Systemic acylcarnitine levels are affected in response to multiple injuries and hemorrhagic shock - an analysis of lipidomic changes in a standardized porcine model.

INTRODUCTION: Along with recent advances in analytical technologies, TCA-cycle intermediates are increasingly identified as promising makers for cellular ischemia and mitochondrial dysfunction during hemorrhagic shock (HS). For traumatized patients, the knowledge of the role of lipid oxidation substrates is sparse. In this study, we aimed to analyze the dynamics of systemic acylcarnitine (AcCa) release in a standardized polytrauma model with HS. METHODS: 52 male pigs (50 ± 5 kg) were randomized into two groups: Group IF (isolated fracture) was subject to a standardized femur shaft fracture. Group PT (polytrauma) was subject to a femur fracture, followed by blunt chest trauma, liver laceration and a pressure controlled hemorrhagic shock for 60 min. Resuscitation was performed with crystalloids. Fractures were stabilized by intramedullary nailing. Venous samples were collected at 6 timepoints (baseline, trauma, resuscitation, 2 h, 4 h and 6 h). Lipidomic analysis was performed via liquid chromatography coupled mass spectrometry. Measurements were collated with clinical markers and near-infrared spectrometry measurements (NIRS) of tissue perfusion. Longitudinal analyses were performed with linear mixed models and spearman's correlations were calculated. A p-value of 0.05 was defined as threshold for statistical significance. RESULTS: From a total of 303 distinct lipids, we identified two species of long-chain AcCas. Both showed a highly significant (p < 0.001) two-fold increase after HS in Group PT that promptly normalized after resuscitation. This increase was associated with a significant decrease of the base excess (p = 0.005) but recovery after resuscitation was faster. For both AcCas, there were significant correlations with decreased muscle tissue oxygen delivery (p = 0.008, p = 0.003) and significant time-lagged correlations with the increase of creatine kinase (p < 0.001, p < 0.001). CONCLUSION: Our results point to plasma AcCas as a possible indicator for mitochondrial dysfunction and cellular ischemia in HS. The more rapid normalization after resuscitation in comparison to acid base changes may warrant further investigation. STUDY TYPE: Experimental Animal Model. LEVEL OF EVIDENCE: N/A.

Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients.

PURPOSE: Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma-specific assessment of the lower extremities for injuries. This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase. METHODS: This diagnostic, prognostic observational cohort study was performed on trauma patient treated at one level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g., open fracture), active elevation of the leg, and cautious elevation of the lower extremity from the heel. SILENT was considered positive when obvious fracture was present and painful or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity, and receiver operating characteristic testing. RESULTS: 403 trauma bay patients were included, mean age 51.6 (SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity was 75% (95%CI 64 to 84%), and overall specificity was 99% (95%CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. AUC was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99). CONCLUSION: The SILENT test is a clinical applicable and feasible rule-out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging. Further large-scale prospective studies might be required to corroborate the beneficial effects of the SILENT test.

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND: The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS: In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS: Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION: Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

3D-navigation for SI screw fixation - How does it affect radiation exposure for patients and medical personnel?

BACKGROUND: 3D-navigation for percutaneous sacroiliac (SI) screw fixation is becoming increasingly common and several studies report great advantages of this technology. However, there is still limited clinical evidence on the efficacy regarding radiation exposure for patient and personnel. METHODS: This is a retrospective, single-center cohort study. All patients who underwent percutaneous sacroiliac screw fixation for an injury of the posterior pelvic ring from 2014 to 2021 were screened. Inclusion criteria were: conclusive radiation dosage reports, signed informed consent, a twelve month follow up and a complete data set. Patients were stratified in two groups (3D-navigation (Group 3D-N) vs. control (Group F)) based on the imaging modality used. Primary outcomes were radiation exposure for patient and personnel. Secondary outcomes were reoperations, complications, and intraoperative precision. RESULTS: Of 392 patients screened, 174 patients (3D-N: n = 50, F: n = 124) could be included for final analysis. We noted a significant reduction of the dose corresponding to potential radiation exposure for medical personnel (-15.3 mGy, 95 %CI: -2.1 to -28.5, p = 0.0232), but also a significant increase of the dose quantifying radiation exposure for patients (+77.0 mGy, 95 %CI: +53.3 to +100.6, p < 0.0001), when using navigation. In addition, the rate of radiographic malplacement was significantly reduced (F: 11.3% vs. 3D-N: 0 %, p = 0.0113) despite a substantial increase in transsacral screw placement (F: 19.4% vs. 3D-N: 76 %). CONCLUSION: Our data clearly suggests that the use of 3D-navigation for percutaneous SI screw fixation decreases radiation exposure for medical personnel, while increasing radiation exposure for patients. Furthermore, intraoperative precision is improved, even in more challenging operations.

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome. METHODS: The TraumaRegister DGU® was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined. RESULTS: 12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%). CONCLUSIONS: The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.

Substitutional semi-rigid osteosynthesis technique for treatment of unstable pubic symphysis injuries: a biomechanical study.

BACKGROUND/PURPOSE: The surgical fixation of a symphyseal diastasis in partially or fully unstable pelvic ring injuries is an important element when stabilizing the anterior pelvic ring. Currently, open reduction and internal fixation (ORIF) by means of plating represents the gold standard treatment. Advances in percutaneous fixation techniques have shown improvements in blood loss, surgery time, and scar length. Therefore, this approach should also be adopted for treatment of symphyseal injuries. The technique could be important since failure rates, following ORIF at the symphysis, remain unacceptably high. The aim of this biomechanical study was to assess a semi-rigid fixation technique for treatment of such anterior pelvic ring injuries versus current gold standards of plate osteosynthesis. METHODS: An anterior pelvic ring injury type III APC according to the Young and Burgess classification was simulated in eighteen composite pelvises, assigned to three groups (n = 6) for fixation with either a single plate, two orthogonally positioned plates, or the semi-rigid technique using an endobutton suture implant. Biomechanical testing was performed in a simulated upright standing position under progressively increasing cyclic loading at 2 Hz until failure or over 150,000 cycles. Relative movements between the bone segments were captured by motion tracking. RESULTS: Initial quasi-static and dynamic stiffness, as well as dynamic stiffness after 100,000 cycles, was not significantly different among the fixation techniques (p ≥ 0.054).). The outcome measures for total displacement after 20,000, 40,000, 60,000, 80,000, and 100,000 cycles were associated with significantly higher values for the suture technique versus double plating (p = 0.025), without further significant differences among the techniques (p ≥ 0.349). Number of cycles to failure and load at failure were highest for double plating (150,000 ± 0/100.0 ± 0.0 N), followed by single plating (132,282 ± 20,465/91.1 ± 10.2 N), and the suture technique (116,088 ± 12,169/83.0 ± 6.1 N), with significantly lower values in the latter compared to the former (p = 0.002) and no further significant differences among the techniques (p ≥ 0.329). CONCLUSION: From a biomechanical perspective, the semi-rigid technique for fixation of unstable pubic symphysis injuries demonstrated promising results with moderate to inferior behaviour compared to standard plating techniques regarding stiffness, cycles to failure and load at failure. This knowledge could lay the foundation for realization of further studies with larger sample sizes, focusing on the stabilization of the anterior pelvic ring.

Simulated full weight bearing following posterior column acetabular fracture fixation: a biomechanical comparability study.

PURPOSE: The incidence of acetabular fractures (AFs) is increasing in all industrial nations, with posterior column fractures (PCFs) accounting for 18.5-22% of these cases. Treating displaced AFs in elderly patients is a known challenge. The optimal surgical strategy implementing open reduction and internal fixation (ORIF), total hip arthroplasty (THA), or percutaneous screw fixation (SF), remains debated. Additionally, with either of these treatment methods, the post-surgical weight bearing protocols are also ambiguous. The aim of this biomechanical study was to evaluate construct stiffness and failure load following a PCF fixation with either standard plate osteosynthesis, SF, or using a screwable cup for THA under full weight bearing conditions. METHODS: Twelve composite osteoporotic pelvises were used. A PCF according to the Letournel Classification was created in 24 hemi-pelvis constructs stratified into three groups (n = 8) as follows: (i) posterior column fracture with plate fixation (PCPF); (ii) posterior column fracture with SF (PCSF); (iii) posterior column fracture with screwable cup fixation (PCSC). All specimens were biomechanically tested under progressively increasing cyclic loading until failure, with monitoring of the interfragmentary movements via motion tracking. RESULTS: Initial construct stiffness (N/mm) was 154.8 ± 68.3 for PCPF, 107.3 ± 41.0 for PCSF, and 133.3 ± 27.5 for PCSC, with no significant differences among the groups, p = 0.173. Cycles to failure and failure load were 7822 ± 2281 and 982.2 ± 428.1 N for PCPF, 3662 ± 1664 and 566.2 ± 366.4 N for PCSF, and 5989 ± 3440 and 798.9 ± 544.0 N for PCSC, being significantly higher for PCPF versus PCSF, p = 0.012. CONCLUSION: Standard ORIF of PCF with either plate osteosynthesis or using a screwable cup for THA demonstrated encouraging results for application of a post-surgical treatment concept with a full weight bearing approach. Further biomechanical cadaveric studies with larger sample size should be initiated for a better understanding of AF treatment with full weight bearing and its potential as a concept for PCF fixation.

Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years?

BACKGROUND/PURPOSE: Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients. METHODS: This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months. RESULTS: This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities. CONCLUSION: Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.

Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients.

PURPOSE: It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions. METHODS: A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region. RESULTS: This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load. CONCLUSION: This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

A Novel Implant for Superior Pubic Ramus Fracture Fixation-Development and a Biomechanical Feasibility Study.

Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient's quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure.

Evaluation of Cannulated Compression Headless Screw (CCHS) as an alternative implant in comparison to standard S1-S2 screw fixation of the posterior pelvis ring: a biomechanical study.

BACKGROUND/PURPOSE: Posterior pelvis ring injuries represent typical high-energy trauma injuries in young adults. Joint stabilization with two cannulated sacroiliac (SI) screws at the level of sacral vertebrae S1 and S2 is a well-established procedure. However, high failure- and implant removal (IR) rates have been reported. Especially, the washer recovery can pose the most difficult part of the IR surgery, which is often associated with complications. The aim of this biomechanical study was to evaluate the stability of S1-S2 fixation of the SI joint using three different screw designs. METHODS: Eighteen artificial hemi-pelvises were assigned to three groups (n = 6) for SI joint stabilization through S1 and S2 corridors using either two 7.5 mm cannulated compression headless screws (group CCH), two 7.3 mm partially threaded SI screws (group PT), or two 7.3 mm fully threaded SI screws (group FT). An SI joint dislocation injury type III APC according to the Young and Burgess classification was simulated before implantation. All specimens were biomechanically tested to failure in upright standing position under progressively increasing cyclic loading. Interfragmentary and bone-implant movements were captured via motion tracking and evaluated at four time points between 4000 and 7000 cycles. RESULTS: Combined interfragmentary angular displacement movements in coronal and transverse plane between ilium and sacrum, evaluated over the measured four time points, were significantly bigger in group FT versus both groups CCH and PT, p ≤ 0.047. In addition, angular displacement of the screw axis within the ilium under consideration of both these planes was significantly bigger in group FT versus group PT, p = 0.038. However, no significant differences were observed among the groups for screw tip cutout movements in the sacrum, p = 0.321. Cycles to failure were highest in group PT (9885 ± 1712), followed by group CCH (9820 ± 597), and group FT (7202 ± 1087), being significantly lower in group FT compared to both groups CCH and PT, p ≤ 0.027. CONCLUSION: From a biomechanical perspective, S1-S2 SI joint fixation using two cannulated compression headless screws or two partially threaded SI screws exhibited better interfragmentary stability compared to two fully threaded SI screws. The former can therefore be considered as a valid alternative to standard SI screw fixation in posterior pelvis ring injuries. In addition, partially threaded screw fixation was associated with less bone-implant movements versus fully threaded screw fixation. Further human cadaveric biomechanical studies with larger sample size should be initiated to understand better the potential of cannulated compression headless screw fixation for the therapy of the injured posterior pelvis ring in young trauma patients.

Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES.

PURPOSE: Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology. METHODS: A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades. RESULTS: 4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000. CONCLUSION: Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

Post-traumatic growth in polytraumatized patients after 20+ years: a long-term follow-up study of 337 patients treated at a level 1 trauma center.

PURPOSE: There is limited research on the long-term psychiatric outcomes of polytraumatized patients. Existing studies focus mainly on the negative sequelae. Post-traumatic growth (PTG) describes positive personal development after severe physical or mental distress. In this study, we investigated post-traumatic growth in polytraumatized patients at least 20 years after trauma. METHODS: Patients treated for polytrauma at a German level 1 trauma center between 1971 and 1990, were contacted 20+ years later. A questionnaire with 37 questions from the stress-related growth scale (SRGS) and the post-traumatic growth inventory (PGI) was administered. PTG was quantified in five specific areas. PTG and patient demographics were then analyzed using logistic regression. RESULTS: Eligible questionnaires were returned by 337 patients. 96.5% of patients reported improvements regarding at least one of the 37 questions. Approximately, a third of patients noticed distinct improvements regarding their relationship to others (29.2%), appreciation of life (36.2%) and attitudes towards new possibilities (32.5%). Patient demographics were significant predictors for the development of PTG: Older (p < 0.001), female (p = 0.042) and married patients (p = 0.047) showed a greater expression of PTG. We also saw significantly more PTG in patients with higher injury severity (p = 0.033). CONCLUSION: 20 years after polytrauma, patients report improvements in their relationship with others, appreciation of life and attitude towards new possibilities. Women and married patients show higher expression of PTG. Furthermore, there is higher expression of PTG with higher age and injury severity. Post-traumatic growth should be identified and fostered in clinical practice. LEVEL OF EVIDENCE: III-prospective long-term follow-up study.

Bariatric metabolic surgery eliminates body mass index as a risk factor for unemployment.

BACKGROUND: The effects of bariatric metabolic surgery (BMS) on health and comorbidities are well-known. Socioeconomic factors have been increasingly in focus in recent investigations. OBJECTIVE: The aim of this study was to analyze the effects of BMS on predictive variables for unemployment. SETTING: This study as performed in one reference center for BMS. Patients were treated between 2011 and 2017. METHODS: The study design was a retrospective cohort study. Inclusion criteria were Roux-en-Y gastric bypass surgery, follow-up of 60 months, and complete data on employment rate. Exclusion criteria were secondary BMS, secondary referral, loss of follow-up, or patients aged 60 years and above. Patients were stratified as employed independent of part-time work and as unemployed if the patient had no current employment at the time of the visit. Follow-up visits were performed after 6, 12, 24, 48, and 60 months. RESULTS: This study included 623 patients; prior to BMS, 239 (38.36%) patients were employed and 384 (61.64%) unemployed. Risk factors for baseline unemployment included increased body mass index (BMI) (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01 to 1.05; P = .010) and increased American Society of Anesthesiology (ASA) score (OR, 3.55; 95% CI, 2.56 to 4.90; P < .001). Unemployment rate dropped to 32.4% after 24 months (P < .001) and increased to 62.8% after 60 months. The BMI continuously decreased. Following BMS, the unemployment rate was no longer associated with BMI (24 months: OR, 0.97; 95% CI, 0.95 to 1.01; P = .220; 60 months: 1.04; 95% CI, 0.97 to 1.11; P = .269). The initial ASA status remained associated with unemployment (OR, 2.20; 95% CI, 1.60 to 3.01; P < .001). CONCLUSION: BMI showed some association with the unemployment rate prior to BMI. The unemployment rate significantly decreased 24 months after BMS but increased to baseline values after 60 months. Following BMS, BMI was no longer associated with unemployment.

How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature.

INTRODUCTION: Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. METHODS: Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. RESULTS: The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma. CONCLUSION: In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.

Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique.

PURPOSE: Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail. METHODS: This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses. RESULTS: This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion. CONCLUSION: The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

The implementation of physicians assistant in a surgical ward improves continuity in daily clinical work and increases comprehensibility of nurses and physicians.

INTRODUCTION: Physician Assistant (PA) have been deployed to increase the capacity of a team, supporting continuity and medical cover. The goal of this study was to assess the implementation of PAs on continuity of surgical rounds, on the collaboration of nurses and physicians and on support of administrative work. METHODS: This cross-sectional survey was performed on nurses and physicians who work full-time at a surgical ward in a Swiss reference center. PAs were introduced in our institution in 2019. Participants answered a self-developed questionnaire 6 and 12 months after the implementation of PAs. Administrative work, teamwork, improvement of workflow, and training of physicians has been assessed. Participants answered questions on a 5-point Likert scale and were stratified according to profession (nurse, physician). RESULTS: Participants (n = 53) reported a positive effect on the regular conduct of rounds (2.9, SD 1.1 points after 6 weeks and 3.5, SD 1.1 points after 12 weeks, p = 0.05). A significant improvement of nurse-doctor collaboration has been reported (3.6, SD 1.0 and 4.2, SD 0.8, p = 0.05). Nurses (n = 28, 52.8%) reported the that PAs are integrated in the physicians team rather than the nurses team (4.0, SD 0.0 points and 4.4, SD 0.7 points, p = 0.266) and a significant beneficial effect on the surgical clinic (3.7, SD 1.0 points and 4.4, SD 0.8 points, p = 0.043). Improved overall management of surgical cases was reported by the physicians (n = 25, 47.2%) (4.8, SD 0.4 and 4.3, SD 0.6, p = 0.046). CONCLUSION: The implementation of PA has improved the collaboration of physicians and nurses substantially. Continuity of rounds has improved and the administrative workload for residents decreased substantially. Overall, the implementation of PA was reported to be beneficial for the surgical clinic.

The number of beds occupied is an independent risk factor for discharge of trauma patients.

Reducing the burden of limited capacity on medical practitioners and public health systems requires a time-dependent characterization of hospitalization rates, such that inferences can be drawn about the underlying causes for hospitalization and patient discharge. The aim of this study was to analyze non-medical risk factors that lead to the discharge of trauma patients. This retrospective cohort study includes trauma patients who were treated in Switzerland between 2011 and 2018. The national Swiss database for quality assurance in surgery (AQC) was reviewed for trauma diagnoses according to the ICD-10 code. Non-medical risk factors include seasonal changes, daily changes, holidays, and number of beds occupied by trauma patients across Switzerland. Individual patient information was aggregated into counts per day of total patients, as well as counts per day of levels of each categorical variable of interest. The ARIMA-modeling was utilized to model the number of discharges per day as a function of auto aggressive function of all previously mentioned risk factors. This study includes 226,708 patients, 118,059 male (age 48.18, standard deviation (SD) 22.34 years) and 108,649 female (age 62.57, SD 22.89 years) trauma patients. The mean length of stay was 7.16 (SD 14.84) days and most patients were discharged home (n = 168,582, 74.8%). A weekly and yearly seasonality trend can be observed in admission trends. The mean number of occupied trauma beds ranges from 3700 to 4000 per day. The number of occupied beds increases on weekdays and decreases on holidays. The number of occupied beds is a positive, independent risk factor for discharge in trauma patients; as the number of occupied beds increases at any given time, so does the risk for discharge. The number of beds occupied represents an independent non-medical risk factor for discharge. Capacity determines triage of hospitalized patients and therefore might increase the risk of premature discharge.

Fat embolism syndrome in patients with bilateral femur fractures: a systematic review and case comparison.

Objectives: Fat embolism and fat embolism syndrome (FES) remain common complications following long bone fractures. Incidence is highest after bilateral femur fractures. We performed a systematic review of FES after bilateral femur fractures and present two cases. Data sources: Systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus, and, Web of Science Library databases was performed in August 2021. Terms used including plural and alternate spellings: "fat embolism,""fat embolism syndrome,""fat embolus," and "bilateral femur fracture." Articles in German and English were considered. No time frame was applied. Study selection: Original studies, case series and case reports on fat embolism after bilateral femur fracture were included. Insufficient documentation or patients with relevant previous heath conditions were excluded. Data extraction: Abstracts were organized using EndNote X9 by Carivate. Three authors independently screened the abstracts; cross check of the extracted data was performed by the senior author. Data synthesis: Scarcity of articles only allowed for a qualitative synthesis. Data was compared with our cases and situated within the scientific background. Results: Ten articles were included for qualitative synthesis (n = 144 patients). The symptoms were inhomogeneous with neurological deficits being most prominent. Degree of displacement was high, when reported. Although the modes and timing of surgery varied, this appeared unrelated with outcome. Conclusions: FES remains a relevant complication after bilateral femur fractures, despite damage control strategies and improved reaming techniques. Fracture displacement and reduction maneuvers might play a more substantial role in the formation than previously accredited. Level of evidence: 4.

Transition from a circular to a linear stapling protocol in laparoscopic Roux-en-Y gastric bypass surgery and its impact on quality of life: a 5-year outcome study.

PURPOSE: Surgical technique in bariatric surgery has been refined over the past decades. This study analysed the effect of changing the stapling protocol on the quality of life (QoL) at a midterm follow-up. METHODS: The retrospective cohort study included patients undergoing Roux-en-Y gastric bypass between June 2012 and March 2016. Patients were stratified into the circular stapling protocol (CSP, n = 117) or the linear stapling protocol (LSP, n = 118). QoL was quantified by the Moorehead score at 12, 24 and 60 months. Multivariate testing was used to identify confounders. RESULTS: The age was 42.8 ± 11.5 years and the body mass index (BMI) was 43.8 ± 6.2 kg/m2, with no baseline intergroup differences. Overall baseline Moorehead score was 0.42 ± 1.1 and improved in both groups after 12 months (1.97 ± 0.74, p < 0.001), 24 months (1.86 ± 0.79, p < 0.001) and 60 months (1.71 ± 0.9, p < 0.001). LSP was associated with improved Moorehead score after 60 months (odds ratio [OR] 1.251, 95% confidence interval [CI] 1.06-1.48, p = 0.010). Overall, a drop of mean BMI occurred and this effect lasted throughout the observation period (- 12.48 kg/m2, p < 0.001). More profound BMI reduction was further positively associated with Moorehead scores after 24 and after 60 months (OR 0.97, p = 0.028; OR 0.96, p = 0.007). Complications, rehospitalisations and reoperations were more frequent in the CSP group (50% vs 23.7%, p < 0.001; 39.7% vs 22.9%, p = 0.009; 37.1% vs 18.6%, p = 0.003). CONCLUSION: The CSP and LSP achieve a long-lasting increase in QoL, although the LSP is associated with fewer complications, persistent weight loss and improved Moorehead score. Therefore, the LSP might be considered the favourable protocol in Roux-en-Y gastric bypass.