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.

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

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

Salvage of a mangled limb with Matriderm® augmented split-skin grafting and maggot biodebridement.

Salvage of a mangled limb can be a long and strenuous way, but it is feasible even with rather simple techniques such as augmented split-skin grafting and maggot biodebridement.

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review.

BACKGROUND: Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. MATERIALS AND METHODS: Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. STUDY SELECTION: Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. DATA EXTRACTION: Two authors independently extracted data using a predesigned form. STATISTICS: Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. RESULTS: Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). CONCLUSIONS: There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

Short-term outcome after appendectomy is related to preoperative delay but not to the time of day of the procedure: A nationwide retrospective cohort study of 9224 patients.

INTRODUCTION: Acute appendicitis is among the most common indications for emergency abdominal surgery. The risk of perforation might increase with a delay in treatment. Therefore, appendicitis is considered a surgical emergency, leading to appendectomies being frequently performed off-hours. However, numerous studies from other medical specialties have shown less favourable outcomes in patients admitted or treated off-hours than in those treated during regular working hours. The purpose of this study was to determine whether the time of day of the procedure and preoperative delay in appendectomy have significant impacts on morbidity and mortality rates. METHODS: All appendectomies recorded in a prospective national quality measurement database (Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC)) between 2010 and 2017 were retrospectively analysed. The inclusion criteria were appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and available information on the time of day the appendectomy was performed. We stratified patients into four groups according to the start of the operation-'MORNING' for surgeries started between 7:00 a.m. and 12:59 p.m., 'AFTERNOON' for surgeries started between 1:00 p.m. and 6:59 p.m., 'EVENING' for surgeries started between 7:00 p.m. and 11:59 p.m., and 'NIGHT' for surgeries started between midnight and 6:59 a.m. In a further analysis, we examined differences between patients who underwent surgery on the admission day and those who underwent surgery later. A total of 9224 patients with a mean age of 36 ± 19 years (54% men) were included and further analysed. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome. Variables were entered into bivariate and multivariate analyses. RESULTS: Of the appendectomies, 38% were performed during the afternoon, 31% in the evening, 18% in the morning, and 13% at night-time. Patients who underwent surgery at night had slightly lower American Society of Anesthesiologists scores, were more often managed as emergency cases (98% of the cases), had fewer comorbidities, and were more often covered by statutory instead of private health insurance than the other patients. Junior attending and resident surgeons performed 88% of all night-time operations. The average duration of surgery was not significantly longer in the night-time group than in the day-time groups. The overall complication rate was 4.7%, ranging from 3.5% in the 'NIGHT' group to 5.0% in the 'AFTERNOON' group. However, the differences between the groups were not significant. The in-hospital mortality rate was 0.12% (n = 11), ranging from 0.082% (n = 1) in the 'NIGHT' group to 0.17% (n = 5) in the 'EVENING' group. The timing of appendectomy was not associated with mortality. However, the rates of complications, in-hospital mortality, and conversion were all significantly higher in patients with a preoperative delay of >24 h. CONCLUSIONS: The time of day of performing an appendectomy does not seem have any significant effect on complication and mortality rates. However, a longer length of preoperative stay significantly increases the risk of complications and mortality. Night-time operations should be preferred over next-day surgery considering the equal perioperative risks observed in this study.

Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?-A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis.

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

[Fever after an Open Ankle Fracture - a Surprising Diagnosis]. / Fieber nach offener Sprunggelenksluxationsfraktur ­ eine unerwartete Diagnose.

Fever after an Open Ankle Fracture - a Surprising Diagnosis Abstract. We present the case of a patient with a second-degree open dislocated ankle fracture and a complex wound situation as well as fever in the postoperative course. The man, originally from Nigeria, spent his annual holidays in a rural area of ​​the country, where he sustained a right-sided open dislocation fracture of his ankle in a car accident. After initial rudimentary care in Nigeria, the patient traveled back to Switzerland on his own, where he has been living for the past ten years. Back in Zurich he presented himself to our Department for Emergency Medicine. He was admitted to our Trauma Unit and received surgical care. After dismissal, the patient developed a fever of up to 39 °C and returned to our hospital. We initially assumed the reason for the fever to be a wound infection and therefore escalated an already established antibiotic regimen. Only on the second day after admission we tested the patient for malaria as the surgical wounds looked too clean to be the source of the fever. The patient was tested positive for malaria and transferred to the Department of Infectious Diseases for further treatment where he made a full recovery.