Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion.

Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.

[Is the 95°blade plate still important in the treatment of proximal femoral pseudarthrosis?] / Hat die 95°-Winkelplatte bei der Behandlung von proximalen Femurpseudarthrosen noch einen Stellenwert?

Due to demographic changes, fractures and subsequently delayed fracture healing as well as pseudarthrosis of the proximal femur are on the increase. In the acute fracture situation, a load-stable treatment with an intramedullary implant (cephalomedullary nail) is generally sought. To date, there is no uniform consensus on the optimal treatment for complicated cases. The aim of this study was to evaluate the clinical and radiological outcome after revision of pseudarthrosis using a 95° blade plate in aseptic proximal femoral pseudarthrosis and to identify the specifications of blade plate treatment.The retrospective study design was used to evaluate data, some of which were prospectively collected. The study period covered January 2010 to December 2020 and 22 patients (10 women, 12 men) with an average age of 59 years were included in this single-center study. All patients showed pseudarthrosis after a femoral fracture type AO 31 A1-A3 or proximal femoral fracture type AO 32 A-C. Clinical and radiological follow-up were performed after 3, 6 and 12 months. Functional outcomes were assessed using the modified Harris hip score (mHHS), the numerical rating scale (NRS) and the short form health survey (SF-12).The postoperative radiological results after reosteosynthesis using a blade plate showed good results and 86.4% of the patient population were healed during the observation period. Pseudarthrosis persisted in four patients and was surgically revised.The functional results showed good results on average, albeit with a high dispersion of 17-91 points in the mHHS. The SF-12 averaged 42.6 (±10.4) points and the psychological score 49.4 (±9.6) points. The postoperative pain level was low both at rest and under stress.It was shown that reosteosynthesis with a blade plate is a surgically demanding but effective treatment option with a low potential for infection and safe bone consolidation, especially for the correction of high-grade axial deviation or varus malalignment.

The pelvic vascular injury score (P-VIS): a prehospital instrument to detect significant vascular injury in pelvic fractures.

PURPOSE: The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management. METHODS: To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient's charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012-2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7%): pelvic fracture with significant bleeding (> 20% of blood volume), Injury of the iliac or femoral artery or blood transfusion of ≥ 6 units (pRBC) prior to ICU admission. The multivariate analysis revealed nine items that constitute the pelvic vascular injury score (P-VIS). RESULTS: In study (1), 467 blunt pelvic trauma patients were included of which 24 (PVI) were presented with significant vascular injury (PVI, N = 24; control (C, N = 443). Patients with pelvic fractures and vascular injury showed a higher ISS, lower haemoglobin at admission and lower blood pressure. Their mortality rate was higher (PVI: 17.4%, C: 10.3%). In the defining and validating process of the score within the TR-DGU, 9227 patients met the inclusion criteria. 2090 patients showed significant peripelvic vascular injury (PVITR-DGU), the remaining 7137 formed the control group (CTR-DGU). Nine predictive parameters for peripelvic vascular injury constituted the peripelvic vascular injury score (P-VIS): age ≥ 70 years, high-energy-trauma, penetrating trauma/open pelvic injury, shock index ≥ 1, cardio-pulmonary-resuscitation (CPR), substitution of > 1 l fluid, intubation, necessity of catecholamine substitution, remaining shock (≤ 90 mmHg) under therapy. The multi-dimensional scoring system leads to an ordinal scaled rating according to the probability of the presence of a vascular injury. A score of ≥ 3 points described the peripelvic vascular injury as probable, a result of ≥ 6 points identified a most likely vascular injury and a score of 9 points identified an apparent peripelvic vascular injury. Reapplying this score to the study population a median score of 5 points (range 3-8) (PVI) and a median score of 2 points (range 0-3) (C) (p < 0.001). The OR for peripelvic vascular injury was 24.3 for the patients who scored > 3 points vs. ≤ 2 points. The TR-DGU data set verified these findings (median of 2 points in CTR-DGU vs. median of 3 points with in PVITR-DGU). CONCLUSION: The pelvic vascular injury score (P-VIS) allows an initial risk assessment for the presence of a vascular injury in patients with unstable pelvic injury. Thus, the management of these patients can be positively influenced at a very early stage, prehospital resuscitation performed safely targeted and further resources can be activated in the final treating Trauma Centre.

Changes in injury patterns, injury severity and hospital mortality in motorized vehicle accidents: a retrospective, cross-sectional, multicenter study with 19,225 cases derived from the TraumaRegister DGU®.

PURPOSE: In the last 20 years, the number of fatalities due to road traffic accidents (RTA) in Germany has steadily decreased from 7503 to 2724 per year. Due to legal regulations, educational measures and the continuous development of safety technology the number of severe traumatic injuries and injury patterns are most likely to change. The aim of the study was to analyse severely injured motorcyclists (MC) and car occupants (CO) that were involved in RTAs in the last 15 years and investigate the development and changes of injury patterns, injury severity and hospital mortality. METHODS: We retrospectively evaluated data from the TraumaRegister DGU® (TR-DGU) considering all RTA-related injured MCs and COs (n = 19,225) that were registered in the TR-DGU from 2006 to 2020 with a primary admission to a trauma center with continuous participation (14 of 15 years) in the TR-DGU, an Injury Severity Score (ISS) ≥ 16 and aged between 16 and 79 years. The observation period was divided into three 5-year interval subgroups for further analysis. RESULTS: The mean age increased by 6.9 years and the ratio of severely injured MCs to COs changed from 1:1.92 to 1:1.45. COs were in 65.8% male and more often severely injured in the age groups under 30, while the majority of severely injured MCs were in the age group around 50 years and in 90.1% male. The ISS (- 3.1 points) as well as the mortality of both groups (CO: 14.4% vs. 11.8%; MC: 13.2% vs. 10.2%) steadily decreased over time. Nevertheless, the standardized mortality ratio (SMR) hardly changed and stayed < 1. Regarding the injury patterns, the greatest decline of injuries with AIS 3 + were to the head (CO: - 11.3%; MC: - 7.1%), in addition, a decrease of injuries to extremities (CO: - 1.5%; MC: - 3.3%), to the abdomen (CO: - 2.6%; MC: - 3.6%), to the pelvis in COs (- 4.7%) and to the spine (CO: + 0.1%; MC: - 2.4%) were observed. Thoracic injuries increased in both groups (CO: + 1.6%; MC: + 3.2%) and, furthermore, pelvic injuries in MCs (+ 1.7%). Another finding was the increase of the utilization of whole body CTs from 76.6 to 95.15%. CONCLUSION: The severity of injuries and their incidence, especially head injuries, have decreased over the years and seem to contribute to a decreasing hospital mortality of polytraumatized MCs and COs injured in traffic accidents. Young drivers and an increasing number of seniors are the age groups at risk and require special attention and treatment.

Analysis of the primary utilization of videolaryngoscopy in prehospital emergency care in Germany.

BACKGROUND: In 2019, the German prehospital airway management guidelines were published. One of the recommendations was the primary utilization of videolaryngoscopy (VL) for every prehospital endotracheal intubation (phETI). Guideline compliance is extremely important in emergency medicine as non-compliance in the worst-case scenario leads to death. The study aims to quantify guideline compliance among emergency medical service (EMS) physicians and, subsequently to analyze subgroups influencing compliance. MATERIAL AND METHODS: An online survey was developed and distributed as a hyperlink via email to all medical directors of EMS (n = 155) and the three main operators of helicopter emergency medical services (HEMS) in Germany. The survey was online from August 1st 2021 until October 3rd 2021. The primary outcome measure was the primary VL utilization. Data were evaluated descriptively. A multivariate regression analysis was used to determine associations between the primary VL utilization and age, sex, educational level, specialization, phETI per year, operating field, VL device type, and guideline knowledge. RESULTS: The analysis included 698 EMS physicians. More than 55% of the EMS physicians do not primarily use a videolaryngoscope for phETI. Multivariate regression analysis showed a significantly higher compliance if the devices C­MAC® or McGrath® were on board, guidelines were known or EMS physicians were female. Age, educational level, specialization or prehospital intubation experience had no significant impact. CONCLUSION: The study shows non-compliance with prehospital airway management guidelines in Germany. The guideline recommendation is based on scientific evidence but is not yet generally accepted by all EMS physicians. Videolaryngoscope device type and sex seem to influence the primary VL utilization. Training for EMS physicians must be extended and individual prehospital airway management should be reconsidered by every EMS physician.

The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization­A Systematic Review

BACKGROUND: Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages. METHODS: This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review. RESULTS: The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized. CONCLUSION: High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.

The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account.

BACKGROUND: Two-tier trauma team activation (TTA)-protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15). METHODS: We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15. RESULTS: During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67-0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001). CONCLUSIONS: The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey.

BACKGROUND: Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency. METHODS: We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine. RESULTS: Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants. CONCLUSIONS: Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated. LEVEL OF EVIDENCE: IV, cross-sectional study.

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator.

BACKGROUND: The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable. QUESTIONS/PURPOSES: We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model? METHODS: We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders. RESULTS: Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N). CONCLUSIONS: The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness. CLINICAL RELEVANCE: The use of an emergency pelvic trainer even for a non-invasive maneuver is advisable.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU®.

INTRODUCTION: To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. MATERIALS AND METHODS: The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. RESULTS: The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. DISCUSSION: The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism.

BACKGROUND: The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism. METHODS: We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS). RESULTS: During the study period, we included 250 patients. Mean age was 43.3 years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7 mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01-25.58) and for lactate > 2.2 mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93-13.48). A lactate level of > 4 mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4-324.29). CONCLUSION: This study identifies age (> 65) and lactate (> 2.2 mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments.

Reconstruction of Large Bone Defects and Complex Non-Unions Using a Free Fibular Bone Graft and a Supplementary Allograft. / Rekonstruktion großer Knochendefekte sowie komplexer Pseudarthrosen mittels freier Fibulatransplantation und eines additiven Allografts.

Large bone defects or complex pseudarthrosis represent an interdisciplinary challenge. Established surgical procedures include autogenous cancellous bone graft, the Masquelet technique or bone transfer via segment transport as well as free microvascular bone transplantation. However, the successful use of all these techniques requires a specialized center with great interdisciplinary expertise. In the following case series we describe the technique of free fibula transplantation and additional allograft. In both cases a good functional result with full mechanical strength of the affected extremity and satisfactory patient comfort has been achieved. In the second case, implant failure with the necessity of revision endoprosthetics occurred during the procedure.

Is there any benefit in the pre-hospital application of pelvic binders in patients with suspected pelvic injuries?

BACKGROUND: Massive hemorrhage is a common cause of death in patients sustaining instable pelvic ring fractures. Pelvic binders have been propagated for rapid, non-invasive pelvic ring stabilization and control of severe pelvic hemorrhage. There is a recommendation to applicate a pelvic binder due to the trauma mechanism alone. However, there is little evidence to support this advice. The aim of this study was to evaluate effects of an early pelvic binder application on transfusion requirements and hospital mortality. METHODS: This was a subgroup analysis of a study investigating clinical examination for pelvic stability. We included 64 patients who showed radiologically proven pelvic ring fracture (Tile type B or C). Study data were complemented by retrospective chart review to assess transfusion requirements. We used descriptive statistical analysis. RESULTS: 37 patients had a pelvic binder applied during prehospital treatment (pb), 27 received no binder (npb). Both showed no statistically significant difference in terms of injury severity or probability of survival. We found a trend towards higher ISS (29.7 vs. 24.4) and a lower probability of survival (RISC-II Prognosis 81% vs. 89%) in the pb group. Risk for massive transfusion according to TASH-Scores (10% vs. 6%), and average number of RPBC transfused (10.5 vs. 7.5) was higher in the pb group, without statistically significance. 20 patients (54%) in the pb group and 15 patients (55%) in the npb group showed a need of RPBC within the first 72 h. There was no significant difference in hospital mortality (20% vs. 13.3%). CONCLUSION: We were unable to identify blood-saving effects with application of a pelvic binder to patients with instable pelvic ring fractures in terms of RPBC requirements. Nevertheless, some salutary effect of prehospital pb application may be assumed. Better studies are needed to elucidate the value of this intervention.

Advances in the Preoperative Planning of Revision Trauma Surgery Using 3D Printing Technology.

The management of complex fractures at the time of revision surgery remains one of the most challenging tasks for orthopaedic trauma surgeons. As the major principle of treatment remains to achieve an anatomic reduction and a stable fixation, precise preoperative diagnostics and treatment planning are of utmost importance. Thus, knowledge of the 3-dimensional anatomy of the fracture site and its surrounding tissue is indispensable. However, radiographic tools have thus far mostly been unable to recapitulate the complexity of the fracture site in toto. In recent years, the development of 3-dimensional (3D) printers has led to novel opportunities in preoperative planning of complex operative procedures. Although the application of 3D printers has become increasingly popular in orthopaedic surgery, its implementation in trauma surgery is so far mostly limited to the preoperative planning of surgery in patients with pelvic and acetabular fractures/defects. Moreover, reports describing the advantages using this sophisticated methodology in revision trauma surgery are sparse. In this article, we report our experience using novel 3D printing technologies for the management of revision surgery in orthopaedic trauma. In particular, we describe the benefit of using 3D printing technologies in the preoperative planning of complex revision surgery of the proximal tibia, the elbow joint, the distal femur, the ankle joint, and several others. With the advantage to preoperatively plan the optimal surgical approach, implant placement, and contouring as well as the possibility to anticipate intraoperative difficulties, we believe that this emerging technology is of significant value for revision surgery in orthopaedic trauma.

Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure.

BACKGROUND: The stabilization strategy for acute high-grade acromioclavicular (AC) joint separations with AC-stabilizing clavicular hook plate (cHP) or coracoclavicular (CC)-stabilizing double double-button suture (dDBS) is still under consideration. HYPOTHESIS: The CC-stabilizing dDBS is superior to the cHP according to an AC-specific radiologic assessment and score system. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Seventy-three consecutive patients with acute high-grade AC joint separation were prospectively followed in 2 treatment groups (64.4% randomized, 35.6% patient-selected treatment): open reduction and cHP (cHP group) or arthroscopically assisted dDBS (dDBS group) performed within 14 days of injury. Patients were prospectively analyzed by clinical scores (Taft, Constant score [CS], numeric analog scale for pain) and AC-specific radiographs (AC distance, CC distance [CCD], relative CCD [rCCD; 100 / AC distance × CCD]) at points of examination (preoperative and 6, 12, and 24 months). The minimal clinically important differences (MCIDs) were assessed by the anchor-based method. RESULTS: Twenty-seven of 35 patients (mean age ± SD: 37.7 ± 9.7 years) after cHP implantation and 29 of 38 patients (34.2 ± 9.7 years) after dDBS implantation were continuously followed until the 24-month follow-up. All patients showed significantly increased scores after surgery as compared with preoperative status (all P < .05). As compared with GI, GII had significantly better outcomes at 24 months (Taft: cHP = 9.4 ± 1.7 vs dDBS = 10.9 ± 1.1, P < .05, MCID = 2.9; CS: cHP = 90.2 ± 7.8 vs dDBS = 95.3 ± 4.4, P < .02, MCID = 16.6) and at 24 months for Rockwood IV/V (Taft: cHP = 9.4 ± 1.7 vs dDBS = 11.1 ± 0.8, P < .0005; CS: cHP = 90.1 ± 7.7 vs dDBS = 95.5 ± 3.1, P < .04). Clinically assessed horizontal instability persisted in 18.52% (GI) and 6.89% (GII; P = .24). The rCCD showed equal loss of reduction at 24 months (GII = 130.7% [control = 111%] vs GI = 141.8% [control = 115%], MCID = 11.1%). CONCLUSION: This prospective study showed significantly superior outcomes in all clinical scores between GII and GI. The subanalysis of the high-grade injury type (Rockwood IV/V) revealed that these patients showed significant benefits from the dDBS procedure in the clinical assessments. The cHP procedure resulted in good to excellent clinical outcome data and displayed an alternative procedure for patients needing less restrictive rehabilitation protocols.

A Consensus-Based Criterion Standard for the Requirement of a Trauma Team.

BACKGROUND: Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team. METHODS: A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria. RESULTS: Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period. CONCLUSIONS: The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.

Trends in total elbow arthroplasty: a nationwide analysis in Germany from 2005 to 2014.

PURPOSE: To date, there has been no study investigating the epidemiology and the changes over time, especially regarding indications, in total elbow replacement in Germany. METHODS: Using German procedure classification system (OPS) codes as well as the associated ICD codes, a retrospective analysis from 2005 to 2014 of the data provided by the Federal Statistical Office of Germany was performed. Total elbow arthroplasties (TEAs) were evaluated for admitting diagnoses, sex, and age of patient and distribution of constraint versus unconstraint prostheses. Furthermore, the number and indications of revision elbow arthroplasty (REA) and explantations were identified. RESULTS: From 2005 to 2014, a total of 3872 patients underwent TEA in Germany. This represents a rise of 84% in this period. Almost 77% of the arthroplasties were performed in females, and over 45% were implanted in patients before the age of 70. During the study, a significant increase in TEA performed on patients for trauma from 12 to 42% and concomitantly, a decrease for the arthritis subgroup from 20 to 2.6% could be revealed. Additionally, almost a doubling of REA in that period could be detected (10.3 to 17.1%). The main revision indication could be found in mechanical complications, such as aseptic loosening (72.1%). Conversely, the number of explantations decreased (12.4 to 5.8%). CONCLUSION: During the study period, the number of TEA performed in Germany nearly doubled. Over the years, the most common indication for total elbow arthroplasty changed from inflammatory arthritis to trauma sequel. Further database analysis may help to identify populations at risk and specify reasons for revisions. LEVEL OF EVIDENCE: Therapeutic Level IV.

Diagnostics and early treatment in prehospital and emergency-room phase in suspicious pelvic ring fractures.

BACKGROUND: Testing for mechanical stability in pelvic ring fractures is advocated for the initial assessment and management of pelvic ring fractures. A survey among trauma surgeons showed that 91% agree with this recommendation. The aim of the present study was to describe the actual workup of patients with a high risk for unstable pelvic fractures in daily routine. METHODS: We performed a prospective multicenter observational study on patients admitted to the emergency room with suspected pelvic ring fractures. Data were collected anonymously via a standardized case report. RESULTS: A total of 254 patients with suspected pelvic injuries from 12 different trauma centers were included in this study. In 95 out of 254 cases a per definition unstable pelvic fracture could be confirmed; 46 type B and 49 type C fractures was confirmed. Mechanical stability examination was carried out in 61% and revealed a sensitivity of 31.6% and a specificity of 92.2%. 11.5% (18 patients) actually showed a mechanical instability (6 B# 12 C#). Regardless, 166 patients (65.4%) received noninvasive external stabilization ahead of diagnostic imaging, as a result of clinical judgment. 72% (24×) showed signs of significant bleeding in the subsequent CT scans. 33 pelvic ring fractures (type B or C) had no prehospital stabilization. CONCLUSION: Testing of mechanical stability of the pelvic ring was carried out less often and with lower consequences for the actual management than expected. It seems worthwhile to rather put on a pelvic binder at earliest occasion based on trauma mechanism or clinical findings to reduce the risk of serious pelvic bleeding.

The Reliability of the Pre-hospital Physical Examination of the Pelvis: A Retrospective, Multicenter Study.

INTRODUCTION: This study assesses the incidence of missed pelvic injuries in the pre-hospital setting. METHODS: All blunt trauma patients (ISS ≥ 9) with pre-hospital suspicion of and/or radiologically proven pelvic fracture documented in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society DGU (2002-2011) were identified and retrospectively analyzed. Patients with a missed pelvic injury in the pre-hospital period were compared with those who were correctly identified. RESULTS: Of the 11,062 patients included, 7201 patients (65.1 %) had a pelvic fracture diagnosed on hospital admission. In 44.1 % (n = 3178) of the patients with confirmed pelvic fracture, no pelvic injury was suspected pre-clinically (overall sensitivity of the pre-hospital pelvic examination: 55.9 %). For type B and C pelvic fractures, 40.5 % and 32.3 %, respectively, were not suspected in the pre-hospital environment. Patients with a not-suspected pelvic injury were significantly more likely to have been involved in a motor vehicle accident, to have a GCS ≤ 8, to be intubated at the scene and to have an ISS of ≥25 (all p < 0.05). Independent risk factors for missing a pelvic injury in the pre-hospital setting were an AIS head ≥3, a GCS ≤ 8 and age above 60 years. The presence of hypotension (SBP ≤ 90 mmHg) as well as a high overall injury severity (ISS ≥ 25) decreased the risk of missing a pelvic injury. CONCLUSION: A significant proportion of severe pelvic fractures type B and C were not suspected in the pre-hospital setting. Therefore, in severely injured blunt trauma patients, a mechanical pelvic stabilization in the pre-hospital environment, irrespective of the findings of the physical examination of the pelvis, should be considered.

Comparison of the Prehospital Trauma Life Support recommendations and the German national guideline on treatment of patients with severe and multiple injuries.

BACKGROUND: The Prehospital Trauma Life Support (PHTLS) concept is well established throughout the world. The aim is to improve prehospital care for patients with major trauma. In 2011, a German Level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published. The scope of this study was the systematic comparison between the educational content of the worldwide PHTLS concept and the German S3 Guideline. METHODS: A total of 62 key recommendations of the German S3 Guideline were compared with the content of the English PHTLS manual (eighth edition). Depending on the level of agreement, the recommendations were categorized as (1) agreement, (2) minor variation, or (3) major variation. Comparison was done via a rating system by a number of international experts in the field of out-of-hospital trauma care. The Delphi method was used to get the final statements by indistinct or board-ranged ratings. RESULTS: Overall, there was no conformity in 12%. In 68% a total agreement and in 88% conformity with slight differences of minor variations were found between the key recommendations of the guideline and the PHTLS manual. The PHTLS primary assessment has a large conformity for the following individual priorities: airway, 92%; breathing, 92%; circulation, 63%; disability, 100%; exposure, 89%. CONCLUSIONS: According to our comparison, the PHTLS manual is largely compatible with the German S3 Guideline from 2011. The 12% divergent statements concern mainly fluid resuscitation. Minor deviations in the prehospital care are due to a national guideline with an emergency medical service with emergency physicians (S3 Guideline) and a global PHTLS concept.