Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

The role of biofilm on orthopaedic implants: the "Holy Grail" of post-traumatic infection management?

The development of post-traumatic infection is potentially a limb threatening condition. The orthopaedic trauma literature lags behind the research performed by our arthroplasty colleagues on the topic of implant-related infections. Surgical site infections in the setting of a recent ORIF are notoriously hard to eradicate due to biofilm formation around the implant. This bacteria-friendly, dynamic, living pluri-organism structure has the ability to morph and adapt to virtually any environment with the aim to maintain the causative organism alive. The challenges are twofold: establishing an accurate diagnosis with speciation/sensitivity and eradicating the infection. Multiple strategies have been researched to improve diagnostic accuracy, to prevent biofilm formation on orthopaedic implants, to mobilize/detach or weaken the biofilm or to target specifically bacteria embedded in the biofilm. The purpose of our paper is to review the patho-physiology of this mysterious pluri-cellular structure and to summarize some of the most pertinent research performed to improve diagnostic and treatment strategies in biofilm-related infections.

[Is the standard retention of syndesmotic positioning screws after ankle fracture fixation safe and feasible? A retrospective cohort study in 140 consecutive patients at a North American trauma centre]. / Ist das routinemäßige Belassen von Syndesmosenschrauben nach operativer Versorgung instabiler Sprunggelenksfrakturen gerechtfertigt? Erfahrung eines US-Traumazentrums an 140 konsekutiven Patienten.

BACKGROUND: Unstable ankle injuries with associated disruption of the distal-fibular syndesmosis are typically managed by adjunctive placement of temporary syndesmotic positioning screws. The widespread notion that positioning screws must be removed by default after healing of the syndesmosis remains a topic of debate which lacks scientific support. The present study was designed to test the hypothesis that syndesmotic positioning screws are safely retained per protocol in asymptomatic patients. PATIENTS AND METHODS: A retrospective analysis of an institutional prospective database was performed during a 5-year time-window at an academic level 1 trauma centre in the United States. All ankle fractures requiring surgical fixation were included in the analysis. The primary outcome parameter consisted of the rate of elective hardware removal for syndesmotic positioning screws within 6 months after surgical fixation. RESULTS: A total of 496 consecutive patients with 496 isolated ankle fractures managed by surgical fixation were included in this study. Of these, 140 injuries were managed by placement of syndesmotic positioning screws. Within 6 months follow-up, 17.1% of all syndesmotic screws were found to be radiographically broken, and 13.6% of syndesmotic screws revealed radiographic signs of loosening. Only 2 patients (1.4%) required the elective removal of symptomatic positioning screws within 6 months of surgical fracture fixation. CONCLUSION: Despite the high rate of radiographic complications related to breaking or loosening of syndesmotic screws in almost one third of all cases, more than 98% of all patients remain asymptomatic and do not require a scheduled hardware removal. The routine removal of syndesmotic positioning screws does not appear to be justified from a patient safety perspective.

Evidence-based medicine: a 'hidden threat' for patient safety and surgical innovation?

We explore the limitations of complete reliance on evidence-based medicine which can be diminished by confounding issues and sampling bias. Other strategies which may be reasonably invoked are discussed.

[Challenging the dogma on inferiority of stainless steel implants for fracture fixation. An end of the controversy?]. / Das Dogma der Minderwertigkeit von Stahlimplantaten zur Frakturversorgung. Ein Ende der Kontroverse?

BACKGROUND: Titanium plates represent the predominant implants of choice for fracture care in Central Europe, based on the apparently favourable properties related to improved "biocompatibility". The present study was designed to test the hypothesis that the use of stainless steel implants for selected fractures represents a safe and efficient treatment modality, which is not associated with an increased rate of complications and surgical revisions. METHODS: We conducted a retrospective analysis of a prospective database during a 5-year study period (01/01/2006-12/31/2010) at an academic Level 1 Trauma Center on all fractures treated by stainless steel plates. Inclusion criteria consisted of all consecutive patients >15 years of age whose fractures were fixated with a stainless steel plate. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of complications and surgical revisions, and the data were placed into context with the published complication rates for titanium plates. RESULTS: A total of 1,001 consecutive patients who underwent surgical fixation of fractures in the indication spectrum of this study were screened. Of these, 751 patients fulfilled the inclusion criteria. These patients had 774 fractures which were fixated with 859 stainless steel plates. Open fractures accounted for 9.6% of all injuries (n=74). The complication rate of the 774 fractures treated with stainless steel plates was 8.01% (n=62), with a surgical revision rate of 5.16% (n=40). These data are below the reported incidence of complications and surgical revisions for titanium plates in the identical indication spectrum in the pertinent literature published. CONCLUSIONS: The fixation of selected fractures with stainless steel implants represents a safe and efficient treatment option, which does not appear to be associated with increased complication rates. These data challenge the anecdotal superiority of titanium plates and should spur a new discussion on the use of stainless steel implants, particularly under the aspect of cost savings in the DRG era.

[Surgical treatment of ankle fractures as an outpatient procedure. A safe and resource-efficient concept?]. / Ambulante Versorgung operativer Spunggelenkfrakturen an einem US-Traumazentrum. Ein valides Modell im DRG-Zeitalter?

BACKGROUND: In many European countries, patients requiring surgical treatment of ankle fractures are generally hospitalized for an average of 8-11 days. This anecdotal concept is largely based on the premise that the inpatient monitoring of soft tissue conditions may lead to a decreased complication rate. The present study was designed to test the hypothesis that the surgical care of isolated ankle fractures as an outpatient procedure represents a safe and feasible concept which is not associated with an increased complication rate. METHODS: A retrospective analysis was performed of a prospective database during a 5-year period (01/01/2005-12/31/2009) at a US academic level 1 trauma center with an institutional protocol of outpatient surgery for isolated ankle fractures. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of postoperative complications and frequency of unplanned surgical revisions outpatient isolated versus inpatient isolated with surgical fixation of ankle isolated fractures. RESULTS: Among 810 consecutive patients with ankle fractures during the study period, 476 met the inclusion criteria. Of these, 256 patients (53.8%) were treated as outpatients. The average length of stay of patients who were admitted as inpatients was 1.5±0.8 days (range 1-5 days). The age distribution was in a similar range for inpatients and outpatients (39±14.1 vs 35±12.8 years), and the injury severity based on the AO/OTA fracture classification revealed a similar distribution of fracture patterns in both groups. The rate of postoperative complications (9.1 vs 3.1%) and of unplanned surgical revisions (3.6 vs 1.2%) was significantly increased in the hospitalized group, compared to patients with ambulatory surgery (P<0.05). CONCLUSION: The surgical treatment of isolated ankle fractures as an outpatient procedure represents a safe and resource-efficient concept which is not associated with an increased complication rate. Cultural differences in the domestic environment of individual patients may have to be taken into consideration.

[Current concepts of patient safety: rapid response system]. / Aktuelle Konzepte der Patientensicherheit : Das "Rapid-response"-System.

The "100,000 lives campaign" initiated a wide-spread implementation of rapid response teams in the United States. A standardized rapid response system (RRS) is designed to reduce the preventable mortality of hospitalized patients who frequently have progressive signs of physiological deterioration minutes to hours before cardiac arrest. The implementation and maturation of a team-based RRS has been shown to significantly reduce the incidence of "COR zero" calls and, in some studies, the in-hospital mortality rate. An alternative model to rapid response teams has been recently proposed which is based on defined clinical triggers to initiate a "rapid response escalation". This clinical triggers program overcomes the classic limitations of a team-based system, such as the overuse of resources and the fragmentation of patient care. The present review outlines the basic RRS concept with a focus on the debate related to the "perfect" patient safety system, namely the validity of a distinct rapid response teams approach versus a trigger-based escalation modality. The implementation of a standardized RRS should also be considered in German hospitals with the aim of improving patient safety and reducing preventable in-hospital mortality.

Impact of the complement cascade on posttraumatic cartilage inflammation and degradation.

The limited ability of articular cartilage to recover from injury, remains an unsolved clinical challenge in orthopaedic surgery. Persistent injury of the articular surface can lead to the development of posttraumatic osteoarthritis. The local inflammatory response contributes to the pathogenesis of osteoarthritis by inducing chondrocyte apoptosis and the de-regulation of chondrocyte matrix remodelling. The role of the complement system in contributing to secondary inflammation-mediated cartilage degradation represents a newer field of investigation. The purpose of this review article is to summarize the known complement-mediated actions in cartilage homeostasis and injury. This article focuses on the known effects of complement on secondary chondrocyte apoptosis, and the interplay of the complement system with pro-inflammatory cytokines. Pharmacological therapies related to complement inhibition will be discussed as they potentially represent a new avenue for attenuating the effect of the complement system on cartilage repair.

Immunohistochemical characterization of Fas (CD95) and Fas Ligand (FasL/CD95L) expression in the injured brain: relationship with neuronal cell death and inflammatory mediators.

Traumatic brain injury causes progressive tissue atrophy and consequent neurological dysfunction, resulting from neuronal cell death in both animal models and patients. Fas (CD95) and Fas ligand (FasL/CD95L) are important mediators of apoptosis. However, little is known about the relationship between Fas and FasL and neuronal cell death in mice lacking the genes for inflammatory cytokines. In the present study, double tumor necrosis factor/lymphotoxin-alpha knockout (-/-) and interleukin-6-/- mice were subjected to closed head injury (CHI) and sacrificed at 24 hours or 7 days post-injury. Consecutive brain sections were evaluated for Fas and FasL expression, in situ DNA fragmentation (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling; TUNEL), morphologic characteristics of apoptotic cell death and leukocyte infiltration. A peak incidence of TUNEL positive cells was found in the injured cortex at 24 hours which remained slightly elevated at 7 days and coincided with maximum Fas expression. FasL was only moderately increased at 24 hours and showed maximum expression at 7 days. A few TUNEL positive cells were also found in the ipsilateral hippocampus at 24 hours. Apoptotic, TUNEL positive cells mostly co-localized with neurons and Fas and FasL immunoreactivity. The amount of accumulated polymorphonuclear leukocytes and CD11b positive cells was maximal in the injured hemispheres at 24 hours. We show strong evidence that Fas and FasL might be involved in neuronal apoptosis after CHI. Furthermore, Fas and FasL upregulation seems to be independent of neuroinflammation since no differences were found between cytokine-/- and wild-type mice.

[Current concepts of polytrauma management: from ATLS to "damage control"]. / Aktuelle Konzepte des Polytraumamanagements: Von ATLS zu "Damage Control".

In recent years, the implementation of standardized protocols for polytrauma management has led to a significant improvement in trauma care as well as to a decrease in post-traumatic morbidity and mortality. As such, the "Advanced Trauma Life Support" (ATLS) protocol of the American College of Surgeons for the acute management of severely injured patients has been established as a gold standard in most European countries since the 1990s. Continuative concepts to the ATLS program include the "Definitive Surgical Trauma Care" (DSTC) algorithm and the concept of "damage control" surgery for polytraumatized patients with immediate life-threatening injuries. These phase-oriented therapeutic strategies appraise the injured patient of the whole extent of the sustained injuries and are in sharp contrast to previous modalities of "early total care" which advocate immediate definitive surgical intervention. The approach of "damage control" surgery takes into account the influence of systemic post-traumatic inflammatory and metabolic reactions of the organism and is aimed at reducing both the primary and the secondary, delayed, mortality in severely injured patients. The present paper provides an overview of the current state of management algorithms for polytrauma patients, with a focus on the standard concepts of ATLS and "damage control".

[Emergency management of thoracic trauma]. / Die Notfallversorgung des Thoraxtraumas.

Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.

Ultrasonography as a reliable diagnostic tool in old quadriceps tendon ruptures: a prospective multicentre study.

Quadriceps tendon rupture is an uncommon injury. In the majority of cases, predispositions as recurrent microtrauma or degenerative changes are present. The diagnosis of acute quadriceps tendon ruptures can usually be made by clinical examination. Ultrasonography has been shown as a reliable, inexpensive and easily available diagnostic tool to confirm the diagnosis. In this study, we evaluated the clinical value of ultrasonography for establishing diagnosis of old quadriceps tendon ruptures. In the prospective time period of 6 years (01/1998-12/2003), the delayed diagnosis of quadriceps tendon rupture was established in six patients with seven cases of old ruptures (one bilateral rupture). The mean age was 50.2 (SD+/-16.9) years in one woman and five men. The mean interval from trauma until diagnosis was 15.2 (SD+/-7.1; range 8-24) weeks. In all cases, ultrasonography represented a reliable and sensitive tool for establishing diagnosis of old quadriceps tendon rupture. We therefore recommend the use of ultrasonography in the diagnostic work up of cases with knee trauma and potential involvement of tendon injuries.

[The role of whole body spiral CT in the primary work-up of polytrauma patients--comparison with conventional radiography and abdominal sonography]. / Die Rolle der Granzköper-Spiral-CT bei der Primärdiagnostik polytraumatisierter Patienten -- Vergleich mit konventioneller Radiographie und Abdomensonographie.

PURPOSE: To evaluate the role of routine "whole body spiral CT"in the primary work-up of polytrauma patients for injuries of the thorax, abdomen and spine, and to compare the results with those of conventional radiography of the chest and spine and abdominal ultrasound. MATERIALS AND METHODS: Fifty consecutive polytrauma patients underwent contrast-enhanced single slice spiral CT (5 mm collimation) from the vertex to the floor of the pelvis as part of the primary work-up after emergency room admission. Overlapping high resolution sections and sagittal reformations of the spine were obtained. Reports of additional chest radiographs (n=43), abdominal ultrasound examinations(n = 47) and spine radiographs (n = 36) performed in the emergency room were available for retrospective comparison. The "final diagnoses," which served as the standard of reference, were taken from the patients' records using all information that be-came available until discharge or death, such as findings from further imaging, surgery and autopsy. RESULTS: CT showed 109(97%) of 112 thoracic and abdominal soft-tissue injuries. Relevant injuries missed were an early splenic laceration and an early pelvic hematoma, both of which became clinically apparent several hours later. There were 4 false positive CT findings. Conventional chest radiography demonstrated only 20% of thoracic and sonography 22% of abdominal injuries. Chest radiography and sonography produced 2 false-positive findings each. CT showed 66 (87%) of 76 vertebral fractures including all 19 unstable ones.CT missed 5 anterior vertebral body and 5 spinous/transverse process fractures. Conventional radiography found 71 % of vertebral fractures including only 50 % of the unstable ones. CONCLUSION: Routine performance of whole body spiral CT as part of the primary work-up of polytrauma patients provides a fast and comprehensive survey and detects almost all soft tissue injuries of the chest and abdomen. It is clearly superior to chest radiography and abdominal sonography. All spinal injuries relevant for the acute management were also seen on CT, but not on conventional radiography.

Role of cerebral inflammation after traumatic brain injury: a revisited concept.

Neuroinflammation occuring after traumatic brain injury (TBI) is a complex phenomenon comprising distinct cellular and molecular events involving the injured as well as the healthy cerebral tissue. Although immunoactivation only represents a one of the many cascades initiated in the pathophysiology of TBI, the exact function of each mediator, activated cell types or pathophysiological mechanism, needs to be further elucidated. It is widely accepted that inflammatory events display dual and opposing roles promoting, on the one hand, the repair of the injured tissue and, on the other hand, causing additional brain damage mediated by the numerous neurotoxic substances released. Most of the data supporting these hypotheses derive from experimental work based on both animal models and cultured neuronal cells. More recently, evidence has been provided that a complete elimination of selected inflammatory mediators is rather detrimental as shown by the attenuation of neurological recovery. However, there are conflicting results reported on this issue which strongly depend on the experimental setting used. The history of immunoactivation in neurotrauma is the subject of this review article, giving particular emphasis to the comparison of clinical versus experimental studies performed over the last 10 years. These results also are evaluated with respect to other neuropathologies, which are years ahead as compared to the research in TBI. The possible reciprocal influence of peripheral and intrathecal activation of the immune system will also be discussed. To conclude, the future directions of research in the field of neurotrauma is considered.

Regulation of chemokines and chemokine receptors after experimental closed head injury.

The expression of the chemokines macrophage inflammatory protein (MIP)-2 and MIP-1alpha and of their receptors CXCR2 and CCR5 was assessed in wild type (WT) and TNF/lymphotoxin-alpha knockout (TNF/LT-alpha-/-) mice subjected to closed head injury (CHI). At 4 h after trauma intracerebral MIP-2 and MIP-1alpha levels were increased in both groups with MIP-2 concentrations being significantly higher in WT than in TNF/LT-alpha-/- animals (p < 0.05). Thereafter, MIP-2 production declined rapidly, whereas MIP-1alpha remained elevated for 7 days. Expression of CXCR2 was confined to astrocytes and increased dramatically within 24 h in both mouse types. Contrarily, CCR5 expression remained constitutively low and was mainly localized to microglia. These results show that after CHI, chemokines and their receptors are regulated differentially and with independent kinetics.