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

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

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

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

Evaluation of cannulated compression headless screws as an alternative implant for superior pubic ramus fracture fixation: a biomechanical study.

BACKGROUND/PURPOSE: Pubic ramus fractures account for the most common types of pelvic fractures. The standard surgical approach for superior pubic ramus fractures (SPRF) is a minimally invasive percutaneous screw fixation. However, percutaneous closed reduction and internal fixation of anterior pelvic ring injuries have high failure rates of up to 15%. The aim of this biomechanical study was to evaluate the stability of SPRF following stabilization with retrograde placed cannulated compression headless screw (CCHS) versus conventional fully and partially threaded screws in an artificial pelvic bone model. METHODS: SPRF type II as described by Nakatani et al. was created by means of osteotomies in eighteen anatomical composite hemi-pelvises. Specimens were stratified into three groups of six specimens each (n = 6) for fixation with either a 7.3 mm partially threaded cannulated screw (group RST), a 7.3 mm fully threaded cannulated screw (group RSV), or a 7.5 mm partially threaded cannulated CCHS (group CCS). Each hemi-pelvic specimen was tested in an inverted upright standing position under progressively increasing cyclic axial loading. The peak load, starting at 200 N, was monotonically increased at a rate of 0.1 N/cycle until 10 mm actuator displacement. RESULTS: Total and torsional displacement were associated with higher values for RST versus CCS and RSV, with significant differences between RST and CCS for both these parameters (p ≤ 0.033). The differences between RST and RSV were significant for total displacement (p = 0.020), and a trend toward significance for torsional displacement (p = 0.061) was observed. For both failure criteria 2 mm total displacement and 5° torsional displacement, CCS was associated with significantly higher number of cycles compared to RST (p ≤ 0.040). CONCLUSION: CCHS fixation presented predominantly superior stability to the standard surgical treatment and could therefore be a possible alternative implant for retrograde SPRF screw fixation, whereas partially threaded screws in group RST were associated with inferior biomechanical stability.

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

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

Standard practice in the treatment of unstable pelvic ring injuries: an international survey.

PURPOSE: Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. METHODS: A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). RESULTS: The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). CONCLUSION: The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

Is a Washer a Mandatory Component in Young Trauma Patients with S1-S2 Iliosacral Screw Fixation of Posterior Pelvis Ring Injuries? A Biomechanical Study.

Background and purpose: Cannulated screws are standard implants for percutaneous fixa-tion of posterior pelvis ring injuries. The choice of whether to use these screws in combination with a washer is still undecided. The aim of this study was to evaluate the biomechanical competence of S1-S2 sacroiliac (SI) screw fixation with and without using a washer across three different screw designs. Material and Methods: Twenty-four composite pelvises were used and an SI joint injury type APC III according to the Young and Burgess classification was simulated. Fixation of the posterior pelvis ring was performed using either partially threaded short screws, fully threaded short screws, or fully threaded long transsacral screws. Biomechanical testing was performed under progressively increasing cyclic loading until failure, with monitoring of the intersegmental and bone-implant movements via motion tracking. Results: The number of cycles to failure and the corresponding load at failure (N) were significantly higher for the fully threaded short screws with a washer (3972 ± 600/398.6 ± 30.0) versus its counterpart without a washer (2993 ± 527/349.7 ± 26.4), p = 0.026. In contrast, these two parameters did not reveal any significant differences when comparing fixations with and without a washer using either partially threaded short of fully threaded long transsacral screws, p ≥ 0.359. Conclusions: From a biomechanical perspective, a washer could be optional when using partially threaded short or fully threaded long transsacral S1-S2 screws for treatment of posterior pelvis ring injuries in young trauma patients. Yet, the omission of the washer in fully threaded short screws could lead to a significant diminished biomechanical stability.

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

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

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

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

Long-term experience with a collagen-elastin scaffold in combination with split-thickness skin grafts for the treatment of full-thickness soft tissue defects: improvements in outcome-a retrospective cohort study and case report.

PURPOSE: The management of severe soft tissue injuries to the extremities with full-thickness wounds poses a challenge to the patient and surgeon. Dermal substitutes are used increasingly in these defects. The aim of this study was to investigate the impact of the type of injury on the success rate of Matriderm® (MD)-augmented split-thickness skin grafting, as well as the role of negative pressure wound therapy (NPWT) in preconditioning of the wounds, with a special focus on the reduction of the bioburden. METHODS: In this study, 45 wounds (44 affecting lower extremities (97.7%)), resulting from different types of injuries: soft tissue (ST), soft tissue complications from closed fracture (F), and open fracture (OF) in 43 patients (age 55.0 ± 18.2 years, 46.7% female), were treated with the simultaneous application of MD and split-thickness skin grafting. The study was designed as a retrospective cohort study from March 2013 to March 2020. Patients were stratified into three groups: ST, F, and OF. Outcome variables were defined as the recurrence of treated wound defects, which required revision surgery, and the reduction of bioburden in terms of reduction of number of different bacterial strains. For statistical analysis, Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, and Pearson's chi-squared test were used. RESULTS: There was no significant difference in the rate of recurrence in the different groups (F: 0%; OF: 11.1%; ST: 9.5%). The duration of VAC therapy significantly differed between the groups (F: 10.8 days; OF: 22.7 days; ST: 12.6 days (p < 0.05)). A clinically significant reduction of bioburden was achieved with NPWT (bacterial shift (mean (SD), F: - 2.25 (1.89); OF: - 1.9 (1.37); ST: - 2.6 (2.2)). CONCLUSION: MD-augmented split-thickness skin grafting is an appropriate treatment option for full-thickness wounds with take rates of about 90%. The complexity of an injury significantly impacts the duration of the soft tissue treatment but does not have an influence on the take rate. NPWT leads to a relevant reduction of bioburden and is therefore an important part in the preconditioning of full-thickness wounds.

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

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

The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center.

BACKGROUND: Upper-extremity injuries often lead to long-term problems in function and quality of life in patients. However, not much is known about the effects in polytrauma patients. This study aimed to describe the upper-extremity injuries in polytrauma patients and to compare self-reported disability and quality of life in polytrauma patients with vs. without upper-extremity injuries. METHODS: We performed a retrospective cohort study of adult patients with an Injury Severity Score ≥ 16 admitted to Erasmus MC between January 1, 2007, and December 31, 2016. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand, Short Form 36, and EuroQol-5D questionnaires. Details on injuries, treatment, and clinical outcome were collected from the national trauma registry and medical files. Characteristics and self-reported outcomes of polytrauma patients with vs. without upper-extremity injuries were compared. RESULTS: In a cohort of 3469 trauma patients, 1246 (36.5%) had upper-extremity injuries. Of these, 278 (22.0%) had severe injuries (Abbreviated Injury Scale score ≥ 3). Upper-extremity injuries were associated with a longer hospitalization (median, 12 days vs. 8 days; P < .001), longer intensive care unit stay (median, 5 days vs. 4 days; P = .005), and lower mortality rate (14.6% vs. 23.9%, P < .001). Among the 598 patients who completed the questionnaires, no differences in the physical component summary score (47 vs. 48, P = .181) and mental component summary score (54 vs. 53, P = .315) of the Short Form 36 questionnaire, as well as the utility score (0.82 vs. 0.85, P = .101) and visual analog scale score (80 vs. 80, P = .963) of the EuroQol-5D questionnaire, were found. However, patients with upper-extremity injuries showed a minor increase in disability in the Disabilities of the Arm, Shoulder and Hand score (9.2 vs. 4.2, P = .023). CONCLUSION: Upper-extremity injuries in polytrauma patients are associated with a longer hospitalization, longer intensive care unit stay, and reduced mortality rate, as well as a minor increase in long-term disability.

Mortality of Adult Respiratory Distress Syndrome in Trauma Patients: A Systematic Review over a Period of Four Decades.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. In addition, its aetiologies are heterogeneous, and the outcome depends on the underlying cause. In trauma care, changes in diagnostics, management and treatment may influence the outcome of posttraumatic ARDS over time, which are attributable to geographic distribution, relate to the definition used and depend on the injury severity. METHODS: We selected studies by searching PubMed using the MeSH terms "acute respiratory distress syndrome", "mortality" and "trauma" and all their combinations. Studies that reported mortality rates for polytrauma patients with ARDS were included. We excluded studies with selected population collectives (e.g. burn patients, isolated thoracic trauma and paediatric trauma) and non-trauma studies. Studies were stratified according to the recruitment year of patients into Decade 1 (prior 1990), Decade 2(1990-1999), Decade 3 (2000-2009) and Decade 4 (later 2009); geographic location (North America or Europe), the definition used in the different studies (American European Consensus Conference (AECC) definition or Berlin definition) and the mean injury severity of the patient populations, respectively. RESULTS: Twenty-three studies between 1 January 1980 and 30 June 2018 were included in the analysis (486,861 patients, 52,561 with posttraumatic ARDS). There was a wide variation in mortality rates among the studies (4-39%). The overall pooled mean mortality rate for all studies was 21.8%, SD ± 8.3%. The mean mortality over the last four decades was similar between decade 1 (25.8%), decade 2 (20.6%), decade 3 (20.7%) and decade 4 (22.5%). Geographical observations comparing Europe and North America revealed no difference [Europe (22.1%) and North America (21.7%)]. The ARDS mortality in publications using the Berlin definition (23%) was comparable to the mortality rate in publications using the AECC definition (22.9%). The mortality rate based on the injury severity showed no alteration (ISS ≤ 25 points, 22.6%, ISS > 25 points, 22.6%). CONCLUSION: In this systematic review, there was no change in the mortality rate over the last four decades, no geographical difference within Western societies, no dependence on the ARDS definition used and no association with injury severity, respectively.

The impact of SARS-CoV-2 (COVID-19) pandemic on trauma bay management and guideline adherence in a European level-one-trauma centre.

PURPOSE: SARS CoV-2 (COVID-19) represents a pandemic that has led to adjustments of routine clinical practices. The initial management in the trauma bay follows detailed international valid algorithms. This study aims to work out potential adjustments of trauma bay algorithms during a global pandemic in order to reduce contamination and to increase safety for patients and medical personnel. METHODS: This retrospective cohort study compared patients admitted to the trauma bay of one academic level-one trauma centre in March and April 2019 with patients admitted in March and April 2020. Based on these datasets, possible adjustments of the current international guidelines of trauma bay management were discussed. RESULTS: Group Pan (2020, n = 30) included two-thirds the number of patients compared with Group Ref (2019, n = 44). The number of severely injured patients comparable amongst these groups: mean injury severity score (ISS) was significantly lower in Group Pan (10.5 ± 4.4 points) compared with Group Ref (15.3 ± 9.2 points, p = 0.035). Duration from admission to whole-body CT was significantly higher in Group Pan (23.8 ± 9.4 min) compared with Group Ref (17.3 ± 10.7 min, p = 0.046). Number of trauma bay admissions decreased, as did the injury severity for patients admitted in March and April 2020. In order to contain spreading of SARS Cov-2, the suggested recommendations of adjusting trauma bay protocols for severely injured patients include (1) minimizing trauma bay team members with direct contact to the patient; (2) reducing repeated examination as much as possible, with rationalized use of protective equipment; and (3) preventing potential secondary inflammatory insults. CONCLUSION: Appropriate adjustments of trauma bay protocols during pandemics should improve safety for both patients and medical personnel while guaranteeing the optimal treatment quality. The above-mentioned proposals have the potential to improve safety during trauma bay management in a time of a global pandemic.

Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review.

BACKGROUND: The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes. METHODS: Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study. RESULTS: After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%). CONCLUSION: According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.

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

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

Antegrade anterior column acetabulum fracture fixation with cannulated compression headless screws-A biomechanical study on standardized osteoporotic artificial bone.

PURPOSE: Due to the increase in life expectancy and high-energy traumas, anterior column acetabular fractures (ACFs) are also increasing. While open reduction and internal fixation (ORIF) is still the standard surgical procedure, minimally invasive, percutaneous fixation of osteoporotic acetabulum fractures (AF) are growing in popularity. The aim of this biomechanical study was to evaluate the biomechanical competence following antegrade fixation with a standard screw versus a cannulated compression headless screw. METHODS: Eight anatomical osteoporotic composite pelvises were given an anterior column fracture. Two groups of eight specimens each (n = 8) for fixation with either a 6.5 mm cannulated compression headless screw in group Anterior Acetabulum Canulated Compression Headless Screw (AACCH), or with a 6.5 mm partially threaded cannulated screw in group Anterior Acetabulum Standard Screw (AASS) where compared. Each specimen was biomechanically loaded cyclically at a rate of 2 Hz with monotonically increasing compressive load until failure. Motions were assessed by means of optical motion tracking. RESULTS: Initial construct stiffness trended higher in group AACCH at 152.4 ± 23.1 N/mm compared to group AASS at 118.5 ± 34.3 N/mm, p = 0.051. Numbers of cycles and corresponding peak load at failure, were significantly higher in group AACCH at 6734 ± 1669 cycles and 873.4 ± 166.9 N versus group AASS at 4440 ± 2063 cycles and 644.0 ± 206.3 N, p = 0.041. Failure modes were breakout of the screws around the proximal entry point. CONCLUSION: From a biomechanical perspective, group AACCH was associated with superior biomechanical competence compared to standard partially threaded cannulated screws and could therefore be considered as valid alternative for fixation of anterior acetabulum fractures.

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

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

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

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

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

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

A quantitative comparison of devices for in vivo biomechanical characterization of human skin.

Non-invasive skin characterization devices are emerging as a valuable tool in clinical skin research. In recent years, the range of available experimental techniques and methods used to determine the biomechanical properties of skin has increased considerably. Although a substantial amount of work has been devoted to assessing the working principle of macroscopic skin characterization devices individually, a rationalization and comparison between them is still lacking. This motivated the present study, which aimed to characterize and compare three commonly used working principles: suction, dynamic shear loading, and indentation. A synthetic model system with tunable mechanical properties was used to assess the three devices, and the results rationalized based on corresponding finite element models. In vivo measurements were performed on healthy volunteers to investigate the capability of differentiating the biomechanical properties of skin at different body locations, and to assess the intra- and inter-rater reliability of each device. The present comparative analysis indicates that the analyzed functional principles perceive the stiffness of human skin differently, with relevant implications for the interpretation of the respective measurement results.