[Implications of prehospital estimation of trauma patients for the treatment pathway-An evaluation of the TraumaRegister DGU®]. / Implikationen der prähospitalen Einschätzung des Traumapatienten auf den Behandlungsverlauf ­ Eine Auswertung aus dem TraumaRegister DGU®.

BACKGROUND: In the prehospital acute treatment phase of severely injured patients, the stabilization of the vital parameters is paramount. The rapid and precise assessment of the injuries by the emergency physician is crucial for the initial treatment and the selection of the receiving hospital. OBJECTIVE: The aim of this study was to determine whether the prehospital emergency medical assessment has an influence on prehospital and emergency room treatment. MATERIAL AND METHODS: Data from the TraumaRegister DGU® between 2015 and 2019 in Germany were evaluated. The prehospital emergency medical assessment of the injury pattern and severity was recorded using the emergency physician protocol and compared with the in-hospital documented diagnoses using the abbreviated injury scale. RESULTS: A total of 47,838 patients with an average injury severity score (ISS) of 18,7 points (SD 12.3) were included. In summary, 127,739 injured body regions were documented in the hospitals. Of these, a total of 87,921 were correctly suspected by the emergency physician Thus, 39,818 injured body regions were not properly documented. In 42,530 cases a region of the body was suspected to be injured without the suspicion being confirmed in the hospital. Traumatic brain injuries and facial injuries were mostly overdiagnosed (13.5% and 14.7%, respectively documented by an emergency physician while the diagnosis was not confirmed in-hospital). Chest injuries were underdocumented (17.3% missed by an emergency physician while the diagnosis was finally confirmed in-hospital). The total mortality of all groups was very close to the expected mortality calculated with the revised injury severity classification II(RISC II)-score (12.0% vs. 11.3%). CONCLUSION: In the prehospital care of severely injured patients, the overall injury severity is often correctly recorded by the emergency physician and correlates well with the derived treatment, the selection of the receiving hospital as well as the clinical course and the patient outcome; however, the assessment of injuries of individual body regions seems to be challenging in the prehospital setting.

[Empirical evaluation of quality indicators for severely injured patients in the TraumaRegister DGU®]. / Empirische Überprüfung der Qualitätsindikatoren für Schwerverletzte im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVE: A systematic assessment of the quality of medical treatment by using key indicators has been required in Germany for many years. These quality indicators (QI) have to satisfy many requirements. Besides an expert review an empirical data-based evaluation is also necessary. The TraumaRegister DGU® (TR-DGU) has reported QI in the annual reports from the beginning. The objective of this study was to validate 40 QI for the treatment of severely injured patients reviewed by experts using data from the TR-DGU. MATERIAL AND METHODS: The association of the 40 QI with hospital mortality was verified using healthcare data from the TR-DGU from a 5­year period (2012-2016). Of these 26 QI consider events while the remaining 14 QI are key indicators, such as time spent in the trauma room. To compensate differences in injury severity, adjusted mortality rates were calculated using the revised injury severity classification (RISC) II score. For this two different approaches were chosen: the hospital-based approach classifies all hospitals into three categories and analyzes the grade of fulfilment of the indicator. The indicator-based approach considers the adjusted mortality depending on the grade of fulfilment of the indicator. RESULTS: The analysis was based on 111,656 cases documented in the TR-DGU (mean age 50 years; 70 % male). The data analysis showed an obvious correlation with mortality for half of the QI, including only three procedural times. A clear correlation in both approaches was shown for two QI: prehospital capnometry in intubated patients and sonography used for patients without whole body computed tomography (CT) scans. Of the 20 QI with a positive result 15 were also positively rated by the experts. Of the 14 QI reported annually since 2017 in the TR-DGU report, 8 (57%) showed a clear correlation with mortality. CONCLUSION: There is no doubt regarding the necessity of scientifically assessing QI. Approximately half of the evaluated QI showed an empirical association with mortality. Interventions and events showed better results than measurements of procedural times; however, many QI may require a refined definition. The interpretation of the results is still challenging due to differences in the patient groups. Secondary endpoints, such as hospital length of stay and quality of life after trauma were not considered here.

[ATLS® and TDSC®: how it fits together : A treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios]. / ATLS® und TDSC®: How it fits together : Ein Behandlungskonzept für MANV und TerrorMANV, lebensbedrohliche oder besondere Lagen.

Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

[Development of a new module for the TraumaRegister DGU® : Better collation of the sequelae of severe injuries during pregnancy]. / Entwicklung eines neuen Moduls für das TraumaRegister DGU® : Folgen schwerer Verletzungen während der Schwangerschaft besser erfassen.

BACKGROUND: Life-threatening injuries during pregnancy are a rare occurrence. The TraumaRegister DGU® (TR-DGU) has been recording whether seriously injured women were pregnant since 2016. This information is not sufficient to enable a differentiated assessment of the quality of care because parameters, such as gestational age, state of pregnancy at discharge and survival of the child are missing. The TraumaRegister working group of the committee on emergency medicine, intensive care and severe trauma management (section NIS) of the German Trauma Society (DGU) therefore came to the conclusion that the fetal outcome or the intactness of the pregnancy after acute treatment is an important measure of the quality of care of pregnant women. They commissioned a task force to work out a suitable data set for a better analysis of such cases. This article presents the so-called fetus module in detail. METHODS: The data set was developed in an interdisciplinary process together with accredited experts from the German Society for Gynecology and Obstetrics (DGGG), the German Society for Perinatal Medicine (DGPM) and the Society for Neonatology and Pediatric Intensive Care Medicine (GNPI). RESULTS: The fetus module comprises 20 parameters describing the pregnancy, the condition of the mother and child on admission and discharge. CONCLUSION: The fetus module will provide important data to make the process and outcome quality of care of severely injured pregnant women measurable and to develop prognostic instruments with which predictions about high-risk constellations for the outcome of mother and child can be made.

Guidelines for using animal models in blast injury research.

Blast injury is a very complex phenomenon and frequently results in multiple injuries. One method to investigate the consequences of blast injuries is with the use of living systems (animal models). The use of animals allows the examination and evaluation of injury mechanisms in a more controlled manner, allowing variables such as primary or secondary blast injury for example, to be isolated and manipulated as required. To ensure a degree of standardisation across the blast research community a set of guidelines which helps researchers navigate challenges of modelling blast injuries in animals is required. This paper describes the guidelines for Using Animal Models in Blast Injury Research developed by the NATO Health Factors and Medicine (HFM) Research Task Group 234.

[Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?] / "Resuscitative endovascular balloon occlusion of the aorta" : Option für nichtkomprimierbare Körperstammblutungen?

Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.

[Update on gunshot wounds to extremities]. / Update zu Schussverletzungen der Extremitäten.

Due to recent rampage and terror attacks in Europe, gunshot wounds have become a focus of attention even though they are still rare in Europe. Approximately 50% of gunshot wounds affect the extremities and to understand the sequelae, a basic knowledge of wound ballistics is indispensable. The energy transmitted from the bullet to the tissue is responsible for the severity of the injury and is dependent on the type of weapon and ammunition. A differentiation is made between low-energy injuries caused, e.g. by pistols and high-energy injuries mostly caused by rifles. The higher energy transfer to the tissue in high-energy injuries, results in a temporary wound cavity in addition to the permanent wound channel with extensive soft tissue damage. High-energy gunshot fractures are also more extensive compared to those of low energy injuries. Debridement seems to be necessary for almost all gunshot wounds. Fractures should be temporarily stabilized with an external fixator due to contamination.

[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]. / Optimierung der Kriterien zur Schockraumalarmierung : Vermeidung von Über- und Untertriage.

INTRODUCTION: Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system. MATERIAL AND METHODS: In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC. RESULTS: This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage. CONCLUSION: Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM).

PURPOSE: The study's purpose is to evaluate the long-term outcome after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) and to identify predictors of quality of life associated with intensive care. METHODS: Fifty-five patients who underwent open abdomen management at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 27 patients completed the 36-Item Short Form Survey (SF-36) quality of life questionnaire. As this is a report solely focused on quality of life, direct treatment-related outcome measures like mortality, closure rates, and incisional hernia development of this study cohort have been reported previously. RESULTS: SF-36 physical role (54.6 ± 41.0 (0-100), p < 0.01), physical functioning (68.4 ± 29.5 (0-100), p = 0.01), and physical component summary (41.6 ± 13.0 (19-62), p = 0.01) scores for the patient population were significantly lower than normative scores. Significant correlations were found between physical functioning and total treatment costs (r = -0.66, p = 0.01), total units of packed red blood cells (r = -0.56, p = 0.04), and the complex intensive care scores (r = -0.50, p = 0.02). Simple and multiple regression analyses demonstrated that the complex intensive care score was the only predictor of physical functioning (R 2 = 0.50, ß = -0.70, p = 0.02). CONCLUSIONS: Despite high short-term mortality and morbidity rates for these critically ill patients, open abdomen treatment using VAWCM allows patients to recover to an acceptable long-term quality of life. The complex intensive care score can be used as a surrogate parameter for the global severity of illness and was the only predictor of physical functioning (SF-36).

[Replacement of the thumb carpometacarpal joint : Current importance of endoprosthetics for operative treatment of rhizarthrosis]. / Endoprothetik am Daumensattelgelenk : Aktueller Stellenwert der Endoprothetik zur operativen Behandlung der Rhizarthrose.

The role of joint replacement in the treatment of osteoarthritis of the thumb carpometacarpal joint is a subject of considerable controversy in the current literature. In German-speaking countries this technique is used much less frequently than resection procedures. Aseptic loosening of the prosthesis is believed to be the major cause of the high failure rates reported for cemented and uncemented types of implants. In this study the different implant designs were evaluated on the basis of the results reported in the international literature. There are only a few studies that cover relatively long follow-up periods and provide convincing results for thumb carpometacarpal joint prostheses in terms of implant survival and function. Aseptic loosening is reported to be the major cause with failure rates of 50 % or more. Although a Norwegian study reported high 5 and 10-year survival rates for various thumb carpometacarpal joint prostheses according to the Norwegian arthroplasty registry, it did not recommend the widespread use of thumb carpometacarpal joint replacement at the present time. In our opinion, joint replacement may be considered as a possible treatment option for advanced osteoarthritis of the thumb carpometacarpal joint but it should not always be recommended because long-term results are inconsistent and similar functional outcomes have been reported for alternative surgical techniques, such as resection arthroplasty.

[Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®]. / Zivile Explosionstraumata - ein unterschätztes Problem? : Ergebnisse einer retrospektiven Analyse aus dem TraumaRegister DGU®.

BACKGROUND: Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive. MATERIAL AND METHODS: A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed. RESULTS: A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %). CONCLUSION: This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.

Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction.

BACKGROUND: The open abdomen has become an accepted treatment option of critically ill patients with severe intra-abdominal conditions. Fascial closure is a particular challenge in patients with peritonitis. This study investigates whether fascial closure rates can be increased in peritonitis patients by using an algorithm that combines vacuum-assisted wound closure and mesh-mediated fascial traction. Moreover, fascial closure rates for patients with peritonitis, trauma or abdominal compartment system (ACS) are compared. METHODS: Data were collected prospectively from all patients who underwent open abdomen management at our institution from 2006 to 2012. All patients were treated under a standardised algorithm that combines vacuum-assisted closure and mesh placement at the fascial level. RESULTS: During the study period, 53 patients (mean age 53 years) underwent open abdomen management for a mean duration of 15 days. Indications for leaving the abdomen open were peritonitis (51 %), trauma (26 %), and ACS or abdominal wall dehiscence (23 %). The fascial closure rate was 79 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. Mortality was 13 %. No patient developed an enteroatmospheric fistula or abdominal wall dehiscence after closure. The mean duration of treatment was significantly longer in peritonitis patients (20 days) than in patients without peritonitis (10 days) (p = 0.03). There were no significant differences in fascial closure rates between patients with peritonitis (87 %), trauma (85 %), and ACS or abdominal wall dehiscence (100 %) (p = 0.647). CONCLUSIONS: Regardless of the underlying pathology, high fascial closure rates can be achieved using a combination of vacuum-assisted closure and mesh-mediated fascial traction.

[Treatment of gunshot fractures of the lower extremity: Part 1: Incidence, importance, case numbers, pathophysiology, contamination, principles of emergency and first responder treatment]. / Behandlung von Schussfrakturen der unteren Extremität : Teil 1: Inzidenz, Bedeutung, eigene Zahlen, Pathophysiologie, Kontamination, Prinzipien der Notfall- und Erstbehandlung.

Gunshot wounds are rare in Germany and are mostly the result of suicide attempts or improper handling of weapons. The resulting injuries involve extensive tissue damage and complications which are thus unique and require a differentiated approach. As trauma centers may be confronted with gunshot wounds at any time, treatment principles must be understood and regularly reevaluated. Due to Bundeswehr operations abroad and the treatment of patients from other crisis regions a total of 85 gunshot wounds in 64 patients were treated between 2005 and 2011. In the majority of cases the lower extremities were affected and we were able to carry out treatment to preserve the extremities. In this article we report on our experiences and the results of treatment of gunshot wounds to the lower extremities. This part of the article deals with the epidemiology and pathophysiology of gunshot wounds to the lower extremities. By means of an evaluation of microbiological findings in a subgroup of patients involved in a civil war (n=10), the problem of multidrug resistant pathogen contamination, colonization and infection is discussed. In addition to a description of initial and emergency treatment of gunshot wounds, measures required for further treatment and decontamination are presented. Finally, the results are discussed with reference to the literature in this field.

[Treatment of gunshot fractures of the lower extremity: Part 2: Procedures for secondary reconstruction and treatment results]. / Behandlung von Schussfrakturen der unteren Extremität : Teil 2: Verfahren der sekundären Rekonstruktion und eigene Behandlungsergebnisse.

BACKGROUND: Gunshot wounds of the lower extremities are always serious injuries, especially in cases in which bone is affected. Contamination and extensive tissue damage can be life-threatening for the patient and severely affect the function of the extremity. Contamination and local infections with multidrug resistant pathogens are regularly encountered particularly in casualties evacuated from crisis regions. Treatment of this special type of injury, which differs in the form and extent from conventional high-energy trauma of the lower extremities, usually requires lengthy and extensive therapy algorithms in order to preserve the affected extremity. PATIENTS AND METHODS: Based on the results of 34 gunshot wounds of the lower extremities which were surgically treated in this department between 2005 and 2011, this article reports on procedures used for wound management, soft tissue reconstruction and restoration of bone continuity. This group included 18 patients with a total of 20 gunshot-related fractures, 40% of which affected the lower leg and 35% the thigh. The affected extremities could be salvaged in all cases. RESULTS: The therapeutic spectrum required for bone reconstruction after soft tissue coverage demonstrated in these case examples ranged from conventional osteosynthesis with or without local cancellous bone transplant with platelet-rich plasma, to healing in a fixator, bone resection and the Masquelet method, distraction osteogenesis using a fixator in order to restore continuity and definitive secondary extension using an intramedullary skeletal kinetic distractor (ISKD) nail. Out of 15 bullet fractures affecting large tubular bones 8 could be healed without any shortening, axis deviation or malrotation. In 7 cases definitive shortening by an average of 20 mm (minimum 10 mm and maximum 40 mm) was necessary. The average treatment time before full weight-bearing was achieved within tolerable pain limits was 66 weeks (minimum 4 weeks and maximum 267 weeks). Secondary osteitis and osteomyelitis following primary restoration was detected in only one case. CONCLUSION: These results show that the treatment of gunshot wounds of the lower extremities is time-consuming and extensive and requires the complete spectrum of modern trauma surgery. Despite the high risk of complications during treatment it is possible and feasible to apply procedures that preserve the extremities.

[Gunshot and stab wounds in Germany--epidemiology and outcome: analysis from the TraumaRegister DGU®]. / Schuss- und Stichverletzungen in Deutschland--Epidemiologie und Outcome : Eine Analyse aus dem TraumaRegister DGU®

BACKGROUND: The management of gunshot wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. Penetrating injuries occur with an incidence of 5% in Germany. They are caused by gunshots or more commonly by knives or other objects, for example during accidents. Since even the number of patients who are treated at level 1 trauma centres is limited by the low incidence, the objective of this study was to assess the epidemiology and outcome of gunshot and stab wounds in Germany. MATERIAL AND METHODS: Since 2009, the trauma registry of the German Trauma Society (TraumaRegister DGU®) has been used to assess not only whether a trauma was penetrating but also whether it was caused by a gunshot or a stabbing. On the basis of this registry, we identified relevant cases and defined the observation period. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2011. We did not specify exclusion criteria in order to obtain as comprehensive a picture as possible of the trauma entities investigated in this study. As a result of the high incidence of gunshot wounds to the head and the implications of this type of injury for the entire group, a subgroup of patients without head injuries was analysed. RESULTS: From 2009 to 2011, there were 305 patients with gunshot wounds and 871 patients with stab wounds. The high proportion of suicide-related gunshot wounds to the head resulted in a cumulative mortality rate of 39.7%. Stab wounds were associated with a lower mortality rate (6.2%). Every fourth patient with a gunshot or stab wound presented with haemorrhagic shock, which was considerably more frequently seen during the prehospital phase than during the inhospital phase of patient management. Of the patients with gunshot wounds, 26.9% required transfusions. This percentage was three times higher than that for patients with blunt trauma. CONCLUSION: In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicide. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required which can provide the basis for an evaluation of the long-term quality of the management of patients with stab or gunshot wounds.

[Calcaneoplasty with radiofrequency cementing following balloon reduction]. / Kalkaneoplastie mit Radiofrequenzzementierung nach Ballonaufrichtung.

The standard surgical procedure for complex calcaneal fractures is open reduction, internal reduction and internal stable angle plate osteosynthesis via a lateral approach. More recently, options for minimally invasive and percutaneous surgical strategies have been presented [4, 7]. As a possible procedural alternative for a covered, surgical treatment of calcaneal fractures, calcaneoplasty is discussed and applied in this context [5]. In this case series of five complex calcaneal fractures presented here, a balloon catheter was used for percutaneous reduction to restore the alignment of the calcaneus.This was followed by placement of PMMA cement in radiofrequency application and osteosynthesis using percutaneous cannulated screws. This Vicenti technique allows stable reduction and retention with early partial weight bearing with an overall low complication rate [17].

[Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]. / Behandlungsregime tiefer sternaler Wundinfektionen nach kardiochirurgischen Eingriffen im interdisziplinären Ansatz.

The aim of this article is to present the importance of a structured and situation-adapted approach based on the diagnostic and therapeutic strategy in the interdisciplinary treatment of 54 patients with deep sternal wound infections (DSWI) after cardiac surgical interventions and the results achieved. The patients were 41 men and 13 women with an average age of 65.1 years, who developed a DSWI after a cardiac surgical intervention during the period 2003-2016. The treatment strategy included a thorough debridement including the removal of indwelling foreign material, the reconstruction with a stable re-osteosynthesis after overcoming the infection and if necessary, situation-related surgical flaps for a defect coverage with a good blood supply and mandatory avoidance of dead spaces. A total of 146 operations were necessary (average 2.7 operations/patient, range 1-7 operations). In 24.1 % of the cases a one-stage approach could be carried out. In 41 patients negative pressure wound therapy (NPWT) with programmed sponge changing was used for wound conditioning (mean 5 changes, standard deviation, SD±â€¯5.6 changes over 22 days, SD±â€¯23.9 days, change interval every 3-4 days in 40.7% of the cases). In 33 patients a bilateral myocutaneous pectoralis major flap was used, in 4 patients a vertical rectus abdominis myocutaneous (VRAM) flap and in 7 patients both were carried out. A total of 43 osteosynthesis procedures were carried out on the sternum with fixed-angle titanium plates. Of the patients 7 died during intensive care unit treatment (total mortality 13 %, n = 5, 9.3 % ≤ 30 days) or in the later course. Of the patients 47 (87.1 %) could be discharged with a cleansed infection. In 2 patients the implant was removed after 2 years due to loosening.

Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update.

PURPOSE: Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS: One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION: As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.