the current literature with respect to the appropriate diagnostic and treatment measures in the thoracic, abdominal and pelvic regions as well as the extremities and describes the latest scientific insights and developments. Available trauma algorithms are presented and the value of various strategies regarding surgical hemostasis for the thorax and abdomen are shown, whereby organ preservation can increasingly be achieved, particularly in the abdomen. With respect to hemostasis in severe pelvic injuries and injuries to the extremities, the regularly used surgical techniques are described and their values are differentially classified.