TNF-alpha and melphalan-based isolated limb perfusion: no evidence supporting the early destruction of tumour vasculature.

BACKGROUND: Isolated limb perfusion with TNF-alpha and melphalan (TM-ILP) is a highly effective treatment for locally advanced tumours of the extremities. Previous research suggests an almost immediate disintegration of the blood supply of the tumour. The aim of the present study was to verify this hypothesis using non-invasive measurements of microvascular perfusion and tissue oxygenation. METHODS: A total of 11 patients were included in the study. TM-ILP was performed under mildly hyperthermic conditions (39 °C) in the extremities via proximal vascular access. Capillary-venous microvascular blood flow, haemoglobin level (Hb) and oxygen saturation (SO2) were determined using laser Doppler and white-light spectroscopy, respectively, before TM-ILP and at 30 min, 4 h, 1 day, 4 days, 1 week, 2 weeks and 6 weeks after TM-ILP from tumour and healthy muscle tissues. RESULTS: Blood flow and Hb were mostly higher, whereas SO2 was lower, in tumour tissue compared with muscle tissue. In both tumour and muscle tissues, blood flow significantly increased immediately after TM-ILP and remained elevated for at least 2 weeks, followed by a return to the initial values 6 weeks after the procedure. CONCLUSION: No signs were found of early destruction of the tumour vasculature. The observations suggest that an inflammatory reaction is one of the key elements of TM-ILP.

[Hollow organ injury and multiple trauma: treatment, course and outcome - an organ-specific evaluation of 1127 patients from the trauma registry of the DGU]. / Inzidenz von Hohlorganverletzungen nach Trauma: Behandlung, Verlauf und Outcome - eine organspezifische Auswertung von 1127 Patienten des Traumaregisters der DGU.

BACKGROUND: The relevance of hollow organ trauma in severely injured patients within a large collective has not been thoroughly reviewed as yet. This study aimed at assessing the prevalence of hollow organ trauma in relation to the outcome and the currently established method of treatment. PATIENTS AND METHODS: Altogether data of all patients of the Trauma Register of the German Society of Trauma Surgery (DGU) (1993 - 2009) were interpreted retrospectively. All patients with an "Injury Severity Score" (ISS) ≥ 16, direct admission to a trauma centre and an age of ≥ 16 years were included. All patients with abdominal trauma (AISabdomen ≥ 2) were compared with patients with hollow organ trauma (AIShollow organ ≥ 2). The following organs were attributed to the hollow organs: stomach, small intestine (duodenum, jejunum / ileum), colon, gall bladder and urinary bladder. RESULTS: From 9268 patients with abdominal injuries 1127 (12.2 %) additionally showed a hollow organ injury (AISabdomen ≥ 2, AIShollow organ 2 - 5) and were analysed in dependence on the classification of the "American Association for the Surgery of Trauma" (AAST) organ severity score. AAST-hollow organ: II°: 4.6 %, III°: 5.3 %, IV°: 2.1 %, V°: 0.2 %. Patients with leading hollow organ injury (grades IV and V) thereby showed a significant increase of lethality (IV°: 32.7 % and V°: 31.3 %). With an increasing grade of hollow organ injury, however, the ISS increased as well. Lethality was not increased over the expected lethality rate (RISC score) due to the additional hollow organ injury though. CONCLUSION: The results presented here show the prevalence and the outcome of hollow organ injury in a large collective within the Trauma Register of the DGU for the first time.

[A novel two-incision minimally invasive method for the treatment of anterior acetabular fractures]. / Der Zwei-Inzisions-Zugang in der Versorgung von Acetabulumfrakturen.

OBJECTIVES: To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures. INTERVENTION: The first TIMI incision is performed using a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held back using a retraction system. After fracture reduction and fixation by isolated screws a conventional reconstruction plate is inserted for fracture neutralization. RESULTS: Since January 2008 we have performed the TIMI method in 88 cases with good results. Recently we have published the data of a first series with 26 patients that were seen at least 12 months after surgery. The mean operative time was 109 ± 30 min and all incisions showed primary healing. Postoperative radiological examination revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft tissue complications and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The average Harris hip score (HHS) was 86.6 ± 8. Quality of life was comparable to control persons in the same age group. CONCLUSIONS: The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited number of incisions a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in patients with a higher risk for postoperative soft tissue complications.

Sample taking during orthopedic surgery: sensitivity and specificity using the BACTEC blood culture system.

The use of blood culture systems for sterile body fluids other than blood has proven to be superior to routine culture methods. This study was conducted in order to assess the performance of the BACTEC blood culture system compared to swab/tissue sample collection for the detection of infection from intraoperative samples taken during surgical procedures. Sensitivity was determined by taking samples (BACTEC and swab/tissue samples) from patients with clinically evident infection (Infection group). Specificity was tested by taking the same sample sets from patients who had aseptic operations with no history of infection (Control group). The sensitivity was found to be much higher for the BACTEC group (50 isolates from 56 samples, sensitivity: 89%) compared to the swab/tissue samples (29 isolates out of 56 samples, sensitivity: 52%). The specificity was lower in the BACTEC group (32 isolates out of 44 samples, specificity: 27%) compared to the swab/tissue samples (1 isolate out of 44 samples, specificity: 98%). We conclude that BACTEC is useful for intraoperative sample collection in cases of low-grade infection. However, it is less specific and there is always the possibility for contamination. Therefore, it is advisable to use this technique in combination with regular tissue samples.

[Kidney injury and multiple trauma: outcome, course and treatment algorithm. An organ-specific evaluation of 835 patients from the trauma register of the DGU]. / Nierenverletzung und Polytrauma: Outcome, Verlauf und Behandlungsalgorithmus. Eine organspezifische Auswertung von 835 Patienten des TraumaRegisters der DGU.

BACKGROUND: The relevance of renal trauma in severely injured patients within a large collective has not yet been thoroughly reviewed. This study aimed at assessing the prevalence of renal trauma in relation to the outcome and the currently established method of treatment. PATIENTS AND METHODS: Altogether data of 35,664 patients of the TraumaRegister of the German Society of Trauma Surgery (DGU) (1996-2007) were interpreted retrospectively. All patients with an injury severity score (ISS) ≥16, direct admission to a trauma center and an age of ≥16 years were included. All patients with abdominal trauma (AIS(Abdomen) ≥2) were compared with patients with abdominal and renal trauma (AIS(Kidney) ≥2). RESULTS: A total of 18,416 patients fulfilled the inclusion criteria of which 6,218 (34.1%) had abdominal injuries. Of these patients with abdominal injury 835 (13.3%) additionally showed a kidney injury (AIS(Abdomen) ≥2, AIS(Kidney) 2-5) and were analyzed according to the classification of the American Association for the Surgery of Trauma (AAST) organ-severity-score. AAST kidney: II°: 45.5%, III°: 31.1%, IV°: 15.6%, V°: 7.8%. Patients with leading kidney injury (grade IV and V) thereby showed a significant increase in mortality (IV: 32.3% and V: 40.0%) and an increase in the need for surgical intervention (IV: 61.5 and V: 81.5%). With an increasing grade of renal injury, however, the ISS is also increased but mortality was not increased over the expected mortality rate (RISC score) due to the additional renal injury. Dialysis rate in the surviving patients showed an increased rate depending on the degree of the kidney injury (II: 5.5%, III: 7.6%, IV: 18.8%, V: 8.3%). CONCLUSION: The results presented here show the prevalence and the outcome of kidney injury in a large collective within the TraumaRegister of the DGU for the first time. Based on the current literature and the findings a treatment algorithm has been developed.

[Multisegmental and minimally invasive dorsal stabilization of thoracic and lumbar vertebral column. Operative technique]. / Multisegmentale und minimal-invasive dorsale Stabilisierung der Brust- und Lendenwirbelsäule : Operative Technik.

Dorsal stabilization of the thoracic and lumbar vertebral column is still the fundamental technique for acute treatment of unstable vertebral fractures and intervertebral ligament injuries as well as in tumor surgery and the treatment of degenerative and inflammatory diseases. The aim is to achieve the best possible anatomical and axis-correct stabilization of the physical lordosis and kyphosis. This article describes in detail the operational preparation (e.g. necessary imaging, possible positioning of the patient) and procedure (e.g. access, placement of screws and plates, wound closure and postoperative follow-up treatment) and possible complications due to misplaced pedicle screws, the rate of which can possibly be reduced by intraoperative 3D imaging.

[Open pertrochanteric fracture of the femur and post-traumatic osteitis in a child : Interposition of a pedicled vascularized fibula to preserve the femoral head]. / Offene pertrochantäre Femurfraktur und posttraumatischer Osteitis beim Kind : Interposition einer gefäßgestielten Fibula zum Hüftkopferhalt.

The free microvascular fibula diaphysis transplant as femoral neck replacement with preservation of the patient's own femoral head due to a severe infection situation represents a rare indication in the treatment of young patients. In the current literature, such surgical methods do not exist. In the case described here, the free microvascular fibula transplant serves as femoral neck replacement with preservation of the patient's own femoral head without any postoperative mobility restrictions. The depicted course of the disease not only shows the effectiveness of this form of treatment in aseptic femoral head necrosis, but also represents a possible treatment in severe infection situations after trauma.

[Minimally invasive dorsal stabilization of the thoracolumbar spine]. / Minimal-invasive dorsale Stabilisierung der thorakolumbalen Wirbelsäule.

Thoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.

[Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume replacement - an analysis of 604 patients from the trauma registry of the DGU]. / Letalität und Outcome beim Mehrfachverletzten nach schwerem Abdominal- und Beckentrauma. Einfluss der präklinischen Volumengabe - Eine Auswertung von 604 Patienten des TraumaRegisters der DGU.

BACKGROUND: Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries. PATIENTS AND METHODS: All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml). RESULTS: Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions. CONCLUSION: In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.

No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of The trauma registry of the DGU with 1,630 patients.

OBJECTIVE: Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure. METHODS: 13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score >16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)). RESULTS: From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (>10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%). CONCLUSIONS: Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

[Giant cell tumors of soft tissue arising in surgical scars]. / Riesenzelltumoren des Weichgewebes (mit niedrig-malignem Potenzial) in Operationsnarben.

Giant cell tumor of soft tissue (GCT-ST) is a rare primary soft tissue tumor with low malignant potential. It is clinically and pathologically similar to the giant cell tumor of the bone. Two cases of GCT-ST in surgical scars are reported. Both tumors were initially regarded as tumor relapses of a leiomyosarcoma of deep soft tissue and a dermal in situ squamous cell carcinoma, respectively. The development of GCT-ST in surgical scars has not been observed previously. These findings suggest chronic inflammation and tissue repair as etiological factors in the development of GCT-ST. The period of time between initial surgical intervention and the development of the GCT-ST seems to be unusually short for the development of a "true" second neoplasm, which may underline the sometimes diffuse border between reactive "pseudosarcomatous" and neoplastic fibro-histiocytic lesions.

[Bite injuries of the hand]. / Bissverletzungen der Hand.

Bite injuries of the hand have a clearly increased risk for infection compared with other regions. Surgical treatment of the wound is indicated, and the debridement must be done thoroughly and with consideration of the wound closure. Antibiotic therapy may be indicated in addition to the surgery if signs of infection exist. Antibiotics alone are not a suitable treatment. Common complications in cases of deficient primary therapy are flexor tenosynovitis, purulent arthritis, and phlegmons of the dorsal hand. These are emergencies and need immediate surgical intervention.

[Embolization of life-threatening intercostal hemorrhaging in a severely injured patient: a rarity in trauma care]. / Embolisation einer lebensbedrohlichen Interkostalblutung bei einem Schwerstverletzten : Eine Rarität in der Traumaversorgung.

Transarterial embolization of ruptured intercostal arteries due to massive bleeding represents an infrequent indication in severely injured patients. The current literature shows isolated case descriptions but no clinical trials exist. In the case depicted here embolization is represented as a form of therapy after haemorrhagic shock caused by a ruptured intercostal artery. The embolization carried out led to an immediate cessation of bleeding. The vital signs returned to normal immediately after the procedure and surgical intervention could be avoided. The course of the disease represented in the following shows the effectiveness of this type of treatment not only for bleeding due to pelvic fractures and abdominal injuries, but also for isolated arterial bleeding in other body regions.

[Isolated limb perfusion for liposarcoma : Histopathological response and subgroup analysis after TNF melphalan-based ILP]. / Isolierte Extremitätenperfusion bei Liposarkomen : Histopathologisches Ansprechen und Subgruppenanalyse nach TNF-Melphalan-ILP.

BACKGROUND: Tumor necrosis factor alpha (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is one of the most effective treatment modalities for unresectable soft tissue sarcoma (STS) of the extremities. Liposarcomas (LS) are a large and heterogeneous subgroup of STS with different biological behavior and prognoses. The aim of this study was to evaluate LS and the different subentities with respect to their responsiveness towards TM-ILP. METHODS: We matched our ILP database with our pathology database to identify patients who received TM-ILP due to STS followed by resection of the residual tumor. We identified 126 patients who matched these inclusion criteria. In this patient group we identified 24 patients with a LS. Histopathological regression was assessed from all resection specimens and was compared between groups: LS vs. non-LS and for myxoid and non-myxoid LS subgroups. RESULTS: There were no significant differences in the overall tumor regression comparing non-LS (median 95%, mean 77%) and LS (median 90%, mean 74%). For the subgroup analysis, a higher grade of regression after TM-ILP was found in myxoid-LS (median 95%, mean 79% ± 31.5) compared to the non-myxoid LS (median 75%, mean 72% ± 24.6). Atypical lipomatous tumors (ALT) were less responsive to TM-ILP treatment (median 40%, mean 40%). CONCLUSION: The histopathological response of LS toward TM-ILP is equally good compared to non-lipomatous STS. Myxoid LS seem to have a tendency towards a better response to TM-ILP compared to non-myxoid LS and ALT showed the lowest response rate in the liposarcoma subgroup. Furthermore, we found that TM-ILP seems to facilitate successful R0 resection. Due to the low number of cases in the subgroups we advocate further research on this topic.

[Management of polytrauma]. / Management des Polytraumas.

The first hours after trauma are decisive. Therefore the treatment chosen demands very strict planning according to concepts of modern quality management. This begins with the fastest possible and most efficient delivery of injured patients to the applicable clinic. Such institutions are permanently ready and have at their service all the necessary diagnostic techniques and surgical and intensive care methods. Effective shock treatment entails standardized procedures accompanied by up-to-date diagnostic and therapeutic measures. After admittance and therapy of life-threatening injuries (immediate measures, damage control surgery), early-stage surgery will follow (soft tissue injuries and fractures). Strategy of damage control orthopedics is growing in acceptance because of the potential danger to life functions due to pro- and anti-inflammatory response induced additional trauma caused by following surgery. Fractures initially stabilized by external fixation can consecutively be treated safely by secondary conversion osteosynthesis. A considerable improvement in quality can be attained through therapeutic procedures approved by all concomitant disciplines and standardized systems with internal and external control methods.

[Current diagnostics for intra-abdominal trauma]. / Moderne Diagnostik des Bauchtraumas.

In case of suspected intra-abdominal injury, fast transport of the patient to a suitable hospital is of high priority. The initial clinical examination aims at identifying patients with potentially life-threatening bleeding that require emergency surgery. In patients with penetrating trauma, laparoscopy is favoured to exclude suspected perforation of the peritoneum. If a peritoneal perforation is identified, exploratory laparotomy is recommended to exclude or treat lacerations of the hollow viscus. Although clinical examination should be performed its sensitivity and specificity of up to 82% and 45%, respectively, are not sufficient as the sole screening method. For the further diagnostic workup, diagnostic peritoneal lavage has been completely replaced by abdominal ultrasound examination in Germany and many other countries. Focussing not only on the detection of free abdominal fluid but also searching for parenchymal organ lesions and performing repeated examinations increases accuracy up to 96%, with specificity of 99.8% and sensitivity of 72.1%. Computed abdominal tomography with a helical scanner with and without intravenous contrast media is currently the gold standard of imaging techniques to identify traumatic abdominal injuries. A sensitivity of 97.2% and specificity of 94.7% can be achieved. False negative findings must be expected with hollow organ injuries. Serial clinical and ultrasound examinations as well as lab testing in conjunction with repeated CT may help to identify such lesions. Increased intra-abdominal pressure (IAP) with consecutive abdominal compartment syndrome and multiple organ dysfunction is a delayed complication from conditions such as severe intra-abdominal bleeding, major bleeding from pelvic ring fractures, and profuse fluid resuscitation. The IAP should be measured routinely in patients at risk, and decompression laparotomy may be indicated with pressures of higher than 20 mmHg.

Neoadjuvant treatment improves capsular integrity and the width of the fibrous capsule of high-grade soft-tissue sarcomas.

BACKGROUND: Neoadjuvant treatment is thought to improve resection with margin-negative surgery in locally advanced soft-tissue sarcomas (STS). Treatment-induced alterations of the tumor peripheryhave not yet been microscopically evaluated. OBJECTIVE: This histopathological study compared limb STS with primary resection and those that had undergone neoadjuvant treatment, emphasizing microscopic changes of the fibrous capsule (FC) and reactive zone (RZ) after neoadjuvant treatment. PATIENTS AND METHODS: Patients with primary high-grade limb sarcomas (N = 76) which have not previously been treated were included. Of those, 37 were primarily resected and 39 were treated with one of the following neoadjuvant treatment modalities: 7x chemotherapy (CTX), 3x radiotherapy (RT), 15x isolated limb perfusion (ILP), 8x CTX + RT, and 6x CTX + ILP. Sizes of the FC and RZ were microscopically measured, and FC-integrity was documented. Histopathologic regression was expressed as a percent. RESULTS: Only 35.1% of untreated sarcomas showed an intact FC. We observed significantly higher capsular integrity after treatment (76.9%). Additionally, the average width of the FC (0.21 mm vs. 0.61 mm) and RZ (0.67 mm vs. 1.48 mm) increased significantly. The extent of histopathologic regression showed a correlation with capsular integrity and width. The combination of two treatment modalities (CTX + RT or ILP) showed strongest effects at the tumor periphery. CONCLUSIONS: Neoadjuvant treatment stabilizes the tumor periphery in STS (e.g., the capsule). Concerning local treatment strategies, these novel histopathologic insights might significantly influence the decision as to whether primary resection is advisable in advanced local soft-tissue sarcoma.

Retrospective lifetime estimation of failed and explanted diamond-like carbon coated hip joint balls.

Diamond-like carbon (DLC) coatings are known to have extremely low wear in many technical applications. The application of DLC as a coating has aimed at lowering wear and to preventing wear particle-induced osteolysis in artificial hip joints. In a medical study femoral heads coated with diamond-like amorphous carbon, a subgroup of DLC, articulating against polyethylene cups were implanted between 1993 and 1995. Within 8.5 years about half of the hip joints had to be revised due to aseptic loosening. The explanted femoral heads showed many spots of local coating delamination. Several of these explanted coated TiAlV femoral heads have been analyzed to investigate the reason for this failure. Raman analysis and X-ray photoelectron spectroscopy (XPS) depth profiling showed that the coating consists of diamond-like amorphous carbon, several Si-doped layers and an adhesion-promoting Si interlayer. Focused ion beam (FIB) transverse cuts revealed that the delamination of the coatings is caused by in vivo corrosion of the Si interlayer. Using a delamination test set-up dissolution of the silicon adhesion-promoting interlayer at a speed of more than 100 µm year(-1) was measured in vitro in solutions containing proteins. Although proteins are not directly involved in the corrosion reactions, they can block existing small cracks and crevices under the coating, hindering the exchange of liquid. This results in a build-up of crevice corrosion conditions in the crack, causing a slow dissolution of the Si interlayer.