Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study.

BACKGROUND: The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. METHODS: Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. RESULTS: Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results. CONCLUSIONS: Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered. TRIAL REGISTRATION: German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury.

BACKGROUND: This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury. METHODS: The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed. RESULTS: On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs. CONCLUSIONS: After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]. / Häufigkeit chronischer Schmerzen nach Arbeitsunfall ­ Eine erste Statuserhebung im BG-lichen Heilverfahren einer Tertiärklinik.

BACKGROUND: Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated. OBJECTIVES: Initial evaluation of frequency of chronic pain after occupational accidents. METHODS: In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months. PRIMARY OUTCOME: frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity. RESULTS: Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002). CONCLUSION: Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

Ilizarov fixator as salvage procedure after frustrating arthrodesis using intramedullary nailing - is there a chance of consolidation?

INTRODUCTION: Arthrodesis of the tibiotalar and subtalar joints is a salvage procedure that has been used successfully for years. Treatment options include internal procedures and external procedures. Retrograde intramedullary nailing is considered a safe procedure with a high degree of stability and comfort. Nevertheless, there are cases in which this internal arthrodesis fails and another procedure must be considered. Ilizarov fixator treatment could be a solution for those patients in whom intramedullary nailing has failed. Even if it means another surgical revision - is it possible to finally achieve consolidation with this method? MATERIALS AND METHODS: In this single-center, retrospective study all documents of patients who underwent tibiotalar and subtalar joints fusion using the Ilizarov external fixator at our institution from 2003 to 2023 as secondary treatment after frustrated first arthrodesis using an intramedullary nail were reviewed. Nineteen patients (17 men and 2 women), with an average age of 55.7 (standard deviation (SD) 8.7, range 34-75) years were included. RESULTS: On average, 1.7 (SD 1.3, range 1-6) arthrodesis attempt were performed before final Ilizarov fixator arthrodesis. The average time spent in the Ilizarov fixator was 19 (SD 4, range 14-29) weeks. In seven cases (36.8%), both the tibiotalar and subtalar joints received bony consolidation in the end. CONCLUSION: If patients have undergone fusion of the tibiotalar and subtalar joints with a retrograde nail and this fails, it is difficult to achieve complete consolidation in the further course. A further attempt at arthrodesis using an Ilizarov fixator is possible, but the overall results are also poor. This procedure must therefore be seen as a last resort before amputation.

Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review.

INTRODUCTION: From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems. MATERIALS AND METHODS: A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account. RESULTS: Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily. CONCLUSION: SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.

Surgical management and results of glenohumeral combination fractures of the anterior glenoid rim and the proximal humerus.

INTRODUCTION: The combination of anterior large glenoid rim fractures (GRF) and proximal humerus fractures (PHF) is rare, with limited data available on specific treatments for these glenohumeral combination fractures (GCF). This study aimed to evaluate the treatment approaches for GCF, analyze patient outcomes, and outline surgical management strategies for different fracture types. MATERIALS AND METHODS: This retrospective study included patients with GCF, excluding those with fossa glenoidalis fractures, isolated greater tuberosity fractures, or small glenoid rim fractures (< 5 mm). Preoperative radiographs, CT scans, and follow-up radiographs were reviewed. Clinical outcomes were assessed using the Constant-Murley Score (CMS), Western Ontario Shoulder Instability Index (WOSI), Rowe Score (RS), and Oxford Shoulder Score (OSS). RESULTS: Sixteen patients with 17 GCFs (mean age 62 years) were followed for an average of 39 months. PHFs were categorized into three-part (76%), four-part (12%), and two-part fractures (12%). The average medial displacement of GRF was 5 mm, with an average dehiscence of 4 mm in the sagittal plane. Fourteen patients (88%) underwent surgical treatment; 35% had only the PHF surgically addressed, while 53% had both lesions surgically treated. Two patients (12%) received non-operative treatment. Complications were observed in 29% of cases, primarily involving the humeral side. The average CMS was 68 points, WOSI was 75%, RS was 77 points, and OSS was 41 points. CONCLUSION: Treating GCF is complex and routinely necessitates surgical intervention, with or without GRF refixation. CT imaging is crucial for precise assessment of fracture morphology. The involvement of the minor tuberosity is critical in selecting the optimal surgical approach and managing the subscapularis muscle.

Pharmacological elevation of sphingosine-1-phosphate by S1P lyase inhibition accelerates bone regeneration after post-traumatic osteomyelitis.

Posttraumatic osteomyelitis and the ensuing bone defects are a debilitating complication after open fractures with little therapeutic options. We have recently identified potent osteoanabolic effects of sphingosine-1-phosphate (S1P) signalling and have now tested whether it may beneficially affect bone regeneration after infection. We employed pharmacological S1P lyase inhibition by 4-deoxypyrodoxin (DOP) to raise S1P levels in vivo in an unicortical long bone defect model of posttraumatic osteomyelitis in mice. In a translational approach, human bone specimens of clinical osteomyelitis patients were treated in organ culture in vitro with DOP. Bone regeneration was assessed by µCT, histomorphometry, immunohistology and gene expression analysis. The role of S1P receptors was addressed using S1PR3 deficient mice. Here, we present data that DOP treatment markedly enhanced osteogenesis in posttraumatic osteomyelitis. This was accompanied by greatly improved osteoblastogenesis and enhanced angiogenesis in the callus accompanied by osteoclast-mediated bone remodelling. We also identified the target of increased S1P to be the S1PR3 as S1PR3-/- mice showed no improvement of bone regeneration by DOP. In the human bone explants, bone mass significantly increased along with enhanced osteoblastogenesis and angiogenesis. Our data suggest that enhancement of S1P/S1PR3 signalling may be a promising therapeutic target for bone regeneration in posttraumatic osteomyelitis.

Minor microbial alterations after faecal diversion do not affect the healing process of anus-near pressure injuries in patients with spinal cord injury - results of a matched case-control study.

STUDY DESIGN: Retrospective matched case-control study including patients with spinal cord injury who presented with an anus-near pressure injury. Two groups were formed based on the presence of a diverting stoma. OBJECTIVES: To evaluate the primary microbial colonisation and secondary infection of anus-near pressure injuries depending on the presence of a pre-existing diverting stoma and to investigate the effect on the wound healing. SETTING: University hospital with a spinal cord injury unit. METHODS: A total of 120 patients who had undergone surgery of an anus-near decubitus stage 3 or 4 were included in a matched-pair cohort study. Matching was realised according to age, gender, body mass index and general condition. RESULTS: The most common species in both groups was Staphylococcus spp.(45.0%). The only significantly different primary colonisation affected Escherichia coli, that was found in the stoma patients less often (18.3 and 43.3%, p < 0.01). A secondary microbial colonisation occurred in 15.8% and was equally distributed, except for Enterococcus spp. that was present in the stoma group only (6.7%, p < 0.05). The time to complete cure took longer in the stoma group (78.5 versus 57.0 days, p < 0.05) and was associated with a larger ulcer size (25 versus 16 cm2, p < 0.01). After correction for the ulcers' size, there was no association to outcome parameters such as overall success, healing time or adverse events. CONCLUSIONS: The presence of a diverting stoma alters the microbial flora of an anus-near decubitus slightly without impact on the healing process.

Medial augmentation plating of aseptic distal femoral nonunions.

BACKGROUND: Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants. METHODS: We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D). RESULTS: Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection. CONCLUSIONS: According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Monteggia fractures and Monteggia-like-lesions: a systematic review.

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Shoulder complaints and incidence of shoulder pathologies after contralateral major amputation in the mid and long-term.

INTRODUCTION: Amputations of the upper extremity are rare but present a life-altering event that is accompanied with considerable restrictions for the affected patients. Even with functional prosthesis, tasks of the amputated limb are usually transferred to the unaffected arm which could result in complaints of the unaffected shoulder in the mid and long term. We therefore aimed to investigate musculoskeletal pain and morphological degenerative changes of the shoulder following a contralateral amputation. MATERIALS AND METHODS: We included all patients with a major amputation treated at our institution with a minimum of three years since the amputation. All patients received an MRI of both shoulders and were investigated using validated scores for the upper extremity and physical activity (SSV, ASES, DASH, GPAQ, SF-36). Results of the MRIs were investigated for morphological changes by two blinded investigators comparing the side of the amputation and the unharmed upper extremity and results were correlated to the time since amputation and their physical activity. RESULTS: A total of 20 patients with a mean age of 56 ± 19.9 years (range, 23-82 years) could be included in the study. The mean time since the amputation was 26.3 ± 19 years (range, 3-73 years). On the unharmed upper extremity, the mean SSV was 61.9 ± 24.6, the mean ASES-Score 54.5 ± 20.3, the Constant-score of 63.7 ± 40.4 and a DASH-score of 47.6 ± 23.8. The MRI of the unharmed shoulder showed significant more full-thickness rotator cuff tears and joint effusion compared to the side of the amputation. Significant differences in the degree of a glenohumeral arthritis, AC-joint arthritis, or partial rotator cuff tears could not be found between shoulders. CONCLUSION: Amputations of the upper extremity are associated with a high disability of the unharmed upper extremity and more full thickness rotator cuff tears compared to the side of the amputation. However, the small number of patients and rotator cuff injuries should be kept in mind when interpreting the data. LEVEL OF EVIDENCE: IV (retrospective case series).

Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

INTRODUCTION: Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data. MATERIALS AND METHODS: Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up. RESULTS: After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score. CONCLUSIONS: Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it. LEVEL OF EVIDENCE: III.

Complication rates following stand-alone lateral interbody fusion: a single institution series after 10 years of experience.

PURPOSE: This retrospective single institution study's goal was to analyze and report the complications from stand-alone lateral lumbar interbody fusions (LLIF). METHODS: This research was approved by the institutional review board (STUDY2021000113). We retrospectively reviewed the database of patients with adult degenerative spine deformity treated via LLIF at our institution between January 2016 and December 2020. RESULTS: Stand-alone LLIF was performed in 158 patients (145 XLIF, 13 OLIF; mean age 65 y.; 88 f., 70 m.). Mean surgical time was 85 min (± 24 min). Mean follow-up was 14 months (± 5 m). Surgical blood loss averaged 120 mL (± 187 mL) and the mean number of fused levels was 1.2 (± 0.4 levels). Overall complication rate was 19.6% (31 total; 23 approach-related, 8 secondary complications). CONCLUSION: Lateral interbody fusion appears to be a safe surgical intervention with relatively low complication- and revision rates.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication.

PURPOSE: To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients. METHODS: Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire. RESULTS: A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%). CONCLUSION: The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Pilot study: advanced haemodynamic monitoring after acute spinal cord injury-Keep the pressure up?

BACKGROUND: Although the use of vasopressors to maintain haemodynamic goals after acute spinal cord injury (SCI) is still recommended, evidence regarding the target values and possible risks of this practice is limited, and data on haemodynamic parameters unaffected by catecholamines are rare. In this pilot study, we show the haemodynamic profile of patients with acute SCI mainly unaffected by vasopressor use and other factors that influence the cardiovascular system. METHODS: From March 2018 to March 2020, we conducted a prospective, single-centre pilot study of 30 patients with acute SCI. Factors that could affect the cardiocirculatory system other than SCI (sepsis, pre-existing heart disease or multiple trauma) led to exclusion. A total of 417 measurements were performed using the PiCCO™ system. RESULTS: The mean systemic vascular resistance index (SVRI, 1447.23 ± 324.71 dyn*s*cm-5*m2), mean central venous pressure (CVP, 10.69 ± 3.16) and mean global end-diastolic volume index (GEDVI, 801.79 ± 158.95 ml/m2) deviated from the reference range, while the mean cardiac index (CI), mean stroke volume index (SVI), mean arterial pressure (MAP), and mean heart rate (HR) were within the reference range, as indicated in the literature. A mixed model analysis showed a significant negative relationship between norepinephrine treatment and MAP (83.97 vs. 73.69 mmHg, p < 0.001), SVRI (1463.40 vs. 1332.14 dyn*s*cm-5*m2, p = 0.001) and GEDVI (808.89 vs. 759.39 ml/m2, p = 0.001). CONCLUSION: These findings could lead to an adaptation of the target range for SVRI and MAP in patients with acute SCI and therefore reduce the use of vasopressors.

Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. OBJECTIVE: The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined. SETTING: University hospital with a spinal cord injury unit. METHODS: A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis. RESULTS: The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = -18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing. CONCLUSION: The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.

Introduction of a modified Degan classification to specify treatment algorithms in fractures of the anterior process of the calcaneus.

BACKGROUND: Fractures of the anterior process of the calcaneus are often missed, and their treatments and results receive little attention in the current literature. The aim of this study was to specify treatment algorithms through a modification of the Degan classification. METHODS: Between 2009 and 2019, patients with APC fractures were retrospectively analyzed. The Degan classification was used and modified. Type III fractures were further divided into subgroups A (not displaced) and B (displaced). The type of treatment and complications were recorded. Return to work and posttraumatic osteoarthritis were determined as primary and secondary outcome parameters, respectively. RESULTS: Forty-one patients with 43 fractures were included. Follow-up averaged 35,5 months (range 1,5-152 months). Fractures were eight type I, six type II, 15 type IIIA and 14 type IIIB. The fracture was initially recognized in 29 (70,7%) patients, and missed in 12 (29,3%) patients, respectively. Overall, the delayed diagnosed fractures had a significantly higher complication rate (p < 0,000) than the initially diagnosed fractures and received surgical treatment significantly (p < 0,009) more often. After surgical treatment of 13 type IIIB, one nonunion occurred. Six missed type IIIA fractures were treated surgically after delayed diagnosis because of persistent symptoms. Two type I fractures required arthrodesis of the Chopart joint. Four patients did not return to work during the follow-up (3 missed type IIIA fractures, 1 type II fracture). CONCLUSION: Missed APC type IIIA fractures are at risk to develop complications, which is why computed tomography diagnostics should be performed if there is any clinical suspicion.

Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale.

BACKGROUND: Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting. METHODS: 70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data. RESULTS: The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49). CONCLUSION: The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.

Rehabilitation during early postoperative period following total knee arthroplasty using single-joint hybrid assistive limb as new therapy device: a randomized, controlled clinical pilot study.

INTRODUCTION: The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients' range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ. MATERIALS AND METHODS: Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded. RESULTS: OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ. CONCLUSIONS: In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.

Tibiocalcaneal arthrodesis using the Ilizarov fixator in compromised hosts: an analysis of 19 patients.

INTRODUCTION: Salvage of joint destruction of the tibiotalar and subtalar joint with necrosis or infection of the talus in compromised hosts is a challenging problem. In these cases, tibiocalcaneal arthrodesis using the Ilizarov external fixator represents a possible alternative to amputation. This retrospective study presents the results and complications of this salvage procedure. MATERIALS AND METHODS: Between 2005 and 2015, 19 patients were treated with tibiocalcaneal arthrodesis using the Ilizarov external fixator. Ten patients received tibiocalcaneal arthrodesis due to an acute or chronic infection with joint destruction. The other nine patients presented posttraumatic necrosis of the talus or Charcot arthropathy. In addition to demographic data, the time spent in the fixator, the major and minor complications and the endpoint of the consolidation were evaluated retrospectively. Furthermore, clinical outcomes were measured using the modified American Orthopedic Foot and Ankle Society (AOFAS) score. RESULTS: The average time spent in the fixator was 22 (range 14-34) weeks. The average follow-up in 17 patients was 116 (range 4-542) weeks. Two patients were lost to follow-up. Complete osseous consolidation was achieved in 14 out of 19 patients. One patient presented partial consolidation, and in four patients, pseudarthrosis could be detected. The mean modified AOFAS score at the final follow-up was 53 out of 86 possible points. CONCLUSION: Tibiocalcaneal arthrodesis using the Ilizarov fixator is a possible salvage procedure even in compromised hosts. However, the healing rates are below the rates reported in the literature for tibiotalar arthrodesis in comparable clinical situations.