Slipped capital femoral epiphysis after tumor prosthesis implantation in a patient receiving chemotherapy.

While the usual etiology of slipped capital femoral epiphysis (SCFE) is idiopathic, there are many other factors that increase the predisposition to slippage. Chemotherapy can be one of them. In this article, we report a rare case of acute SCFE after tumor prosthesis implantation in a patient who received chemotherapy. A 10-year-old girl with osteosarcoma of the right distal femur underwent (neo-) adjuvant chemotherapy, wide tumor resection, and reconstruction using a growing tumor prosthesis and a short non-cemented femoral stem. Half a year after implantation, she developed aseptic loosening. Revision surgery was performed using a hydroxyapatite (HA)-coated cementless femoral stem. Postoperative plain radiographs revealed SCFE that was treated by closed reduction and screw fixation. The patient recovered without complications, and unaffected hip showed no radiographic signs of slippage on follow-up. The forces of implanting a tumor prosthesis, particularly with a non-cemented stem, can increase the risk of an acute SCFE. The controversy over prophylactic pinning of the uninvolved hip in chemotherapy-associated SCFE is unresolved. Pinning can be considered only in the presence of abnormal prodromal radiological findings.

Incidence and management of secondary deformities after megaendoprosthetic proximal femur replacement in skeletally immature bone sarcoma patients.

INTRODUCTION: Megaendoprosthetic reconstruction of bone defects in skeletally immature patients has led to the development of unique complications and secondary deformities not observed in adult patient cohorts. With an increasing number of megaendoprosthetic replacements performed, orthopedic oncologists still gain experience in the incidence and type of secondary deformities caused. In this study, we report the incidence, probable cause and management outcome of two secondary deformities after megaendoprosthetic reconstruction of the proximal femur: hip dysplasia and genu valgum. MATERIALS AND METHODS: Retrospective analysis of 14 patients who underwent primary and/or repeat reconstruction/surgery with a megaendoprosthetic proximal femur replacement between 2018 and 2022. RESULTS: Mean patient age was 9.1 years (range 4-17 years). Stress shielding was observed in 71.4%. Hip dislocation was the most frequent complication (50%). While four dislocations occurred without an underlying deformity, secondary hip dysplasia was identified in 58.3% (n = 7/12) of intraarticular resections and reconstructions, leading to dislocation in 71.4% (n = 5/7). A genu valgum deformity was observed in 41.6% (n = 5/12). The incidence of secondary hip dysplasia and concomitant genu valgum was 42.9% (n = 3/7). Triple pelvic osteotomy led to rebound hip dysplasia in two cases (patients aged < 10 years), whereas acetabular socket replacement led to stable hip joints over the course of follow-up. Temporary hemiepiphyseodesis was applied to address secondary genu valgum. CONCLUSIONS: Patients aged < 10 years were prone to develop secondary hip dysplasia and genu valgum following proximal femur replacement in this study. Management of secondary deformities should depend on remaining skeletal growth. Stress shielding was observed in almost all skeletally immature patients.

Cortical Desmoid of the Distal Femur-Incidentaloma or Insertional Tendinopathy?

BACKGROUND: The cortical desmoid (DFCI) of the posteromedial femoral condyle is considered an asymptomatic incidental finding in adolescents without clinical relevance. The aim of this study was to evaluate the clinical relevance of DFCI from both a tumor orthopedic and sports medicine point of view. METHODS: n = 23 patients (13.74 ± 2.74 years; nineteen female, four male) with DFCI of the posteromedial femoral condyle were included. A localized posteromedial knee pain on exertion was differentiated from non-specific knee pain. Symptom duration, additional pathologies, number of MRIs, sports activity and training intensity, downtime, therapeutic modalities, and relief/remission of symptoms were documented. The Tegner activity scale (TAS) and Lysholm score (LS) were collected. The influence of specific posteromedial pain, MRI presence of paratendinous cysts, sports level as well as physiotherapy on downtime and LS/TAS was statistically analyzed. RESULTS: 100% reported knee symptoms at initial presentation. A localized posteromedial pain was documented in 52%. In 16/23 (70%) additional functional pathologies were diagnosed. Patients were physically highly active with high training intensities (6.52 ± 5.87 h/week) and performance level (65% competitive vs. 35% recreational). Patients underwent 1.91 ± 0.97 MRIs (max four). Symptom duration was 10.48 ± 11.02 weeks. A follow-up examination was performed after 12.62 ± 10.41 months (n = two lost to follow-up). 17/21 had physiotherapy, on average 17.06 ± 13.33 units. Overall downtime was 13.39 ± 12.50 weeks, the return-to-sports (RTS) rate 81%. 100%/38% reported a relief/remission of complaints. LS was 93.29 ± 7.95, median TAS before onset of knee complaints/at follow-up 7 (6-7)/7 (5-7). Specific posteromedial pain, presence of paratendinous cysts, sports level and physiotherapy had no significant influence on downtime and outcome parameters (n.s.). CONCLUSIONS: DFCI as a pathognomonic finding is recurrently encountered in the MRIs of children and adolescents. This knowledge is essential to spare patients from overtreatment. Contrary to the literature, the present results implicate a clinical relevance of DFCI particularly in those who are physically highly active with localized pain on exertion. Structured physiotherapy as basic treatment is recommended.

Increased UHMWPE Particle-Induced Osteolysis in Fetuin-A-Deficient Mice.

Particle-induced osteolysis is a major cause of aseptic prosthetic loosening. Implant wear particles stimulate tissue macrophages inducing an aseptic inflammatory reaction, which ultimately results in bone loss. Fetuin-A is a key regulator of calcified matrix metabolism and an acute phase protein. We studied the influence of fetuin-A on particle-induced osteolysis in an established mouse model using fetuin-A-deficient mice. Ten fetuin-A-deficient (Ahsg−/−) mice and ten wild-type animals (Ahsg+/+) were assigned to test group receiving ultra-high molecular weight polyethylene (UHMWPE) particle implantation or to control group (sham surgery). After 14 days, bone metabolism parameters RANKL, osteoprotegerin (OPG), osteocalcin (OC), alkaline phosphatase (ALP), calcium, phosphate, and desoxypyridinoline (DPD) were examined. Bone volume was determined by microcomputed tomography (µCT); osteolytic regions and osteoclasts were histomorphometrically analyzed. After particle treatment, bone resorption was significantly increased in Ahsg−/− mice compared with corresponding Ahsg+/+ wild-type mice (p = 0.007). Eroded surface areas in Ahsg−/− mice were significantly increased (p = 0.002) compared with Ahsg+/+ mice, as well as the number of osteoclasts compared with control (p = 0.039). Fetuin-A deficiency revealed increased OPG (p = 0.002), and decreased levels of DPD (p = 0.038), OC (p = 0.036), ALP (p < 0.001), and Ca (p = 0.001) compared with wild-type animals. Under osteolytic conditions in Ahsg−/− mice, OPG was increased (p = 0.013), ALP (p = 0.015) and DPD (p = 0.012) were decreased compared with the Ahsg+/+ group. Osteolytic conditions lead to greater bone loss in fetuin-A-deficient mice compared with wild-type mice. Reduced fetuin-A serum levels may be a risk factor for particle-induced osteolysis while the protective effect of fetuin-A might be a future pathway for prophylaxis and treatment.

[E-scooter, e-bike and bicycle injuries in the same period-A prospective analysis of a level 1 trauma center]. / E-Scooter­, E-Bike- und Fahrradverletzungen im gleichen Zeitraum ­ eine prospektive Vergleichsstudie eines Level-1-Traumazentrums.

BACKGROUND: The actual number of accidents in e­scooter drivers in Germany seems to be significantly higher than the current figures from the Statistisches Bundesamt suggest. This epidemiological study examines e­scooter injuries and compares them with e­bike and bicycle injuries. OBJECTIVE: In order to create a comparable database on the dangers of e­scooters, e­bikes and bicycles, the typical injury patterns were analyzed and prevention options derived from them. MATERIAL AND METHODS: All accidents involving e­scooters, e­bikes and bicycles that were presented via the university emergency room of a level 1 trauma center between 15 June 2019 and 31 October 2020 were prospectively investigated. RESULTS: In our study, 68 accidents in e­scooter drivers were included, of which only 11.8% (n = 8) were recorded by the police. Significantly more of them were male than female (p = 0.032) with a mean age of 31.1 (±13) years. At the same time, we registered 34 accidents in e­bike riders and 356 in cyclists. In all three groups, most injuries occurred to the head, followed by injuries to the upper extremities. Significantly more e­scooter drivers had an ISS ≥ 16 than in the group of injured cyclists (p = 0.016). E­scooter riders who had an accident had a significantly longer length of stay in hospital, than e­bike riders (p = 0.003) and cyclists (p = 0.001), 52.9% (n = 18) of e­bike riders and 53.3% (n = 113) cyclists wore a helmet, compared to only 1.5% (n = 1) of e­scooter riders. The most common cause of accidents among e­bike riders (17.7%; n = 6) and cyclists (10.4%; n = 37) was slipping away on tram rails, while for e­scooter riders it was colliding with a curb (7.4%; n = 5). CONCLUSION: The three patient collectives examined showed different causes and profiles of injuries. The reasons for an increased proportion of seriously injured people compared to cyclists are electromobility, driving under the influence of alcohol and inadequate wearing of a helmet on e­scooters when head injuries dominate. 73.5% (n = 50) of the e­scooter accidents recorded by us were not registered by the police and therefore do not appear in the current statistics of the statistisches Bundesamt. As a result, a much higher number of e­scooter accidents can be assumed. Preventive measures could include the introduction of compulsory helmets, a higher number of traffic controls and the expansion of bike tracks.

"The Baltic Sea Germ": A Case Report of Necrotizing Fasciitis following Vibrio vulnificus Infection.

Reported is an 80-year-old patient with septic shock from necrotizing fasciitis secondary to a Vibrio vulnificus (Vv) infection. The patient reports having been swimming in the Baltic Sea after a minor trauma to the left leg. Emergency superficial necrosectomy followed by intensive medical therapy was performed. Antibiotic therapy was initiated with a third-generation cephalosporin and a tetracycline. Vv was detected in the intraoperative microbiological smears. Instead of a leg amputation and a flap, due to the patient's age, a split skin covering to consolidate the wound was performed. Vv is a gram-negative rod bacterium of the genus Vibrio. Vv occurs in warm, low-salinity seawater (brackish water). In Germany, Vv occurs primarily in river mouths of the low-salinity Baltic Sea. Infections by Vv can occur through open wounds or by eating raw infected seafood, especially oysters. Infection via wounds often take a fulminant lethal course. Patients with chronic diseases, weakened immune system, and open wounds are particularly at risk. Infections with Vv are rare, but occur worldwide. Global warming is expected to spread Vv as water temperature increases and the dilution effect of sea level rise further decreases ocean salinity, and natural disasters promote the spread of Vv.

[Rupture of the pectoralis major muscle in amateur athletes: a rare injury or often overlooked?] / Die Ruptur des M. pectoralis major beim Hobbysportler ­ seltene Verletzung oder oft übersehen?

INTRODUCTION: A rupture of the pectoralis major muscle is a rare injury pattern overall, but it is frequently described in athletes, particularly in weightlifting. The risk of sustaining this type of injury is present especially during the eccentric phase of muscle loading. An association between such injuries and the abuse of anabolic steroids is described in the literature, but there is no coherent evidence to support this. We report the case of a young patient with a normal habitus who suffered a humeral rupture of the pectoralis major muscle during recreational sports. There was no history of excessive weight training or use of anabolic steroids. CASE HISTORY: This 33-year-old patient reported a sudden onset of left pectoral pain during training on the chest fly machine as well as a whip-like popping sound, followed by an immediate painful restriction of movement in the left arm. A clinical examination revealed a mild haematoma located on the left medial upper arm with localised tenderness and a discrete asymmetry of the contour of the pectoral muscles. Due to the typical medical history, we established the indication for surgical exploration although the clinical picture was rather discrete and only an incomplete rupture was seen in an MRI scan. Intraoperatively, we detected a complete rupture of the sternocostal part of the pectoralis major muscle with marked retraction and haematoma. Reinforcement and reinsertion were performed at the "footprint" using titanium anchors (2 x 5.5mm Corkscrew FT, Arthrex, Florida). The patient was able to resume his sports activities at the pre-traumatic level four months after surgery. CONCLUSION: A rupture of the insertion of the pectoralis major muscle must also be considered in amateur athletes with a typical history. The characteristic clinical symptoms described in the literature mostly refer to competitive athletes and bodybuilders, but these injuries can also be diagnosed in amateur athletes with lower muscle mass by subtle clinical examination. Nevertheless, there is a considerable risk of underestimating the extent of the injury. In case of doubt, surgical exploration should be performed promptly in amateur athletes. Surgical refixation of the humeral rupture of the pectoralis major muscle is the gold standard and should not be reserved to high-performance athletes.

Injuries and Overuse Injuries in Show Jumping-A Retrospective Epidemiological Cross-Sectional Study of Show Jumpers in Germany.

This retrospective cross-sectional epidemiological study deals with sport-specific injury patterns in show jumping. A total of 363 show jumpers of all levels (S) answered a retrospective questionnaire about injuries and overuse damages which occurred in the course of their careers. Demographic data and information on injuries in various body regions were collected. In addition to descriptive analysis, significance tests were performed. For better statistical comparability with other sports, exposure time was extrapolated with total career duration and weekly training hours, and injuries per 1000 jumping hours were calculated. The study included 251 (69%) women and 112 (31%) men, who were on average 26.9 ± 10.9 years old. The injury rate for the entire collective was 3.7 per 1000 h of exposure. The most frequently affected body region was the head (31%). Overuse complaints play a subordinate role and mainly affect the upper extremities (65%). The riders of the professional lower performance levels are less likely to injure themselves per 1000 h than riders of the higher performance levels. Riders who often or always wore a helmet suffered significantly fewer head injuries (p = 0.008) and had a significantly lower total injury duration than riders who did not wear a helmet (p = 0.006). Similarly, the study showed that riders who often or always wore a safety vest suffered significantly fewer spinal injuries (p = 0.017) and had significantly fewer injuries per 1000 riding hours (p = 0.031) than riders who did not wear a safety vest. Based on the present results, there should be an extension of the general helmet requirement and a requirement to wear safety vests in show jumping in general.

Geriatric Proximal Femur Fractures During the Covid-19 Pandemic - Fewer Cases, But More Comorbidities.

BACKGROUND: The COVID-19 pandemic is challenging healthcare systems worldwide. This study examines geriatric patients with proximal femur fractures during the COVID-19 pandemic, shifts in secondary disease profile, the impact of the pandemic on hospitalization and further treatment. METHODS: In a retrospective monocentric study, geriatric proximal femur fractures treated in the first six months of 2020 were analyzed and compared with the same period of 2019. Pre-traumatic status (living in a care home, under supervision of a legal guardian), type of trauma, accident mechanism, geriatric risk factors, associated comorbidities, time between hospitalization and surgery, inpatient time and post-operative further treatment of 2 groups of patients, aged 65-80 years (Group 1) and 80+ years (Group 2) were investigated. RESULTS: The total number of patients decreased (70 in 2019 vs. 58 in 2020), mostly in Group 1 (25 vs. 16) while the numbers in Group 2 remained almost constant (45 vs. 42). The percentage of patients with pre-existing neurological conditions rose in 2020. This corresponded to an increase in patients under legal supervision (29.3%) and receiving pre-traumatic care in a nursing home (14.7%). Fractures were mostly caused by minor trauma in a home environment. In 2020, total number of inpatient days for Group 2 was lower compared to Group 1 (p = 0.008). Further care differed between the years: fewer Group 1 patients were discharged to geriatric therapy (69.6% vs. 25.0%), whereas in Group 2 the number of patients discharged to a nursing home increased. CONCLUSIONS: Falling by elderly patients is correlated to geriatric comorbidities, consequently there was no change in the case numbers in this age group. Strategic measures to avoid COVID-19 infection in hospital setting could include reducing the length of hospital stays by transferring elderly patients to a nursing home as soon as possible and discharging independent, mobile patients to return home.

Injuries in underwater rugby: a retrospective cross-sectional epidemiological study.

INTRODUCTION: Underwater rugby (UWR) is a team sport which combines swimming sprints, apnoea diving, a good overview of the three-dimensional underwater space and wrestling for the ball.This was the first epidemiological study of UWR injuries in a large international collective. METHODS: A questionnaire containing 124 questions was distributed to 198 active UWR players and completed under the supervision of medical staff. Demographic data and information about injuries in ten different body regions were collected. RESULTS: Of the 198 respondents, 106 (53.5%) were male and 92 (46.5%) were female. On average, each UWR player suffered a median of 19.5 (IQR 44) injuries. Based on the exposure time, means of 37.7 (SD 90.0) injuries per 1000 playing hours per player and 9.9 (20.1) injuries per year were found. Significant injuries mainly occurred to the head region (45.7%). Bruises and sprains were observed more often than fractures and dislocations. Male athletes had a longer total injury break time (median 4.8 [IQR 10.5] days), than female athletes (4 [8.6] days). Female athletes had more injuries (median 20 [IQR 26.8]) than male athletes (18.5 [63]). The length of the injury-related break time increased with the rise in body mass index. CONCLUSIONS: The risk of severe injury in UWR is low compared to other ball sports like water polo and rugby. UWR is played under water and the impact of tackles is lessened by the water. Further studies should record chronic injuries in UWR and establish measures to prevent injury.

Acceptance, Barriers, and Future Preferences of Mobile Health Among Patients Receiving Trauma and Orthopedic Surgical Care: Paper-Based Survey in a Prospective Multicenter Study.

BACKGROUND: Smartphones have become an essential part of everyday life and it is undeniable that apps offer enormous opportunities for dealing with future challenges in public health. Nevertheless, the exact patient requirements for medical apps in the field of orthopedic and trauma surgery are currently unknown. OBJECTIVE: The aim of this study was to define target groups, evaluate patient requirements, and the potential and pitfalls regarding medical apps specific for patients receiving orthopedic and trauma surgical care. METHODS: A prospective multicenter study was conducted between August 2018 and December 2019 at a German trauma center and 3 trauma surgery/orthopedic practices. A paper-based survey consisting of 15 questions evaluated information regarding smartphone and medical app usage behavior. In addition, suggested app functions were rated using Likert scales. Descriptive statistics and binary log-binomial regression were performed. RESULTS: A total of 1055 questionnaires were included in our statistical analysis. Approximately 89.57% (945/1055) of the patients in this study owned a smartphone. Smartphone ownership probability decreased with every decade of life and increased with higher levels of education. Medical information was obtained via mobile web access by 62.65% (661/1055) of the patients; this correlated with smartphone ownership in regard to age and educational level. Only 11.18% (118/1055) of the patients reported previous medical app usage, and 3.50% (37/1055) of the patients received an app recommendation from a physician. More than half (594/1055, 56.30%) of the patients were unwilling to pay for a medical app. The highest rated app functions were information about medication, behavioral guidelines, and medical record archival. An improved treatment experience was reported through the suggested app features by 71.18% (751/1055) of the patients. CONCLUSIONS: Mobile devices are a widely used source of information for medical content, but only a minority of the population reported previous medical app usage. The main target group for medical apps among patients receiving orthopedic and trauma surgical care tends to be the younger population, which results in a danger of excluding fringe groups, especially the older adults. Education seems to be one of the most important pull factors to use smartphones or a mobile web connection to obtain health information. Medical apps primarily focusing on an optimized patient education and flow of information seem to have the potential to support patients in health issues, at least in their subjective perception. For future target group-oriented app developments, further evidence on the clinical application, feasibility, and acceptance of app usage are necessary in order to avoid patient endangerment and to limit socioeconomic costs.

Development of Case Numbers during the COVID-19 Pandemic in a Center of Maximum-Care for Traumatology and Orthopedic Oncology.

(1) Background: The COVID-19 pandemic has led to a significant change in the utilization of trauma surgery and tumor orthopedic hospital facilities. (2) Methods: In a monocentric retrospective analysis, the weekly numbers of cases requiring intra-clinical treatment in the first four months of 2020 were compared with those of 2019. Patients' visits to the emergency department and shock room, consultation hours, work-related accidents, case numbers in the normal and intensive care units, ventilation hours, the "Simplified Acute Physiology Score/ Therapeutic Intervention Scoring System" (SAPS/TISS), the average length of stay in hospital, the number of operations and their degree of urgency, as well as deaths, were analyzed in a study based on the data from 7606 outpatient consultations in 2019 and 6755 in 2020, as well as 993 inpatient cases in 2019 and 950 in 2020. (3) Results: There was a significant reduction in the number of treatments per week in the emergency department (261 ± 29 vs. 165 ± 25; p < 0.001) with the same number of shock room treatments and fewer consultation hour contacts (226 ± 29 vs. 119 ± 65; p = 0.012). There were fewer inpatient cases (66 ± 7 vs. 42 ± 11; p = 0.001), resulting in a fall in the days of hospitalization (492 ± 63 vs. 308 ± 78; p < 0.001) and number of operations (73 ± 7 vs. 55 ± 10; p = 0.012), especially elective procedures (20 ± 3 vs. 7 ± 7; p = 0.008). The SAPS/TISS score was lower (1351 ± 1213 vs. 399 ± 281; p = 0.023). Fewer fracture treatments and septic surgeries were performed, while the number of procedures to treat orthopedic malignancies remained constant. (4) Conclusions: During the first phase of the COVID-19 pandemic, we observed a significant reduction in the number of cases treated in orthopedics. While the number of multiple-injured patients was unchanged, fewer patients presented for primary and regular care. Treatment of acute injuries and malignant tumor diseases was not at risk. There was no effect on in-house mortality. We see a potential for the recruitment of medical staff from the outpatient department, operating room, and the ward. In the event of a future second wave, our results may allow for early planning, particularly of the all-important human resources. Reorganization by hospitals and decreased patient numbers in trauma surgery can enable the reallocation of medical staff, equipment, and beds to increase capacity for COVID-19 patients.

[Injuries in inline skater hockey]. / Verletzungen im Inline-Skaterhockey.

In Germany, Inline Skater Hockey (ISH) is played by about 7500 active players on inline skates with equipment comparable to ice hockey using a hard-plastic ball. The aim of this retrospective epidemiological cross-sectional study is to record the frequency and types of injuries in this sport, for which there is a lack of medically adequate studies in the literature. A questionnaire comprising 112 items was used to collect demographic data, injuries in eight body regions and defined overuse injuries. 274 ISH players with an average age of 24.5 ± 6.2 years and an exposure time of 2787 ±â€Š2063 hours were examined. 5701 injuries were recorded, 60.5 % of which were minor bruises, abrasions and wounds. The total injury rate per 1000 hours was 9.6 ±â€Š17.7, with an injury-related break of 12.8 ±â€Š21.8 weeks per player. Field players with visors had highly significantly fewer head injuries (2.8 ±â€Š6.1 vs. 8.9 ± 13.1; p < 0.001) with highly significantly (p < 0.001) fewer lacerations, nasal bone fractures, eye injuries and dental injuries. There was a weak negative correlation between facial protection and number of head injuries (r = -0.386, p < 0.001). In conclusion, frequency and types of injuries in ISH are comparable to ice hockey during training. In accordance with ice hockey, protective equipment in ISH can significantly reduce the occurrence of head injuries. Preventive attention should be paid to the wearing of a full visor and to education about the occurrence of concussions despite the use of a protective helmet.

Acute Joint Blockage due to Abrasion-Related Dislocation of a Silastic Radial Head Prosthesis: A Histological Examination after 14 Years of Durability.

The implantation of a radial head prosthesis can take place as a therapeutic option after radial head fracture. There are various implants for this purpose. Many studies and case reports about silastic radial head prosthesis implantation describe foreign body reactions with accompanying synovitis and poor functional results. A few studies have investigated the reason for the material failure and the accompanying synovitis. The case report presented shows an unusually long durability of an in situ 14-year silastic radial head prosthesis. 14 years after implantation, a previously full-time working and healthy patient presented himself with a dislocation of the silastic radial head prosthesis and atraumatic joint blockage of the right elbow triggered by a negligible movement. The prosthesis was removed surgically. We found a macroscopic foreign body reaction intraoperatively. In a histopathological examination, with hematoxylin and eosin staining (HE) in 40x and 100x magnification, we have seen an aseptic inflammatory response to foreign bodies with activated epithelial cells and multinucleated giant cells with intracytoplasmic foreign material. Due to these problems, the silastic radial head prosthesis is no longer used today. However, there are still patients with the implanted silastic radial head prosthesis, which should therefore be checked regularly. A metal prosthesis also does not seem to be an optimal alternative due to cartilage wear and loss of ROM. The choice of prosthesis material should be selected carefully and patient-specific in radial head prosthetics according of the results presented.

Trauma induced clotting factor depletion in severely injured children: a single center observational study.

BACKGROUND: Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated. METHODS: Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range. RESULTS: The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19-28] vs. 5 [4-6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively). CONCLUSIONS: This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.

A Selection of Trauma Scores Might Not Correlate with Coagulation Factor Activity following Multiple Injuries: A Retrospective Observational Study from a Level 1 Trauma Center.

Loss and dilution of coagulation factors have been observed following multiple trauma. Timely recognition of reduced clotting factor activity might facilitate therapeutic action to restore normal coagulation function. This study investigates the potential role of some well-known trauma scores in predicting coagulation factor activity after multiple injuries. A dataset comprising the coagulation factor activities of 68 multiply injured adult patients was analyzed. The following trauma scores were evaluated: AIS, ISS, NISS, GCS, RTS, TRISS, RISC, and TASH score. To investigate the effect of trauma severity with respect to a single anatomic injury location, two groups according to the AIS (<3 vs. ≥3 points) were formed. Differences between these two groups were analyzed for five different body regions (head, thorax, abdomen, pelvis, extremities) using the Mann-Whitney U-test. Spearman's rank correlation coefficient rho was calculated to reveal possible relationships between trauma scores and clotting factor activities. The analysis showed clearly reduced clotting factor activities with a significant reduction of FII (83 vs. 50%; P = .021) and FV (83 vs. 46%; P = .008) for relevant (AIS ≥ 3 points) pelvic injuries. In contrast, traumatic brain injury according to the AIS head or the GCS does not appear to lead to a significant decrease in coagulation factor activities. Furthermore, the other scores studied show at best a fair correlation with coagulation factor activity. In this context, the RTS score seems to be the most suitable. Additionally, the predictive value of the TASH score, which was specifically developed to predict the need for mass transfusion, was also limited in this study. We would like to explicitly point out that this is not a criticism of the trauma scores, since they were developed in a completely different context.

Lollipop Sign - Ossification at Wire Ends after Osteosynthesis?

INTRODUCTION: Heterotopic ossification (HO) is abnormal formation of new bone in the soft tissue. HO occurs outside the normal bone within soft tissues such as muscles and tendons, and histologically, it is no different from skeletal bone. It is still not clear what factors stimulate HO. The soft tissue around the hip joint has been identified as the most common location for HO. Patients with HO usually have no clinical symptoms; however, it can become very painful and lead to severe functional limitations. The standard diagnostic procedure consists of conventional X-ray diagnostics and/or skeletal scintigraphy. Local radiation and nonsteroidal anti-inflammatory drugs are the classical options for treatment and prophylaxis of HO. We describe two pediatric patients with "lollipop-like" HO at the end of Kirschner wires (K-wires, steel) and titanium elastic nails (TENs, titanium). CASE REPORT: A 9-year-old girl, 1 year after Salter and Pemberton osteotomy with K-wires, and a 15-year-old boy, 1 year after fracture of the right femur treated by osteosynthesis with TENs, were treated in our department due to HO. The girl did not report any symptoms, while the boy had pain in the location where the ossification had formed. However, examination of the girl's hip showed that the range of motion in the hip affected by HO was limited in comparison with the opposite unaffected hip. CONCLUSION: To the best of our knowledge, lollipop-like HO around protruding K-wires or TENs has not yet been described. According to literature, HO is mainly located in the pelvic region and at the elbow. Most studies investigating HO describe cases which have occurred after cemented or uncemented hip replacement surgery. In the cases presented here, HO might have been stimulated by repetitive muscle trauma above the protruding K-wire and TENs, the trauma caused by the operation, bone marrow cells dispersed intraoperatively, or by a combination of these and other factors. There are numerous studies on strategies to prevent HO after joint replacement. We suggest "lollipop sign" as a name for this rare type of HO around the end of K-wires/TENs in pediatric patients.

A single intraperitoneal injection of bovine fetuin-A attenuates bone resorption in a murine calvarial model of particle-induced osteolysis.

Particle-induced osteolysis, which by definition is an aseptic inflammatory reaction to implant-derived wear debris eventually leading to local bone destruction, remains the major reason for long-term failure of orthopedic endoprostheses. Fetuin-A, a 66kDa glycoprotein with diverse functions, is found to be enriched in bone. Besides being an important inhibitor of ectopic calcification, it has been described to influence the production of mediators of inflammation. Furthermore, a regulatory role in bone metabolism has been assigned. In the present study, the influence of a single dose of bovine fetuin-A, intraperitoneally injected in mice subjected to particle-induced osteolysis of the calvaria, was analyzed. Twenty-eight male C57BL/6 mice, twelve weeks of age, were randomly divided into four groups. Groups 2 and 4 were subjected to ultra-high molecular weight polyethylene (UHMWPE) particles placed on their calvariae while groups 1 and 3 were sham-operated. Furthermore, groups 3 and 4 received a single intraperitoneal injection of 20mg bovine fetuin-A while groups 1 and 2 were treated with physiologic saline. After 14days calvarial bone was qualitatively and quantitatively assessed using microcomputed tomography (µCT) and histomorphometrical approaches. Application of fetuin-A led to a reduction of particle-induced osteolysis in terms of visible osteolytic lesions and eroded bone surface. The reduction of bone thickness and bone volume, as elicited by UHMWPE, was alleviated by fetuin-A. In conclusion, fetuin-A was found to exert an anti-resorptive effect on particle-induced osteolysis in-vivo. Thus, fetuin-A could play a potentially osteoprotective role in the treatment of bone metabolic disorders.

Impact of vitamin E-blended UHMWPE wear particles on the osseous microenvironment in polyethylene particle-induced osteolysis.

Aseptic loosening mediated by wear particle-induced osteolysis (PIO) remains the major cause of implant loosening in endoprosthetic surgery. The development of new vitamin E (α-tocopherol)-blended ultra-high molecular weight polyethylene (VE-UHMWPE) with increased oxidation resistance and improved mechanical properties has raised hopes. Furthermore, regenerative approaches may be opened, as vitamin E supplementation has shown neuroprotective characteristics mediated via calcitonin gene-related peptide (CGRP), which is known to affect bone remodeling in PIO. Therefore, the present study aimed to further clarify the impact of VE-UHMWPE wear particles on the osseous microenvironment and to identify the potential modulatory pathways involved. Using an established murine calvaria model, mice were subjected to sham operation (SHAM group), or treated with UHMWPE or VE-UHMWPE particles for different experimental durations (7, 14 and 28 days; n=6/group). Morphometric analysis by micro-computed tomography detected significant (p<0.01) and comparable signs of PIO in all particle-treated groups, whereas markers of inflammation [tumor necrosis factor (TNF)-α/tartrate resistant acid phosphatase (TRAP) staining] and bone remodeling [Dickkopf-related protein 1 (DKK-1)/osteoprotegerin (OPG)] were most affected in the early stages following surgery. Taking the present data into account, VE-UHMWPE appears to have a promising biocompatibility and increased ageing resistance. According to the α-CGRP serum levels and immunohistochemistry, the impact of vitamin E on neuropeptidergic signaling and its chance for regenerative approaches requires further investigation.