Platelet-rich plasma as a potential prophylactic measure against frozen shoulder in an in vivo shoulder contracture model.

INTRODUCTION: Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling. MATERIALS AND METHODS: An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague-Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest). RESULTS: The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0-1]) compared to controls (median = 2 [IQR = 1-3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups. CONCLUSIONS: In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study.

BACKGROUND: The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management. METHODS: Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs. RESULTS: We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care. CONCLUSIONS: We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit. TRIAL REGISTRATION: Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Rate of intraoperative problems during sacroiliac screw removal: expect the unexpected.

BACKGROUND: The indications for sacroiliac screw (SI) removal have been under debate. Data on complication rates of SI screw removal is missing in the current literature. The objective of this study was to compare the rate of intra- and perioperative problems and complications during SI screw removal to those with SI screw fixation. METHODS: A retrospective observational study with two interventions in the same cohort was performed. Consecutive patients who underwent both sacroiliac screw fixation for an isolated fracture of the pelvic ring and removal of the same implants between November 2008 and September 2015 (n = 19; age 57.3, SD 16.1 years) were included. Intraoperative technical problems, postoperative complications, duration of surgery, and radiation dose were analysed. RESULTS: Intraoperative technical problems occurred in 1/19 patients (5%) during SI screw fixation and in 7/19 cases (37%) during SI screw removal (p = .021). Postoperative complications were seen in 3/19 patients after SI screw fixation and in 1/19 patients after SI screw removal (p = 0.128). The surgical time needed per screw was longer for screw removal than for implantation (p = .005). The amount of radiation used for the whole intervention (p = .845) and per screw (p = .845) did not differ among the two interventions. CONCLUSIONS: Intraoperative technical problems were more frequent with SI screw removal than with SI screw fixation. Most of the intraoperative technical problems in this study were implant-related. They resulted in more surgical time needed per screw removed but similar radiation time.

Standards for external fixation application: national survey under the auspices of the German Trauma Society.

INTRODUCTION: External fixation is widely accepted as a provisional or sometimes definitive treatment for long-bone fractures. Indications include but are not limited to damage control surgery in poly-traumatized patients as well as provisional bridging to definite treatment with soft tissue at risk. As little is known about surgeon's habits in applying this treatment strategy, we performed a national survey. METHODS: We utilized the member database of the German Trauma Society (DGU). The questionnaire encompassed 15 questions that addresses topics including participants' position, experience, workplace, and questions regarding specifics of external fixation application in different anatomical regions. Furthermore, we compared differences between trauma centre levels and surgeon-related factors. RESULTS: The participants predominantly worked in level 1 trauma centres (42.7%) and were employed as attendings (54.7%). There was widespread consensus for planning and intra-operative radiographical control of external fixation. Surgeons appointed at a level I trauma centre preferred significantly more often supra-acetabular pin placement in external fixation of the pelvis rather than the utilization of iliac pins (75.8%, p = 0.0001). Moreover, they were more likely to favor a mini-open approach to insert humeral pins (42.4%, p = 0.003). Overall, blunt dissection and mini-open approaches seemed equally popular (38.2 and 34.1%). Department chairmen indicated more often than their colleagues to follow written pin-care protocols for minimization of infection (16.7%, p = 0.003). CONCLUSION: Despite the fact that external fixation usage is widespread and well established among trauma surgeons in Germany, there are substantial differences in the method of application.

Local effect of zoledronic acid on new bone formation in posterolateral spinal fusion with demineralized bone matrix in a murine model.

BACKGROUND: Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. METHODS: A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n = 10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10 µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n = 10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10 µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10 weeks after surgery. RESULTS: The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1-S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. CONCLUSIONS: A single local application of zoledronic acid with DBM putty during posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our results justify further investigations to potentially use local application of zoledronic acid in future clinical studies.

The impact of public versus private insurance on trauma patients.

BACKGROUND: The socioeconomic status has been associated with disparities in the incidence and mortality of traumatic injuries. However, there is a lack of studies on the level of health insurance with regard to various epidemiologic data of traumatic injuries, which this study opted to clarify. MATERIALS AND METHODS: All consecutive 6595 patients admitted to a level one trauma center in 2012 and 2013 were included in this retrospective cohort study. Patients were grouped according to their health insurance status (public versus private extended health care insurance) and compared with regard to several epidemiologic variables, that is, the type of injuries, inhospital outcome, and surgical procedures. RESULTS: Public insurance coverage was significantly more common than private insurance (75% versus 25%). Public insurance was associated with younger age, male sex, transfers to another hospital or mental institution, head concussions, head fractures, and increased mortality. Contrarily, patients with private insurance were more often associated with longer hospital stay, discharge to a rehabilitation clinic, fractures of the proximal humerus, and shoulder dislocations. However, there were no significant differences for the remaining majority of studied variables. CONCLUSIONS: In a trauma setting, the level of insurance does not seem to play a crucial role in most types of injuries and surgical procedures in a country with a high level of obligatory health care coverage. Nonetheless, it appears that publicly insured patients are more commonly younger, males, transferred to another hospital more often, more prone to head trauma, and subject to increased mortality, whereas privately insured patients show longer hospital stays, increased transfers to rehabilitation clinics, and more fractures of the proximal humerus.

Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients.

BACKGROUND: The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours. METHODS: A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05. RESULTS: The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001). CONCLUSIONS: Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.

The benefits of elective spinal implant removal: a retrospective study of 137 patients.

PURPOSE: While spinal instrumentations are becoming more common, the advantages of elective spinal implant removal remain ambiguous. We hypothesized that elective implant removal of the posterior spine is beneficial. METHODS: A retrospective study evaluated 137 consecutive trauma patients with elective implant removal of the posterior spine. If additional cages were present, they were not removed. Primary outcomes were the change in pre- and post-operative pain, fingertip-floor distance (FFD), and Cobb angles. Some secondary outcomes consisted of complications, work disability, and pelvic incidence (PI). Different stabilization approaches and cage sizes were compared. RESULTS: The presence and amount of pain as well as the FFD showed significant improvement. There was no loss of reduction. Delayed wound healing was observed in 9%, but only 3% needed revision. Thoracic fascial dehiscences were seen only in patients (9%) that had stand-alone posterior surgery. Larger cages were associated with increased work disability. An increased PI was associated with less post-operative pain and decreased FFD. CONCLUSIONS: In this study, trauma patients benefited from elective implant removal of the posterior spine due to lower presence and level of pain, improved function and low revision rates; irrespective of an initial combined or stand-alone posterior approach or varying cage sizes. However, stand-alone posterior instrumentation may be accompanied by increased rates of fascial dehiscence surgeries and larger cages may lead to increased work disability. Increased PI may be associated with less pain after spinal implant removal.

Influence of high-heeled shoes on the sagittal balance of the spine and the whole body.

PURPOSE: Wearing high heels is associated with chronic pain of the neck, lower back and knees. The mechanisms behind this have not been fully understood. The purpose of this study was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels. METHODS: Lateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups. RESULTS: Standing in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p < 0.0001], and increased knee (Δ 2.4° ± 2.9°, p = 0.0009) and ankle flexion (Δ 38.7° ± 3.4°, p < 0.0001). The differences in C7 and meatus vertical axis, cervical and lumbar lordosis, thoracic kyphosis, spino-sacral angle, pelvic tilt, sacral slope, and spinal tilt were not significant. Individuals adapting with less-than-average knee flexion responded to high heels by an additional increase in cervical lordosis (Δ 5.8° ± 10.7° vs. 1.8° ± 5.3°). CONCLUSIONS: In all participants, wearing high heels led to increased flexion of the knees and to more ankle flexion. While some participants responded to high heels primarily through the lower extremities, others used increased cervical lordosis to adapt to the shift of the body's center of gravity. This could explain the different patterns of pain in the neck, lower back and knees seen in individuals wearing high heels frequently.

The value of modular hemiarthroplasty for unstable femoral neck fractures in elderly patients with coxarthrosis.

BACKGROUND: Displaced femoral neck fractures are common in the elderly patient. The surgical treatment options consist of a hemiarthroplasty (HA) or total hip arthroplasty (THA). However, the best surgical choice is still under debate. Bipolar HAs do not address preexisting arthritic changes of the acetabulum, which may lead to an unfavorable clinical outcome. The purpose of the present study was to conduct a long term follow-up analysis of the bipolar hemiarthroplasty with particular focus on the influence of preoperative acetabular osteoarthritis on the functional outcome. METHODS: In a retrospective observational study, the medical charts of consecutive patients treated with a bipolar hemiarthroplasty at a level one trauma center between 2004 and 2008 were reviewed before a final radiographic and clinical follow-up was performed. The outcome variables consisted of arthritic findings on the pre- and postoperative x-rays with particular focus on double fond osteophyte (DFO) and posterior wall sign (PWS) as well as the revision rate and functional scores. RESULTS: This study included 102 patients with a mean age of 77.2 years. Most patients (75 %) had a Kellgren-Lawrence grading scale (KLGS) of 2 or 3. While only 30 % of patients had a DFO, most patients (73 %) had a PWS. The DFO correlated significantly with the KLGS, but no correlation was seen with the clinical outcome. Most patients showed a decreased offset by a mean of -7.8 mm. The mean modified Harris Hip Score (HHS) of 90.3 and the mean Merle d'Aubigné score of 10.8 correlated significantly. Despite a significant correlation of the HSS subcategory of pain and the preoperative KLGS, there was no statistical relationship between the arthritic x-ray measurements and the clinical outcome. CONCLUSIONS: In the presented study population, the presence of radiographic acetabular osteoarthritis did not influence the clinical outcome after bipolar hemiarthroplasty for displaced femoral neck fractures.

Correlation Between Arthroscopy Simulator and Video Game Performance: A Cross-Sectional Study of 30 Volunteers Comparing 2- and 3-Dimensional Video Games.

PURPOSE: To investigate the association between arthroscopy simulator performance and video game skills. METHODS: This study compared the performances of 30 volunteers without experience performing arthroscopies in 3 different tasks of a validated virtual reality knee arthroscopy simulator with the video game experience using a questionnaire and actual performances in 5 different 2- and 3-dimensional (D) video games of varying genres on 2 different platforms. RESULTS: Positive correlations between knee arthroscopy simulator and video game performances (ρ = 0.63, P < .001) as well as experiences (ρ = 0.50, P = .005) were found. The strongest correlations were found for the task of catching (hooking) 6 foreign bodies (virtual rings; "triangulation") and the dribbling performance in a sports game and a first-person shooter game, as well as the meniscus resection and a tile-matching puzzle game (all ρ ≥ 0.60, P < .001). No correlations were found for any of the knee arthroscopy simulator tasks and a strategy game. CONCLUSIONS: Although knee arthroscopy performances do not correlate with 2-D strategy video game skills, they show a correlation with 2-D tile-matching puzzle games only for easier tasks with a rather limited focus, and highly correlate with 3-D sports and first-person shooter video games. These findings show that experienced and good 3-D gamers are better arthroscopists than nonexperienced and poor 3-D gamers. LEVEL OF EVIDENCE: Level II, observational cross-sectional study.

Prevention of heterotopic ossification: an experimental study using a plasma expander in a murine model.

BACKGROUND: Heterotopic ossification (HO) is a frequent complication following orthopedic and trauma surgery. It often leads to substantial morbidity as many affected patients suffer from pain and joint contractures. Current prophylactic measures include nonsteroidal anti-inflammatory drugs (NSAID) and local radiation. However, several disadvantages such as delayed fracture healing and impaired ossification have been reported. For this reason, a novel approach for prevention of HO was searched for. We hypothesized that systemic administration of hydroxyethyl starch (HES), a substance known to influence microcirculation, would reduce formation of HO in a murine model. METHODS: A pre-established murine model was used where HO has been shown to develop following Achilles tendon tenotomy. Twenty CD1 mice were randomly assigned to a control (n = 10) or treatment group (n = 10). The treatment group received two intravenous HES injections perioperatively, while the control group underwent tenotomy only. After ten weeks, the mice were euthanized and micro CT scans of the hind limbs were performed. HO was manually identified and quantitatively assessed. A Wilcoxon rank sum test was used for comparison of both groups. RESULTS: The mean heterotopic bone volume in the control group was significantly larger compared to the HES group (2.276 mm(3) vs. 0.271 mm(3), p = 0.005). A reduction of mean ectopic bone volume of 88 % was found following administration of HES. CONCLUSION: A substantial reduction of HO formation was found following perioperative short-term administration of HES. This work represents a preliminary study, necessitating further studies before drawing ultimate conclusions. However, this simple addition to current prophylactic measures might lead to a more effective prevention of HO in the future.

Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study.

INTRODUCTION: Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets. METHODS: One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions. RESULTS: Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted. CONCLUSIONS: This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.

Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series.

BACKGROUND: The minimally invasive, balloon-assisted reduction and cement-augmented internal fixation of the tibial plateau is an innovative surgical procedure for tibial plateau fractures. The close proximity of balloons and cement to the knee joint poses a potential risk for osteonecrosis; especially in the case of thin bone lamellae. However, there are no studies about the vitality of the cement-surrounding tissue after these tibioplasties. Therefore, our goal was to assess the osseous vitality after cement-augmented balloon tibioplasty using single photon emission computed tomography/computed tomography (SPECT/CT) in a series of patients. METHODS: This case series evaluated available consecutive patients, whose tibial plateau fractures were treated with balloon-assisted, cement-augmented tibioplasty and received a SPECT/CT. Primary outcome variables were osseous vitality on SPECT/CTs according to the semiquantitative tracer activity analysis. The mean uptake of eight tibial regions of interest was referenced to the mean uptake count on the same region of the contralateral leg to obtain a count ratio. Osteonecrosis was defined as a photopenic area or cold defect. Secondary variables included clinical and radiological follow-up data. Statistics were carried out in a descriptive pattern. RESULTS: Ten patients with a mean age of 59 years and a mean follow up of 18 months were included. Calcium phosphate (CaP) substitute bone cement was used in 60% and polymethyl methacrylate mixed with hydroxyapatite (PMMA/HA) bone cement in 40%. Normal to high SPECT/CT activity without photopenic areas were observed in all patients and the mean tracer activity ratio was four, indicating vital bone in all patients. There were no postoperative infections and only one 57 year old patient with hemineglect and CaP cement showed failed osseous consolidation. The mean Tegner and Lysholm as well as the Lysholm scores were three and 80, respectively. CONCLUSIONS: This novel study about cement-augmented balloon tibioplasties showed that osseous vitality remains intact according to SPECT/CT analysis; irrespective of the type of cement and even in the presence of thin bone lamellae. This procedure was safe and well-suited for lateral tibial plateau fractures in particular. Surgeons may consider using PMMA/HA bone cement for void filling in elderly fracture patients without concern about bone viability.

Correlation of pelvic incidence with radiographical parameters for acetabular retroversion: a retrospective radiological study.

BACKGROUND: Pelvic incidence (PI) has been linked to several degenerative processes within the spinopelvic system. Acetabular retroversion is a recognised risk factor for osteoarthritis of the hip. We therefore hypothesised that these two factors might be part of a specific anatomical variant associated with degenerative changes. This study was performed to clarify this issue. METHODS: The pelvic incidence was measured on 589 computertomographical data sets acquired between 2008 and 2010. For 220 patients a 2D rendering in an antero-posterior view of the CT data set was performed to evaluate the parameters of acetabular retroversion. Those included the prominence of the ischial spine sign (PRISS), the cross-over sign (COS) and the posterior wall sign (PWS). Between 477 and 478 hips were evaluated depending on the parameter of retroversion. RESULTS: The mean pelvic incidence was significantly lower in hips positive for the PRISS and the PWS. However, there were no significant differences between hips positive or negative for the COS. DISCUSSION: As hypothesised, the lower PI values in PWS and PRISS positive hips suggest a link between PI and retroversion of the acetabulum. Whether this is of any clinical relevance remains, however, unknown. CONCLUSION: Acetabular retroversion is linked to PI. In hips where the prominence of the ischial spine sign and/or the posterior wall sign was present, the mean pelvic incidence value was lower.

Evaluation of pelvic ring injuries using SPECT/CT.

OBJECTIVE: The incidence of pelvic fractures is relatively low compared with other fracture locations. The low incidence is in great contrast to the high morbidity and mortality. Particularly in the elderly, with apparently isolated fractures of the pubic rami, these observations are believed to be due to additional occult lesions of the posterior pelvic ring. In these cases diagnosis cannot be established by conventional imaging alone and SPECT/CT is considered as a diagnostic adjunct. The aim of this study was to assess concomitant bony or soft tissue lesions within the pelvic ring in a population of patients with fractures of the anterior elements. MATERIALS AND METHODS: In all patients with no obvious lesions of the posterior pelvic ring on X-rays and CT or with suspicious but inconclusive findings on CT an additional SPECT/CT was carried out in a non-acute setting within 3 days of the trauma. RESULTS: In all cases additional lesions within the pelvic ring were found. Most lesions were vertical sacral fractures, followed by transverse fractures, one non-dislocated fracture of the acetabulum on the side of the pubic rami fracture, and one post-traumatic dilatation of the sacroiliac joint with increased tracer uptake. CONCLUSION: According to our results after SPECT/CT all patients with pubic rami fracture suffered additional lesions, none detectable previously by X-ray or CT, within the pelvic ring. In this context SPECT/CT has proved to be very helpful in the clinical routine to visualize occult fractures and instability within the sacroiliac joint.

The compliance with and knowledge about radiation protection in operating room personnel: a cross-sectional study with a questionnaire.

INTRODUCTION: Radiation protection is becoming more important with an ongoing increase in radiation exposure due to the use of X-rays in minimally invasive procedures in orthopaedic and trauma surgeries. However, sufficient education in medical physics and radiation protection can often be improved. MATERIALS AND METHODS: A questionnaire consisting of four questions about personal data and ten questions about radiation protection was distributed to lead consultants, consultants, residents, medical students, and medical technical assistants at two institutions, a level 1 trauma center and a children's hospital. RESULTS: This study consisted of 83 participants. The compliance with radiation protection, i.e., usage of a dosimetry, an apron, and a thyroid shield on a regular basis was only seen in 54 %. Participants from the trauma center wore a dosimeter and thyroid shield significantly more often. The regular use of a thyroid shield differed significantly between job positions. It was observed in 80 % of students, but only 15 % of technical assistants. Only 65 % of all knowledge questions were answered correctly. There was a discrepancy between incorrectly answered knowledge questions (35 %) and those marked as uncertain (20 %). Different job positions did not have an impact on the answers to the questions in most instances. CONCLUSIONS: The compliance with and the knowledge about radiation protection seems to be unnecessarily low in trauma physicians and technical assistants. The discrepancy in falsely answered questions and those marked as uncertain may suggest that participants may overestimate their knowledge about radiation protection, which is potentially harmful due to the increased radiation exposure. Therefore, we advocate a quick and valuable training of trauma surgeons and medical staff addressing the important preventive measures, some of which are illustrated in the present study. These consist of wearing dosimetry and protection devices, reduction in X-ray duration, preferably antero-posterior C-arm positioning with the image intensifier close to the patient and the surgeon, maximal distance, collimation, and increased voltage. Furthermore, the use of visual feedback on complex and potentially hazardous radiation facts may be useful for training purposes. STUDY DESIGN: Cross-sectional study with a questionnaire.

SPECT/CT for imaging of the spine and pelvis in clinical routine: a physician's perspective of the adoption of SPECT/CT in a clinical setting with a focus on trauma surgery.

Injuries of the axial skeleton are an important field of work within orthopaedic surgery and traumatology. Most lesions following trauma may be diagnosed by means of conventional plain radiography, computed tomography or magnetic resonance imaging. However, for some aspects SPECT/ CT can be helpful even in a trauma setting. In particular, the combination of highly sensitive but nonspecific scintigraphy with nonsensitive but highly specific computed tomography makes it particularly useful in anatomically complex regions such as the pelvis and spine. From a trauma surgeon's point of view, the four main indications for nuclear medicine imaging are the detection of (occult) fractures, and the imaging of inflammatory bone and joint diseases, chronic diseases and postoperative complications such as instability of instrumentation or implants. The aim of the present review was to give an overview of the adoption of SPECT/CT in a clinical setting.

Mechanical testing of a device for subcutaneous internal anterior pelvic ring fixation versus external pelvic ring fixation.

BACKGROUND: Although useful in the emergency treatment of pelvic ring injuries, external fixation is associated with pin tract infections, the patient's limited mobility and a restricted surgical accessibility to the lower abdomen. In this study, the mechanical stability of a subcutaneous internal anterior fixation (SIAF) system is investigated. METHODS: A standard external fixation and a SIAF system were tested on pairs of Polyoxymethylene testing cylinders using a universal testing machine. Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz with sinusoidal lateral compression/distraction (+/-50 N) and torque (+/- 0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700 and 900 cycles. RESULTS: There was no significant difference in translational stiffness between the SIAF and the standard external fixation when compared at 500 (p = .089), 700 (p = .081), and 900 (p = .266) cycles. Rotational stiffness observed for the SIAF was about 50 percent higher than the standard external fixation at 300 (p = .005), 500 (p = .020), and 900 (p = .005) cycles. No loosening or failure of the rod-pin/rod-screw interfaces was seen. CONCLUSIONS: In comparison with the standard external fixation system, the tested device for subcutaneous internal anterior fixation (SIAF) in vitro has similar translational and superior rotational stiffness.

Effect of elevated serum alcohol level on the outcome of severely injured patients.

BACKGROUND: The influence of high blood alcohol level (BAL) on the outcome of severely injured patients and the corresponding pathophysiological changes is a controversial issue. OBJECTIVE: To carry out a prognostic study to compare the physiological values and short-term outcome of severely injured patients depending on their serum alcohol level. METHODS: A total of 383 severely injured patients with an Injury Severity Score (ISS) ≥17 were admitted to the trauma division between October 2008 and December 2009 and enrolled into this study. Patients were grouped according to their BAL (>0.5‰,'BAL positive' vs <0.5‰,'BAL negative'). Trauma mechanism, pattern of injury and its treatment, and a course of intensive care treatment, physiological parameters and outcome with respect to mortality were analysed. RESULTS: Both groups had similar ISS. In comparison with the BAL-negative group, patients in the BAL-positive group had a significantly lower Glasgow Coma Scale score (9.64 vs 12 points; p=0.005) and, although not significant, a trend towards higher values of the Abbreviated Injury Score for the head (3.29 vs 2.81 points; p=0.146). Furthermore, significantly higher lactate (3.11 mmol/L vs 2.02 mmol/L; p<0.001) levels and lower median arterial pressure values (87.9 mm Hg vs 99.4 mm Hg; p=0.006) were seen in the BAL-positive group at day of admission. However, the overall in-hospital mortality was comparable to that in BAL-negative patients (19.6% vs 21.5%). Similarly, hospital stay (15.29 vs 17.55 days) and duration of intensive care unit treatment (8.53 vs 8.36 days) were not significantly affected by a high BAL upon admission. CONCLUSIONS: Severely injured patients with a raised BAL have a higher incidence of severe traumatic brain injury and worse initial physiological parameters. However, the survival rate and in-hospital stay is not influenced. This supports the theory of a neuroprotective role of alcohol.