[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

Improved gait parameters following surgical revascularization in patients with intermittent claudication.

Objective: Intermittent claudication (IC) is known to be associated with impaired gait parameters, with a higher incidence of falls and higher oxygen consumption due to uneconomic walking. However, the influence of arterial disobliteration in patients with IC on their gait pattern has rarely been investigated to date. The aim of this study was to examine the gait patterns before and after inflow revascularization by surgical disobliteration of pelvic and inguinal arteries (ie, common iliac artery, external iliac artery, common femoral artery, profound femoral artery, superficial femoral artery) in IC patients. Successful surgical disobliteration of inflow arteries (improvement of ankle brachial pressure index of ≥0.2 and patent common iliac, external iliac, common femoral, profound femoral, and superficial femoral arteries) is known to improve the painless walking distance for patients with IC due to peripheral arterial disease; however, its influence on gait parameters is unclear. We hypothesized that the gait parameters would also improve after surgery. Improved gait parameters can lead to a more economic walking process, lower oxygen consumption, a lower risk of falls, and a higher quality of life. Methods: In a single-center, exploratory, longitudinal study, we examined the gait parameters of 20 IC inpatients of our hospital before and after surgical disobliteration of pelvic and inguinal arteries. Spatiotemporal parameters such as range of motion of the hip and knee joint, stance phase, cadence, and foot rotation were obtained using the Diers 4Dmotion Lab (Diers International). The gait parameters were obtained under painful walking conditions preoperatively and with the patients walking pain free at the same speed postoperatively. Results: A total of 20 patients were examined. Surgical revascularization led to a higher walking cadence (mean, plus 7.88 steps; 95.5 steps/min vs 87.6 steps/min; P = .024), an increased range of motion of the hip joint (mean, plus 2.0°; 35.1° vs 33.1°; P = .038), and improved foot rotation (mean, plus 2.0°; 11.0° vs 9.0°; P = .02). Regarding other parameters such as step length, stance phase, and step duration, smaller differences were detected in this study. Conclusions: In this exploratory study, we found that surgical revascularization of pelvic and inguinal arteries in IC patients improved certain gait parameters. Further studies with larger patient numbers are needed to confirm these data and provide more evidence on this subject.

Current Trends in Orthopaedics and Trauma in Germany.

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

Effect of Expansion Media on Functional Characteristics of Bone Marrow-Derived Mesenchymal Stromal Cells.

The therapeutic efficacy of mesenchymal stromal cells (MSCs) has been shown to rely on their immunomodulatory and regenerative properties. In order to obtain sufficient numbers of cells for clinical applications, MSCs have to be expanded ex vivo. Expansion media with xenogeneic-free (XF) growth-promoting supplements like human platelet lysate (PL) or serum- and xenogeneic-free (SF/XF) formulations have been established as safe and efficient, and both groups provide different beneficial qualities. In this study, MSCs were expanded in XF or SF/XF media as well as in mixtures thereof. MSCs cultured in these media were analyzed for phenotypic and functional properties. MSC expansion was optimal with SF/XF conditions when PL was present. Metabolic patterns, consumption of growth factors, and secretome of MSCs differed depending on the type and concentration of supplement. The lactate per glucose yield increased along with a higher proportion of PL. Many factors in the supernatant of cultured MSCs showed distinct patterns depending on the supplement (e.g., FGF-2, TGFß, and insulin only in PL-expanded MSC, and leptin, sCD40L PDGF-AA only in SF/XF-expanded MSC). This also resulted in changes in cell characteristics like migratory potential. These findings support current approaches where growth media may be utilized for priming MSCs for specific therapeutic applications.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents.

BACKGROUND AND PURPOSE: The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training. MATERIAL AND METHODS: We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019. RESULTS: Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events. CONCLUSION: A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

Evaluation of the decision-making process within the table-top exercise of the Terror and Disaster Surgical Care (TDSC®) course.

PURPOSE: The threat of terror is omnipresent in Europe and the number of attacks worldwide is increasing. The target of attacks in Europe is usually the civilian population. Incalculable dangerous situations at the scene of the event and severe injury patterns such as complex gunshot and explosion injuries with a high number of highly life-threatening people present rescue forces, emergency physicians and subsequently hospitals with medical, organizational as well as tactical and strategic challenges. The Terror and Disaster Surgical Care (TDSC®) course trains clinical decision-makers to meet these challenges of a TerrorMASCAL in the first 24-48 h. METHODS: A table-top exercise was developed for the TDSC® course as a decision training tool, which was prospectively evaluated in six courses. The evaluation took place in 3 courses of the version 1.0, in 3 courses in the further developed version 2.0 to different target values like, e.g., the accuracy of the in-hospital triage. Furthermore, 16 TDSC® course instructors were evaluated. RESULTS: For the evaluation, n = 360 patient charts for version 1.0 and n = 369 for version 2.0 could be evaluated. Overall, the table-top exercise was found to be suitable for training of internal clinical decision makers. Version 2.0 was also able to depict the action and decision-making paths in a stable and valid manner compared to the previous version 1.0. The evaluation of the instructors also confirmed the further value and improvement of version 2.0. CONCLUSION: With this prospective study, the table-top exercise of the TDSC® course was tested for decision stability and consistency of the participants' decision paths. This could be proven for the selected target variables, it further showed an improvement of the training situation. A further development of the table-top exercise, in particular also using digital modules, will allow a further optimization. http://www.bundeswehrkrankenhaus-ulm.de.

A novel approach for large-scale manufacturing of small extracellular vesicles from bone marrow-derived mesenchymal stromal cells using a hollow fiber bioreactor.

Mesenchymal stromal cells (MSCs) are promising therapeutic candidates in a variety of diseases due to having immunomodulatory and pro-regenerative properties. In recent years, MSC-derived small extracellular vesicles (sEVs) have attracted increasing interest as a possible alternative to conventional cell therapy. However, translational processes of sEVs for clinical applications are still impeded by inconsistencies regarding isolation procedures and culture conditions. We systematically compared different methods for sEV isolation from conditioned media of ex vivo expanded bone marrow-derived MSCs and demonstrated considerable variability of quantity, purity, and characteristics of sEV preparations obtained by these methods. The combination of cross flow filtration with ultracentrifugation for sEV isolation resulted in sEVs with similar properties as compared to isolation by differential centrifugation combined with ultracentrifugation, the latter is still considered as gold standard for sEV isolation. In contrast, sEV isolation by a combination of precipitation with polyethylene glycol and ultracentrifugation as well as cross flow filtration and size exclusion chromatography resulted in sEVs with different characteristics, as shown by surface antigen expression patterns. The MSC culture requires a growth-promoting supplement, such as platelet lysate, which contains sEVs itself. We demonstrated that MSC culture with EV-depleted platelet lysate does not alter MSC characteristics, and conditioned media of such MSC cultures provide sEV preparations enriched for MSC-derived sEVs. The results from the systematic stepwise evaluation of various aspects were combined with culture of MSCs in a hollow fiber bioreactor. This resulted in a strategy using cross flow filtration with subsequent ultracentrifugation for sEV isolation. In conclusion, this workflow provides a semi-automated, efficient, large-scale-applicable, and good manufacturing practice (GMP)-grade approach for the generation of sEVs for clinical use. The use of EV-depleted platelet lysate is an option to further increase the purity of MSC-derived sEVs.

Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU®).

PURPOSE: Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated. METHODS: We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score. RESULTS: We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected. CONCLUSION: We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.

Research in orthopaedic trauma surgery: approaches of basic scientists and clinicians and the relevance of interprofessional research teams.

BACKGROUND: An increasing clinical workload and growing financial, administrative and legal burdens as well as changing demands regarding work-life balance have resulted in an increased emphasis on clinical practice at the expense of research activities by orthopaedic trauma surgeons. This has led to an overall decrease in the number of scientifically active clinicians in orthopaedic trauma surgery, which represents a serious burden on research in this field. In order to guarantee that the clinical relevance of this discipline is also mirrored in the scientific field, new concepts are needed to keep clinicians involved in research. METHODS: Literature review and discussion of the results of a survey. RESULTS/CONCLUSION: An interdisciplinary and -professional team approach involving clinicians and basic scientists with different fields of expertise appears to be a promising method. Although differences regarding motivation, research focuses, funding rates and sources as well as inhibitory factors for research activities between basic scientists and clinicians exist, successful and long-lasting collaborations have already proven fruitful. For further implementation of the team approach, diverse prerequisites are necessary. Among those measures, institutions (e.g. societies, universities etc.) must shift the focus of their support mechanisms from independent scientist models to research team performances.

[Orthopedics and trauma surgery-Decathlon of medicine : Is a full education possible during resident education?] / Orthopädie und Unfallchirurgie ­ Zehnkampf der Medizin : Doch werden wir dem in der Weiterbildung noch gerecht?

BACKGROUND: When the specialties of orthopedics and trauma surgery were merged in 2006 in Germany, the learning content significantly increased while the training time remained the same. Less and less junior doctors learn the whole spectrum of orthopedics and trauma surgery for diagnosis, treatment and aftercare options. OBJECTIVE: How can continuing education concepts be designed to meet the wide range of theoretical and practical content required in residency training to become an orthopedic and trauma surgeon? RESULTS AND CONCLUSION: Orthopedics and trauma surgery is one of the most diverse specialties in terms of patients, clinical pictures and fields of activity. Accordingly, residency training must also be broadly based. This can be achieved through structured and well-planned training concepts. Furthermore, digital simulators could be used to prepare residents for working with patients. Rotation models in the outpatient area could also be beneficial in order to gain an insight into the outpatient care of musculoskeletal diseases. In addition to the active involvement of the resident in the training, the interest and participation of the trainers is also important in order to actively promote junior physicians and prepare them for their later work.

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

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

Diagnostic options for blunt abdominal trauma.

PURPOSE: Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature. METHODS: We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm. RESULTS: A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries. CONCLUSIONS: MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

[Safety aspects, emergency preparedness and hazard prevention in hospitals concerning mass casualty incidents (MCI)/terror-related MCI : Prospects on future challenges based on survey results from the 3rd emergency conference of the DGU]. / Sicherheitsaspekte und Vorbereitung zur Notfallvorsorge und Gefahrenabwehr in Kliniken bei MANV/TerrorMANV : Ausblick auf zukünftige Herausforderungen anhand von Umfrageergebnissen zur 3. Notfallkonferenz der DGU.

BACKGROUND: Worldwide terrorist activities since "9/11" and subsequently also in the European region have led to a rethinking in the context of the evaluation of critical infrastructure in Germany, also with respect to security at and in hospitals. OBJECTIVE: This publication deals with the evaluation of existing concepts on topics such as "alerting", "security", "communication" and "preparation" in the aforementioned context. MATERIAL AND METHODS: Based on a literature review as well as a survey among participants of the 3rd emergency conference of the DGU (German Society for Trauma Surgery), this topic and the currently existing situation are further analyzed and presented. RESULTS: The data obtained illustrate that while the majority of hospitals have a hospital alert and response planning, the frequency of updates and intrahospital communication to increase awareness show significant variation. Furthermore, the results illustrate a heterogeneity of the existing intrahospital alerting concepts as well as a lack of security concepts and cooperation with security and guard services. Furthermore, it is evident that the topic of a possible CBRN (chemical, biological, radiological, nuclear) threat is not yet adequately perceived or implemented in the risk analysis. DISCUSSION: The latent threat of terrorist activities appears to have led German hospitals to address the issue of hospital alarm and response planning in their assessment as critical infrastructure and to have implemented this for the most part; however, the subordinated areas and the consequences that can be derived from alarm planning do not yet show the necessary stringency to ultimately ensure adequate responses in these special scenarios with respect to security in and at German hospitals.

Neuromapping of the Capsuloligamentous Knee Joint Structures.

PURPOSE: To investigate neuromuscular electromyographic response of the of the upper and lower leg muscles after the application of an intraoperative, isolated mechanical stimulus of the capsuloligamentous structures, including the anterior (ACL) and posterior cruciate ligaments (PCL), lateral (LM) and medial menisci (MM), plica mediopatellaris (PM), and Hoffa's fat pat (HFP). METHODS: The electromyographic response of the upper and lower leg muscles (M. rectus femoris; M. vastus medialis; M. semitendinosus; M. biceps femoris; M. gastrocnemius lateralis) of 15 male patients were measured after an isolated mechanical stimulus of the capsuloligamentous structures during an arthroscopic intervention using a customized intraoperative setup. Target parameters were the short (SLR; <30 milliseconds) and medium latency responses (MLR; >30 milliseconds) after the mechanically-induced trigger. RESULTS: The ACL, PCL, LM, and MM displayed high interindividual reproducibility of >76%. The MM was the only structure indicating both an SLR and MLR for all muscles. Although signals could be detected, there was no reproducibility in electromyographic signal activation for the HFP. The most rapid MLR was observed for the PM (quadriceps: 37 milliseconds). CONCLUSIONS: Each stimulated structure displayed an individual MLR response, which allowed us to create neuromapping combining the anatomical and quantitative representations of the individual muscular activation patterns after isolated mechanical stimulation of the capsuloligamentous knee joint structures, corroborating our hypothesis. LEVEL OF EVIDENCE: Diagnostic - Level II.