Severe necrotizing soft tissue infections-Is wound microbiology a prognostic factor for clinical outcome?

Necrotizing soft tissue infections (NSTIs) represent similar pathophysiological features, but the clinical course might range from subacute to a rapidly progressive, fulminant sepsis. Initial wound microbiology is the base for the Guiliano classification. The timeline of microbiological colonization has not been described during the clinical course. The role of the different microbiological pathogens on the outcome and mortality is unclear. One hundred eighty patients were included with septic inflammation response syndrome on admission. Initial wound microbiology and the changes in wound microbiology were analysed during the clinical course and correlated with outcome and risk indicators. Overall mortality was 35%. Higher age, a high Charlson Comorbidity Index or ASA score and truncal infections were highly prognostic for a lethal outcome. Microbiological findings revealed significant differences in the persistence of bacteria during the course of disease. Streptococci were only detectable within the first 5 days, whereas other bacteria persisted over a longer period of time. Initial microbiological findings correlated with better prognosis when no causative agent was identified and for gram-negative rods. Varying survival rates were observed for different Streptococci, Staphylococci, Enterococci and other bacteria. The highest odds ratio for a lethal outcome was observed for Enterococci and fungi. Microbiological colonization changes during the clinical course of NSTIs and some microbiologic pathogens are predictive for worsening the outcome and survival. Streptococcus pyogenes is only detectable in the very early phase of NSTI and after 6 days not anymore detectable. Later Enterococci and fungi showed the highest odds ratios for a lethal outcome. Enterococci bacteria and fungi have yet not been considered of clinical relevance in NSTI or even as indicator for worsening the outcome.

[LiLa classification for paediatric long bone fractures. Intraobserver and interobserver reliability]. / LiLa-Klassifikation für Frakturen der langen Röhrenknochen im Wachstumsalter. Intra- und Interobserverreliabilität.

BACKGROUND: There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS: During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS: A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS: The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.

[Utilization rates of lower extremity prostheses in Germany and Switzerland: A comparison of the years 2005-2008]. / Verwendungsraten von Prothesen der unteren Extremität in Deutschland und der Schweiz: Ein Vergleich der Jahre 2005-2008.

BACKGROUND: In the United States the use of total hip arthroplasty (THA) has substantially increased over the last decade. It is not known, however, if this trend can be applied to other countries as well. The aim of the current study was therefore a detailed comparison of hip, knee, and ankle arthroplasty utilization rates in Germany and Switzerland in the years 2005-2008 and a secondary comparison with the United States. PATIENTS AND METHODS: Based on datasets from the national statistical offices the number of inhabitants, gender and age distributions and the number of primary and revision surgeries were determined. These figures served for calculating primary, revision and overall surgical volumes, revision burden, primary and revision rates per 100,000 inhabitants, gender and age-specific primary and revision rates. A comparably smaller dataset was provided for the respective US analyses. RESULTS: In Germany, Switzerland and the US the number of implanted total and partial hip arthroplasties per 100,000 inhabitants rose from 235.8, 238.2 and 116.8 in 2005 to 254.7, 262.7 and 127.3 in 2008, respectively. For total and partial knee arthroplasty the rates were 156.3, 140.1 and 178.2 implantations in 2005 and 188.3, 176.8 and 213.6 in 2008, respectively. With 13.6% the revision burden in Germany was 3.6% higher than in Switzerland and accounted for 11.2% in the US. In 2008 it was 15.1% in Germany, was hence 4.6% higher than in Switzerland and remained stable at 11.2% in the US. For knee replacements the 2005 German revision burden was 11.1% which was 3.5% higher than in Switzerland and was 7.4% in the US. In 2008 it was 12.8% in Germany and 4.2% lower in Switzerland and in the US it accounted for 8.9%. In all three countries the revision burden for knee arthroplasty was constantly lower than for hip arthroplasty. CONCLUSION: In all three countries the primary rates for hip and knee replacements rose over the years but those for knee arthroplasty to a higher extent. The 2008 revision burden was highest in Germany for both types of arthroplasty. In Switzerland there was a transient revision burden decrease with a new increase from the year 2007 onwards. The US hip replacement utilization rates per 100,000 inhabitants were considerably lower than those in Germany and Switzerland and for knee replacements they were slightly higher.

[Do paediatric and adult surgeons follow different approaches to physeal fractures?]. / Haben Kinderchirurgen und Erwachsenenchirurgen unterschiedliche Therapieansätze bei der Behandlung von Wachstumsfugenlösungen?

INTRODUCTION: The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS). METHODS: 62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases. RESULTS: Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis. DISCUSSION: There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

[Diagnostic approaches to acute knee injury in childhood and adolescence. Yesterday and today]. / Diagnostisches Vorgehen beim Kniegelenktrauma im Kindes- und Jugendalter. Gestern und heute.

INTRODUCTION: Clinical examination of acute knee injury in childhood is often difficult and therefore magnetic resonance imaging (MRI) serves as an additional diagnostic tool. The aim of the present study was to evaluate on the one hand the indications for diagnostic arthroscopy and on the other hand the indications for MRI. METHODS: Of the children treated between 1990 and 1999, 87 (group 1) underwent arthroscopy after clinical examination. Between 2000 and 2006 (group 2) 83 patients were examined using MRI after clinical examination and 53 were subsequently submitted to arthroscopy. RESULTS: In group 1 the clinical diagnosis was verified by arthroscopy in 79%. In group 2 the clinical and arthroscopic diagnoses were consistent in 60% of the patients. The MRI diagnosis was correctly recognized for patella dislocation in all cases, for ligament injuries in 83% and for meniscus injuries in 56%. Due to the application of MRI before arthroscopy the fraction of diagnostic arthroscopies could be reduced from 22% to 13%. CONCLUSION: The number of diagnostic arthroscopies in childhood can be reduced by application of MRI.

Effects of local delivery of trapidil on neointima formation in a rabbit angioplasty model.

1. Smooth muscle cell (SMC) proliferation can result in luminal reduction of a vessel following balloon angioplasty. This study was designed (i) to determine if local administration of trapidil (triazolopyrimidine) into a vessel wall reduces neointima formation, and (ii) to explore the mechanism involved in the subsequent reduction in cell proliferation. 2. Following balloon angioplasty in 40 anaesthetized New Zealand White rabbits, trapidil (50-200 mg) or its vehicle (saline) was injected into the dilated vessel wall of the right femoral artery. Experimental groups and time of investigation: (I) vehicle (2 weeks, n = 3), (II) trapidil-100 mg (2 weeks, n = 3), (III) vehicle (3 weeks, n = 8), (IV) trapidil-50 mg (3 weeks, n = 5); (V) trapidil-100 mg (3 weeks, n = 9) or (V) trapidil-200 mg (3 weeks, n = 7). 3. After 2 weeks, there was a significant reduction of intimal hyperplasia (expressed as intima to media area ratio) in the trapidil group compared with vehicle (0.44 +/- 0.04 vs 0.93 +/- 0.04, *P < 0.05) and also a significant reduction in cell proliferation (% ratio of BrdU-positive cells to total cell number: vehicle 14 +/- 2% vs trapidil 6 +/- 1%, *P < 0.05). 4. After 3 weeks, there was a dose-dependent reduction of intimal hyperplasia in the trapidil groups compared with vehicle (trapidil 50 mg 1.14 +/- 0.04; trapidil 100 mg 0.91 +/- 0.09*; trapidil 200 mg 0.77 +/- 0.09* vs vehicle 1.67 +/- 0.23, *P < 0.05). 5. Thus, the local administration of trapidil to the rabbit femoral artery reduces the neointima formation, which occurs 2 or 3 weeks after balloon angioplasty via a mechanism, which is dependent on inhibition of cell proliferation.