Active Motion Laboratory Test Apparatus for Evaluation of Total Elbow Prostheses.

Purpose: The goal of this study was to develop a dynamic elbow testing apparatus that reproduces active joint motion at different shoulder positions to quantify the capabilities of total elbow arthroplasty designs. Methods: We designed a testing apparatus to create active cyclic elbow joint motion in human cadaveric and sawbones composite upper extremities. Two pneumatic actuators recreated humerus-originating muscles while rubber bands simulated forearm muscle action. Arthroplasty durability was quantified through laxity assessment at predetermined cyclic loading intervals. Results: Humeral forces were recorded in three specimens to generate active elbow motion at different degrees of shoulder abduction. The laxity in varus and valgus was measured as deflection between two fixed markers. Conclusions: In vitro simulation of elbow biomechanics through active cyclic elbow motion at different degrees of shoulder abduction may characterize in vivo performance of total elbow arthroplasty. Clinical relevance: Quantifying total elbow arthroplasty stability after cyclic loading in different shoulder positions may assist preclinical evaluation of arthroplasty designs.

Testing of Novel Total Elbow Prostheses Using Active Motion Experimental Setup.

PURPOSE: The goal of this study was to test a novel uncemented and unconstrained total elbow arthroplasty (Kaufmann total elbow) design that is stabilized through a ligament reconstruction. METHODS: We quantified the implant stability after 25,000 cycles, which represents the time between implantation and when ligament and bone healing has occurred. We used an active motion experimental setup that applies tendon loads via pneumatic cylinders and reproduces the forearm-originating dynamic stabilizers of the elbow. The novel total elbow arthroplasty was actuated for 5,000 full flexion-extension cycles at 5 different shoulder positions. Four Sawbones and 4 cadaver elbows were employed. Angular laxity and implant stability were recorded prior to testing and after each 5,000-loading cycle. RESULTS: Four Sawbones and 4 cadaver elbows were implanted with the uncemented total elbow arthroplasty and did not demonstrate fixation failure or substantial laxity after 25,000 cycles of loading imparted at different shoulder positions. CONCLUSIONS: Our findings demonstrate that the Kaufmann total elbow replacement implanted into cadaver and Sawbones specimens did not exhibit fixation failure or excessive laxity after 25,000 cycles. CLINICAL RELEVANCE: An uncemented, nonmechanically linked total elbow arthroplasty that gains component fixation using intramedullary screws and employs a ligament reconstruction to stabilize the elbow has the potential to be a valuable management option, particularly in younger patients.

Influence of the COVID-19 pandemic on causes for the development of carbon monoxide intoxications.

Introduction: Several causes can lead to carbon monoxide (CO) intoxication. A first-line treatment option for such intoxications is hyperbaric oxygenation (HBO2) therapy. The COVID-19 pandemic has been changing everyday life in Germany since March 2020, mainly caused by statutory provisions. Our aim was to review whether these changes have an influence on the causes and frequency for the development of CO intoxication. Methods: We retrospectively analyzed the data of patients who were treated for CO intoxication in our institution between April 2019 and March 2021. Besides demographic data, we compared the overall number and documented causes for each CO intoxication in the period of April 2020 to March 2021 with the period between April 2019 and March 2020. Results: After applying inclusion and exclusion criteria, 139 patients were included. We found a significant decrease in the overall number of patients who needed treatment since the beginning of the COVID-19 pandemic. However, the share of CO intoxication caused by the indoor use of coal stoves, coal barbecue, or suicide attempts increased. In contrast, the share of cases caused by apartment or house fire, smoking waterpipe, or gas stoves decreased. Conclusion: The COVID-19 pandemic and the associated restrictions lead to a significant reduction in the number of patients in need for HBO2 therapy due to CO-Intoxication. The causes leading to CO intoxication also changed since the beginning of the COVID-19 pandemic. We observed a shift toward causes related to the indoor use of coal-fired stoves and barbecues as well as suicide attempts.

Strength of Humeral and Ulnar Intramedullary Screw Fixation.

PURPOSE: The goal of this study was to test the pullout strength of intramedullary (IM) screws from within the humerus to establish their ability to seat an uncemented elbow arthroplasty. METHODS: Six humerus and 6 ulna Sawbones specimens were drilled with a drill bit diameter of 5/16 inches, and the inner cortex was hand tapped for a ⅜-16 thread. A ⅜-16 custom-made titanium screw with an outer bolt diameter of 3/8 inches and 16 threads per inch was inserted by hand into the tapped holes. The specimens were then axially tensile loaded at a rate of 5 mm per minute until either the screw began to pull out from the bone or a fracture was noted. RESULTS: Intramedullary screw fixation in the humerus achieved an average pullout strength of 1,439 pound-force (6,401 N), and IM screw fixation in the ulna achieved an average pullout strength of 882 pound-force (3,923 N). A fracture was noted in 3 humeral specimens, with 3 screws pulling out. In the ulna, the IM axial load caused a fracture in 5 specimens, and in 1 specimen, the screw pulled out. CONCLUSIONS: Our findings demonstrate that IM screw fixation can create a tensile force within the screw that is greater than that required to generate the calculated level of compression between the implant and bone. CLINICAL RELEVANCE: This may be beneficial in ensuring fixation between arthroplasty components and bone.

Doctor, when can I drive? - Range of functional ankle motion during driving.

BACKGROUND: Driving a motor vehicle needs a specific joint mobility and yet only limited knowledge exists regarding the necessary ankle range of motion. The goal of this study is to characterize the sequence and range of ankle motion. METHODS: The arc of plantarflexion/dorsiflexion and supination/pronation was recorded in the right and left ankle using electrogoniometers while thirty laps were driven by fifteen healthy participants around a course in a manual transmission car with a left sided steering wheel. The driver was required to perform the following maneuvers during each lap: (I) Vehicle acceleration and gear change, (II) Sudden evasion, (III) Routine turning, (IV) Rapid turning, (V) Vehicle acceleration followed by emergency braking. RESULTS: Driving required the right ankle to plantarflex 13±9 and dorsiflex 22±7 while supinating 15±7 degrees and pronating minimally. The left ankle plantarflexed 19±10and dorsiflexed 17±10 while supinating 15±7 degrees and pronating minimally. The right ankle dorsiflexed significantly more (p=0.00), and yet the left ankle had a significantly higher maximum plantarflexion and range of plantarflexion/dorsiflexion (p=0.00). Emergency braking resulted in a significantly higher maximum plantarflexion as well as plantarflexion/dorsiflexion range when compared to other maneuvers. CONCLUSION: This study describes the range of ankle motion identified to drive a car with a manual transmission and a left-sided steering wheel. The right and left ankle exhibit different arcs of motion during driving. This knowledge may assist when evaluating a patient's driving capability. Further studies are needed to investigate whether movement restrictions impair driving. LEVEL OF EVIDENCE: Basic science study.

Human iPSC-derived iMSCs improve bone regeneration in mini-pigs.

Autologous bone marrow concentrate (BMC) and mesenchymal stem cells (MSCs) have beneficial effects on the healing of bone defects. To address the shortcomings associated with the use of primary MSCs, induced pluripotent stem cell (iPSC)-derived MSCs (iMSCs) have been proposed as an alternative. The aim of this study was to investigate the bone regeneration potential of human iMSCs combined with calcium phosphate granules (CPG) in critical-size defects in the proximal tibias of mini-pigs in the early phase of bone healing compared to that of a previously reported autograft treatment and treatment with a composite made of either a combination of autologous BMC and CPG or CPG alone. iMSCs were derived from iPSCs originating from human fetal foreskin fibroblasts (HFFs). They were able to differentiate into osteoblasts in vitro, express a plethora of bone morphogenic proteins (BMPs) and secrete paracrine signaling-associated cytokines such as PDGF-AA and osteopontin. Radiologically and histomorphometrically, HFF-iMSC + CPG transplantation resulted in significantly better osseous consolidation than the transplantation of CPG alone and produced no significantly different outcomes compared to the transplantation of autologous BMC + CPG after 6 weeks. The results of this translational study imply that iMSCs represent a valuable future treatment option for load-bearing bone defects in humans.

Aseptic Loosening after THA and TKA - Do gender, tobacco use and BMI have an impact on implant survival time?

PURPOSE: Aseptic loosening (AL) has been reported to be one of the most frequent complications in Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). The aim of this study was to identify the effects of gender, current tobacco use and BMI on the incidence of AL and implant survival time in THA and TKA. METHODS: Between July 2012 and December 2016 all patients that were diagnosed with an AL of a primary THA or primary TKA and underwent revision surgery at a single institution were retrospectively reviewed for this study. For each patient gender, current tobacco use, BMI, and implant survival time were obtained from the medical records. RESULTS: 202 patients with 85 THA and 117 TKA were included in this study. There was no impact of the gender on implant survival times (p > 0.05) in THA and TKA. In the TKA group current tobacco use was associated with a significant shorter implant survival time (p < 0.05). For THA and TKA with cemented stem fixation a significant increase of AL was seen in overweight compared to normal weight patients (p < 0.05) and in obese compared to normal weight patients (p < 0.05). CONCLUSION: The results demonstrate that current tobacco use and elevated BMI are associated with increased rates of AL in TKA. Also, in THA with cemented stem fixation an elevated BMI is associated with an increased incidence of AL.

Total Elbow Arthroplasty: Elbow Biomechanics and Failure.

Total elbow arthroplasty (TEA) has lower revision-free survivorship than other major joint replacement. Despite this, elbow replacement has remained popular. Surgical technique for TEA destabilizes the elbow by removing the medial and lateral collateral ligaments and, frequently, the radiocapitellar articulation. Current semiconstrained implants aim to allow for physiological varus and valgus motion by employing a sloppy hinge; however, over time, these designs fail owing to nonanatomic force transmission. Nonanatomic force transmission results from ligament release, force transmission primarily to the humeral and ulnar shafts, and radial head resection. These altered biomechanics may be the source of complications seen in semiconstrained arthroplasty. These complications perpetuate the cycle of failure and ultimately have poor salvage options.

Doctor, when can I drive?-the range of elbow motion while driving a car.

BACKGROUND: Immobilization of the upper extremity after an acute injury or postoperatively affects an individual's ability to safely operate a motor vehicle. The elbow is particularly sensitive to immobilization, with subsequent stiffness leading to functional limitations. Most activities of daily living are successfully achieved within a "functional arc" of elbow motion between 30° and 130° of flexion. No objective guidelines exist regarding the range of motion needed to safely operate a vehicle. In this study, we measured the range of motion of right and left elbows while driving a manual-transmission car. MATERIALS AND METHODS: Using electro-goniometers, we measured the flexion and extension, as well as pronation and supination, of the right and left elbows in 20 healthy, right hand-dominant subjects while driving a car. These measurements were recorded on (1) city streets, (2) country roads, and (3) highways. RESULTS: For city streets, the range of motion in terms of flexion and pronation/supination was 15°-105° and 0°-45°/0°-35°, respectively, for the right elbow and 20°-95° and 0°-45°/0°-40°, respectively, for the left. For country roads, it was 10°-100° and 0°-40°/0°-35°, respectively, for the right elbow and 20°-95° and 0°-30°/0°-30°, respectively, for the left. For highways, it was 5°-100° and 0°-40°/0°-35°, respectively, for the right elbow and 20°-90° and 0°-30°/0°-25°, respectively, for the left. Mean pronation was significantly higher for the right elbow (P < .01). CONCLUSION: This study describes the range of elbow motion identified to drive a car with a manual transmission and a left-sided steering wheel. Mean pronation of the right elbow is significantly higher than that of the left. Further studies are needed to investigate the relevance of movement restrictions as they relate to handedness, steering-wheel side, and driving impairment.

Doctor, when can I drive? - Range of motion of the knee while driving a car.

BACKGROUND: One of the most important activities of daily living is operating a motor vehicle. With increasing age the prevalence of musculoskeletal disorders such as knee osteoarthritis may interfere with an individual's ability to do so safely. Physicians are tasked with determining a patient's ability to drive and yet the necessary joint range of motion required for driving a car has not been characterized. METHODS: The range of motion of the right and left knees was recorded using electrogoniometers in 20 healthy subjects while driving a car on three route types (a) city streets, b) country roads and c) highways). Special emphasis was placed on the left knee associated with changing a gear. RESULTS: The range of motion while driving is 40-80° for the right and 20-85° flexion for the left knee. A significant difference was noted for each side (p < 0.01) with a higher flexion occurring in the left knee (p < 0.01). The average position of the knee while changing a gear (beginning, maximum, ending) was: right: 55°±10°, 62°±10°, 53°±10°; left: 67°±7°, 39°±8°, 66°±8° (mean flexion±standard deviation). CONCLUSION: This study characterized the knee range of motion that occurs while driving a car. Our data suggests that common driving activities such as accelerating a vehicle or braking can be achieved with the right knee through a limited range of motion. The greater range of motion and the higher flexion of the left knee are mainly attributed to the gear changing. The present data may benefit physicians in their evaluation of driving capability.

Neutral or Natural? Functional Impact of the Coronal Alignment in Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a very successful procedure. The alignment in TKA has been identified as being of importance to prevent early implant failure and patient dissatisfaction. Our hypothesis was that patients with a preoperative varus deformation remaining in a slight varus alignment as their natural alignment after TKA will have superior clinical results compared with patients who are restored in neutral alignment. A total of 115 patients were corrected from varus to neutral (varus-neutral) and in 33 patients a preoperative varus alignment was kept in varus (varus). Standardized preoperative and postoperative full-length hip-knee-ankle radiographs under full weight-bearing conditions were performed in all patients. The patients' knees were categorized preoperatively and postoperatively based on the angle between mechanical femoral axis and mechanical tibial axis. Knees with alignment between ± 3 degrees were categorized as neutrally aligned, whereas alignment within ≤ -3 degrees was categorized as varus. The Knee Injury Osteoarthritis Outcome Score (KOOS) and Oxford Knee Score were determined retrospectively. The varus group scored significantly better in total KOOS (p < 0.05) compared with the varus-neutral group. Also, a trend was visible in the Oxford Knee Score but this was not significant (p > 0.05). This trend was even more evident in varus knees which were slightly undercorrected. The results support the assumption that leaving a residual varus alignment after TKA leads to better functional outcomes in TKA for patients with preoperative varus osteoarthritis.

Molecular- and microarray-based analysis of diversity among resting and osteogenically induced porcine mesenchymal stromal cells of several tissue origin.

Mesenchymal stromal cells (MSCs) play a pivotal role in modern therapeutic approaches in bone-healing disorders. Although bone marrow-derived MSCs are most frequently used, the knowledge that many other adult tissues represent promising sources for potent MSCs has gained acceptance. In the present study, the osteogenic differentiation potential of porcine skin fibroblasts (FBs), as well as bone marrow- (BMSCs), adipose tissue- (ASCs) and dental pulp-derived stromal cells (DSCs) were evaluated. However, additional application of BMP-2 significantly elevated the delayed osteogenic differentiation capacity of ASC and FB cultures, and in DSC cultures the supplementation of platelet-rich plasma increased osteogenic differentiation potential to a comparable level of the good differentiable BMSCs. Furthermore, microarray gene expression performed in an exemplary manner for ASCs and BMSCs revealed that ASCs and BMSCs use different gene expression patterns for osteogenic differentiation under standard media conditions, as diverse MSCs are imprinted dependent from their tissue niche. However, after increasing the differentiation potential of ASCs to a comparable level as shown in BMSCs, a small subset of identical key molecules was used to differentiate in the osteogenic lineage. Until now, the importance of identified genes seems to be underestimated for osteogenic differentiation. Apparently, the regulation of transmembrane protein 229A, interleukin-33 and the fibroblast growth factor receptor-2 in the early phase of osteogenic differentiation is needed for optimum results. Based on these results, bone regeneration strategies of MSCs have to be adjusted, and in vivo studies on the osteogenic capacities of the different types of MCSs are warranted. Copyright © 2016 The Authors Tissue Engineering and Regenerative Medicine published by John Wiley & Sons, Ltd.

The composite of bone marrow concentrate and PRP as an alternative to autologous bone grafting.

One possible alternative to the application of autologous bone grafts represents the use of autologous bone marrow concentrate (BMC). The purpose of our study was to evaluate the potency of autologous platelet-rich plasma (PRP) in combination with BMC. In 32 mini-pigs a metaphyseal critical-size defect was surgically created at the proximal tibia. The animals were allocated to four treatment groups of eight animals each (1. BMC+CPG group, 2. BMC+CPG+PRP group, 3. autograft group, 4. CPG group). In the BMC+CPG group the defect was filled with autologous BMC in combination with calcium phosphate granules (CPG), whereas in the BMC+CPG+PRP group the defect was filled with the composite of autologous BMC, CPG and autologous PRP. In the autograft group the defect was filled with autologous cancellous graft, whereas in the CPG group the defect was filled with CPG solely. After 6 weeks radiological and histomorphometrical analysis showed significantly more new bone formation in the BMC+CPG+PRP group compared to the BMC+CPG group and the CPG group. There were no significant differences between the BMC+CPG+PRP group and the autograft group. In the PRP platelets were enriched significantly about 4.7-fold compared to native blood. In BMC the count of mononuclear cells increased significantly (3.5-fold) compared to the bone marrow aspirate. This study demonstrates that the composite of BMC+CPG+PRP leads to a significantly higher bone regeneration of critical-size defects at the proximal tibia in mini-pigs than the use of BMC+CPG without PRP. Furthermore, within the limits of the present study the composite BMC+CPG+PRP represents a comparable alternative to autologous bone grafting.

A comparison of bone regeneration with human mesenchymal stem cells and muscle-derived stem cells and the critical role of BMP.

Adult multipotent stem cells have been isolated from a variety of human tissues including human skeletal muscle, which represent an easily accessible source of stem cells. It has been shown that human skeletal muscle-derived stem cells (hMDSCs) are muscle-derived mesenchymal stem cells capable of multipotent differentiation. Although hMDSCs can undergo osteogenic differentiation and form bone when genetically modified to express BMP2; it is still unclear whether hMDSCs are as efficient as human bone marrow mesenchymal stem cells (hBMMSCs) for bone regeneration. The current study aimed to address this question by performing a parallel comparison between hMDSCs and hBMMSCs to evaluate their osteogenic and bone regeneration capacities. Our results demonstrated that hMDSCs and hBMMSCs had similar osteogenic-related gene expression profiles and had similar osteogenic differentiation capacities in vitro when transduced to express BMP2. Both the untransduced hMDSCs and hBMMSCs formed very negligible amounts of bone in the critical sized bone defect model when using a fibrin sealant scaffold; however, when genetically modified with lenti-BMP2, both populations successfully regenerated bone in the defect area. No significant differences were found in the newly formed bone volumes and bone defect coverage between the hMDSC and hBMMSC groups. Although both cell types formed mature bone tissue by 6 weeks post-implantation, the newly formed bone in the hMDSCs group underwent quicker remodelling than the hBMMSCs group. In conclusion, our results demonstrated that hMDSCs are as efficient as hBMMSCs in terms of their bone regeneration capacity; however, both cell types required genetic modification with BMP in order to regenerate bone in vivo.

Bone marrow aspiration concentrate and platelet rich plasma for osteochondral repair in a porcine osteochondral defect model.

BACKGROUND: Bone marrow aspiration concentrate (BMAC) may possess a high potency for cartilage and osseous defect healing because it contains stem cells and multiple growth factors. Alternatively, platelet rich plasma (PRP), which contains a cocktail of multiple growth factors released from enriched activated thrombocytes may potentially stimulate the mesenchymal stem cells (MSCs) in bone marrow to proliferate and differentiate. METHODS: A critical size osteochondral defect (10×6 mm) in both medial femoral condyles was created in 14 Goettinger mini-pigs. All animals were randomized into the following four groups: biphasic scaffold alone (TRUFIT BGS, Smith & Nephew, USA), scaffold with PRP, scaffold with BMAC and scaffold in combination with BMAC and PRP. After 26 weeks all animals were euthanized and histological slides were cut, stained and evaluated using a histological score and immunohistochemistry. RESULTS: The thrombocyte number was significantly increased (p = 0.049) in PRP compared to whole blood. In addition the concentration of the measured growth factors in PRP such as BMP-2, BMP-7, VEGF, TGF-ß1 and PDGF were significantly increased when compared to whole blood (p<0.05). In the defects of the therapy groups areas of chondrogenic tissue were present, which stained blue with toluidine blue and positively for collagen type II. Adding BMAC or PRP in a biphasic scaffold led to a significant improvement of the histological score compared to the control group, but the combination of BMAC and PRP did not further enhance the histological score. CONCLUSIONS: The clinical application of BMAC or PRP in osteochondral defect healing is attractive because of their autologous origin and cost-effectiveness. Adding either PRP or BMAC to a biphasic scaffold led to a significantly better healing of osteochondral defects compared with the control group. However, the combination of both therapies did not further enhance healing.

The use of biodegradable sutures for the fixation of tibial eminence fractures in children: a comparison using PDS II, Vicryl and FiberWire.

BACKGROUND: Arthroscopic suture fixation of tibial eminence fractures using FiberWire is a favorable therapeutic option. The application of biodegradable material may be of advantage especially during childhood. The aim of this study was to evaluate the biomechanical properties using the biodegradable suture materials PDS II and Vicryl compared with FiberWire. METHODS: Bone mineral density was evaluated by pqCT in 18 human knee specimens and 3 similar groups were formed. A standardized anterior tibial eminence fracture was created and suture fixation was performed using each suture material (PDS II, Vicryl, FiberWire) in 6 specimens. Cyclic testing and destructive loading to failure was conducted. RESULTS: Both testing modalities showed PDS II to be inferior to the other evaluated suture materials. Although significantly higher failure loads were seen with FiberWire sutures, Vicryl yielded comparable stiffness in load-to-failure testing. No significant differences between Vicryl and FiberWire could be observed under nondestructive cyclic conditions. CONCLUSIONS: Even though FiberWire yields a superior ultimate failure load, Vicryl presented comparable results under cyclic conditions. CLINICAL RELEVANCE: For tibial eminence fractures in children, Vicryl should be considered as an alternative biodegradable suture material. The use of PDS II cannot be advocated.

Cyclic long-term loading of a bilateral fixed-angle plate in comparison with tension band wiring with K-wires or cannulated screws in transverse patella fractures.

PURPOSE: A bilateral fixed-angle plate was biomechanically compared to the two currently preferred methods of osteosynthesis for transverse patella fractures. It was hypothesized that the new angle-stable implant would provide a secure and sustainable fracture fixation, superior to the established standard techniques. METHODS: Twenty-one identical patellae made of polyurethane foam (Sawbones(®)), osteotomized to create a transverse two-part fracture, were fixed with modified anterior tension wiring, cannulated lag screws with anterior tension wiring or bilateral polyaxial 2.7-mm fixed-angle plates. The testing protocol consisted of 10,000 repetitive cycles using a non-destructive physiological load between 100 and 300 N at a simulated knee flexion of 60°. RESULTS: All 21 Sawbone(®)-patellae sustained repetitive loading up to 10,000 cycles without failing. The anterior tension wire group displayed significant displacement of the fracture gap (0.7 ± 0.2 mm) during cyclic loading, while both lag screws with tension wiring and bilateral fixed-angle plates showed no fracture gap widening at all (p < 0.01). CONCLUSION: The bilateral fixed-angle plate and cannulated lag screws with anterior tension wiring preserved a constantly reduced fracture gap over 10,000 tensile cycles in contrast to modified anterior tension wiring, which exhibited significant widening of the gap after initial loading. Results of in vitro testing indicate that bilateral fixed-angle plates provide sustainable fixation stability offering a promising new option in the treatment for transverse patella fractures.

The impact of arterial hypertension on polytrauma and traumatic brain injury.

BACKGROUND: Pre-hospital hypotension in trauma patients is associated with high mortality. Especially for patients with severe traumatic brain injury (TBI), arterial normotension or even hypertension (AHT) is considered an important mechanism for sustaining adequate cerebral perfusion pressure. The effect of pre-hospital arterial hypertension (pAHT) on in-hospital mortality after trauma has not been studied to date. METHODS: We retrospectively analyzed data in the trauma registry of the German Society for Trauma Surgery (DGU) on all trauma patients in Germany from 1993 to 2008 who were 16 to 80 years old at the time of the trauma and had an injury severity score (ISS) of 9 or above (total, 42 500 patient data sets). For the analysis, we divided the patients into two groups: those with and those without TBI. We further divided the TBI patients into five subgroups depending on the course of their systolic blood pressure up to the moment of their arrival at the hospital. We also analyzed the patients' demographic data, patterns of injury, and accident mechanisms. RESULTS: Trauma patients with TBI and pAHT (142 of 561 patients) had a significantly higher mortality than normotensive TBI patients (25.3% vs. 13.5%, p<0.001). Arterial hypertension that either rises or falls before the patient reaches the hospital is associated with higher in-hospital mortality. A logistical regression analysis of 5384 patients revealed that patients with pAHT (n = 561) had an odds ratio of 1.9 (95% confidence interval, 1.4 to 1.6) for death in the hospital compared to normotensive patients (n = 6020). CONCLUSION: Systolic blood pressure values above 160 mm Hg before arrival in the hospital worsen the outcome of trauma patients with TBI.

Distal radius fractures: current concepts.

Despite the frequency of distal radius fractures, the optimal treatment remains without consensus opinion. A trend toward increased distal radius fracture open reduction and internal fixation has been identified, with biomechanical and clinical studies suggesting treatment advantages of certain fixation methods over others. Well-controlled patient trials are still missing to lend objective findings to management algorithms. This article reviews the literature over the past 5 years to guide our management regarding this common upper-extremity injury.

Decreasing mortality after femoral neck fracture treated with bipolar hemiarthroplasty during the last twenty years.

PURPOSE: The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty. METHODS: Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated. RESULTS: Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age. CONCLUSION: Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected.