Clinical long-term results of radial head arthroplasty in comminuted radial head fractures.

Modern radial head prostheses have recently become more common in the treatment of comminuted radial head fractures. The goal of this study was to evaluate how well the EVOLVE® modular metallic radial head implant prosthetic restores the functional range of motion and stability of the elbow. 30 patients with comminuted radial head fractures received an arthroplasty with an EVOLVE® prosthesis in our institution. 20 of those patients were available for long-term follow-up (mean > 10 years). The outcomes were assessed on the basis of pain, motion, and strength. The overall outcome was scored with functional rating scores. According to the Broberg-Morrey elbow evaluation score, after a mean follow-up period of 10.2 years, ten (50.0%) patients were rated as very good, four (20.0%) as good, six (30.0%) as satisfactory, and none as poor. In the long-term results the Broberg-Morrey score increased from 79 (in short-term results) to 89 points. The Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure questionnaire showed an average of 16.2 points. Initially, patients had an extension deficit of 20°, which was reduced to 5° at the latest follow-up. In our long-term results, an improvement in the function of the elbow was observed after arthroplasty using a metallic modular radial head implant. Comminuted radial head fractures with elbow instability can be treated effectively with the EVOLVE® radial head prosthesis, which restores stability in acute treatment. Our long-term results after 10.2 years demonstrate good functional outcome and low major complication rate. IV.

CCL-2 as a possible early marker for remission after traumatic spinal cord injury.

STUDY DESIGN: Prospective observational study. OBJECTIVES: To describe the correlation between CCL-2, CCL-3, CCL-4 and CXCL-5 serum levels and remission after traumatic spinal cord injury (SCI) in a human protocol compared with animal studies. SETTING: Germany, Rhineland-Palatinate (Rheinland-Pfalz). METHODS: We examined the serum levels of CCL-2, CCL-3, CCL-4 and CXCL-5 over a 12-week period; in particular, at admission and 4, 9 and 12 h, 1 and 3 days and 1, 2, 4, 8 and 12 weeks after trauma. According to our study design, we matched 10 patients with TSCI and neurological remission with 10 patients with an initial ASIA A grade and no neurological remission. In all, 10 patients with vertebral fracture without neurological deficits served as control. Our analysis was performed using a Luminex Cytokine Panel. Multivariate logistic regression models were used to examine the predictive value with respect to neurological remission vs no neurological remission. RESULTS: The results of our study showed differences in the serum expression patterns of CCL-2 in association with the neurological remission (CCL-2 at admission P=0.013). Serum levels of CCL-2 and CCL-4 were significantly different in patients with and without neurological remission. The favored predictive model resulted in an area under the curve (AUC) of 93.1% in the receiver operating characteristic (ROC) analysis. CONCLUSIONS: Our results indicate that peripheral serum analysis is a suitable concept for predicting the patient's potential for neurological remission after TSCI. Furthermore, the initial CCL-2 concentration provides an additional predictive value compared with the NLI (neurological level of injury). Therefore, the present study introduces a promising approach for future monitoring concepts and tracking techniques for current therapies. The results indicate that future investigations with an enlarged sample size are needed in order to develop monitoring, prognostic and scoring systems.

Exploratory study to suggest the possibility of MMP-8 and MMP-9 serum levels as early markers for remission after traumatic spinal cord injury.

STUDY DESIGN: A prospective observational study reporting the correlation between matrix metalloprotein serum levels and remission after traumatic spinal cord injury (SCI). OBJECTIVES: To investigate serum cytokine levels as predictive markers. SETTING: Germany, Rhineland-Palatinate (Rheinland-Pfalz). METHODS: Between 2010 and 2015, data sets from 115 patients (33 female, 82 male) after traumatic SCI were recorded at the BG Trauma Centre Ludwigshafen. We examined the serum levels of Matix metallopraoteinases (MMPs) MMP-2, MMP-8, MMP-9, MMP-10 and MMP-12 over a 12-week period, that is, at admission and 4, 9, 12 h, 1 and 3 days and 1, 2, 4, 8 and 12 weeks after trauma. Following the same match-pair procedure as in our previous studies, we selected 10 patients with SCI and neurological remission (Group 1) and 10 patients with an initial American Spinal Injury Association (ASIA) A grade and no neurological remission (Group 0). Ten patients with an isolated vertebral fracture without neurological deficits served as a control group (Group C). Our analysis was performed using a Luminex Performance Human High Sensitivity Cytokine Panel. Multivariate logistic regression models were used to examine the predictive value of MMPs with respect to neurological remission vs no neurological remission. RESULTS: MMP-8 and MMP-9 provided significantly different values. The favoured predictive model allows to differentiate between neurological remission and no neurological remission in 97% of cases. CONCLUSIONS: The results indicate that further studies with an enlarged collective are warranted in order to investigate current monitoring, prognostic and tracking techniques as well as scoring systems.

Analysis of prehospital care and emergency room treatment of patients with acute traumatic spinal cord injury: a retrospective cohort study on the implementation of current guidelines.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The aims of the current study were (i) to analyze prehospital and emergency room treatment of patients with acute traumatic spinal cord injury (SCI) and (ii) to analyze whether recommendations given by the current guidelines are implemented. SETTING: German level I trauma center. METHODS: All patients suffering from traumatic SCI who were initially surgically treated in our hospital in the period from January 2008 to December 2013 were included in this study. Available data documented as a standard procedure in our trauma center included patient's demographic and medical information, as well as trauma mechanisms, cause of injury, neurological diagnosis and detailed clinical information about prehospital and early hospital management procedures. Retrospectively, statistical analysis was performed to describe spinal immobilization rates, transportation times and methylprednisolone administration. RESULTS: A total of 133 patients (mean age: 50.5±21.2 years) met the inclusion criteria. Immobilization was performed on 69.9% of the patients with traumatic SCI. From 60 patients suffering from cervical traumatic SCI, 47 patients had a cervical collar. Full immobilization was only performed in 34 of these 60 patients. Mean time from accident site to emergency room was 61.3±28.7 min. In 25 out of the 133 patients included in the current study, early surgery was not possible because of insufficient circulation and/or increased intracranial pressure. A total of 108 patients could be prepared for early surgery within 322.8±254.1 min after the accident. CONCLUSION: The current study shows that recommendations of the current literature and guidelines are mostly followed.

sCD95L in serum after spinal cord injury.

STUDY DESIGN: A prospective observational study reporting correlation between sCD95L (serum cluster of differentiation 95 ligand) serum levels and remission after traumatic spinal cord injury (SCI). OBJECTIVES: To describe the correlation between sCD95L serum levels and remission after traumatic SCI in a human protocol compared with animal studies. SETTING: Rhineland-Palatinate (Rheinland-Pfalz), Germany. METHODS: We included 45 patients with traumatic SCI. According to their neurological outcome, patients were divided into two groups, patients with (G1, n=26) and without (G2, n=19) remission. Blood was collected on post-admission and according to a fixed scheme, that is, after 4, 9, 12 h, 1, 3 days and 1, 2, 4, 8, 12 weeks. RESULTS: By comparing G1 with G2, we found a correlation between neurological remission and sCD95L serum concentrations. Consistently elevated levels of sCD95L in G1 between 9 h and 1 month after injury show significantly differing values 7 days after injury. This indicates a correlation between patients with clinically documented neurological remission and elevated sCD95L serum concentrations. CONCLUSIONS: In opposite to animal studies, our patients with neurological remission show on average higher levels of sCD95L compared with patients without. Therefore, spinal cord-injured patients would probably not profit from neutralizing CD95L. Our results present that the transfer of findings from animal studies to humans must always be considered critically. We were able to show that peripheral serum cytokine expression is suitable to state processes after SCI in humans.

Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept.

METHODS: Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. RESULTS: A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. DISCUSSION: The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. TAKE HOME MESSAGE: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft.

A pilot study on temporal changes in IL-1ß and TNF-α serum levels after spinal cord injury: the serum level of TNF-α in acute SCI patients as a possible marker for neurological remission.

STUDY DESIGN: Serum levels of interleukin-1ß (IL-1ß) and tumour necrosis factor-α (TNF-α) were measured over a 12-week period in 23 patients with spinal cord injury (SCI) with and without neurological improvement. OBJECTIVES: To determine the course of IL-1ß and TNF-α in patients with SCI and observe a possible relationship between improvements in neurological functioning and cytokine levels. SETTING: All patients were treated at the BG Trauma Centre, Ludwigshafen, Germany. All lab work was done at the University Hospital, Heidelberg. METHODS: Spinal cord injury was classified according to the American Spinal Injury Association (ASIA) impairment scale (AIS) in 23 patients. TNF-α and IL-1ß levels were measured upon arrival at the hospital, after 4 h, 9 h and 12 h, on days 1 and 3 and at the end of weeks 1, 2, 4, 8 and 12. RESULTS: Temporal changes in TNF-α and IL-1ß in SCI patients were seen. Patients with AIS improvement (Group 1) had significantly lower TNF-α levels at 9 h compared with patients without AIS improvement (Group 2; P<0.01). The course of IL-1ß fluctuated greatly between 4 h and week 1 in the groups; however, between 2 and 12 weeks post trauma, there was an overall decline in both groups. CONCLUSION: Measuring serum levels of TNF-α and IL-1ß over time could be useful in tracking the course of SCI. Our data show differences in measured cytokines over a 12-week period for SCI patients with and without neurological improvement.

A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients.

STUDY DESIGN: A retrospective study reporting specific complications of certain skin flaps for treating pressure ulcers. OBJECTIVES: To describe the rate and type of complications after pressure ulcer surgery in patients with spinal cord injury. SETTING: Germany, Rheinland Pfalz. METHODS: We collected data from 352 patients treated with 421 skin flaps to determine the rate and type of complications of each skin flap used. RESULTS: In this study, we analyzed the results of 421 skin flaps in 352 patients with a total of 657 pressure ulcers from January 2006 to December 2010. Our patients had ischial, pelvic, sacral, trochanteric and lower extremity ulcers. Ischial ulcers were most common, followed by sacral and trochanteric ulcers. There were 87 complications in 421 flaps, which was an overall rate of 21%. Suture line dehiscence was the most common complication with 27 cases (31%), followed by 22 cases of infection (25.2%), 17 cases of hematoma (19.5%), 12 cases of partial necrosis (13.7%) and 9 cases of total flap necrosis (10.3%). CONCLUSION: Pressure ulcers in spinal cord-injured patients are very common and difficult and expensive to treat. The high rate of complications and the associated costs suggest the importance of evaluating the efficacy of treatment options. Conservative procedures have been standardized, but there still has been limited success in establishing guidelines on how to manage complications arising from flap surgery. Our extensive documentation of flap plastics will be useful managing complications after the surgical treatment of pressure ulcers in spinal cord-injured patients.

Increase in soluble CD95L during subacute phases after human spinal cord injury: a potential therapeutic target.

STUDY DESIGN: A pilot study measuring the levels of serum-soluble CD95 ligand (CD95L) in eight spinal cord-injured patients. OBJECTIVES: To determine the soluble concentration of CD95L in spinal cord injury (SCI) patients after trauma. METHODS: We collected blood samples from eight patients with acute traumatic SCI. Soluble CD95L serum levels were determined using an enzyme-linked immunosorbent assay. American Spinal Injury Association (ASIA) was determined according to ASIA classification. The patients were monitored, and venous blood was drawn after arrival at the hospital on the 1st and 3rd day and during the 1st, 2nd, 4th, 8th and 12th weeks after trauma. RESULTS: The average patient age was 48.1 years (18-86 years). Three patients were paraplegic (two incomplete, one complete), five were quadriplegic (one complete, four incomplete). The serum concentration of soluble CD95L (sCD95L) decreased during the 1st week (41 ng(- l)) and increased after the 2nd week in all eight patients. It peaked during the 4th week (68.5 ng (- l)) and reached a plateau during the 12th week (76.2 ng (- l)). There are many possible explanations for not being able to detect a statistical significance, one of course being the small sample size. CONCLUSION: Promising results for anti-CD95L therapy have already been documented in lab studies with rodents. Anti-CD95L blocks the pro-apoptotic and proinflammatory activity of membrane-bound CD95L during the acute phase of SCI. We observed that sCD95L levels are elevated during the subacute and intermediate phases of SCI. It would be of great interest to study a larger group of patients to determine whether higher sCD95 levels are correlated with improved or impaired neurological outcome or with increasing levels of autoimmune components in peripheral blood.

[Results of nonunion treatment with bone morphogenetic protein 7 (BMP-7)]. / Ergebnisse der Pseudarthrosenbehandlung mit "bone morphogenetic protein 7" (BMP-7).

BACKGROUND: Complex patterns of impaired bone healing can result in a severe economic and social burden for the patient. Herein we describe the local application of recombinant human bone morphogenetic protein 7 (BMP-7). The goal of this prospective study is to review the indications, application and validation of this therapy. MATERIAL AND METHOD: From June 2002 to June 2008, we applied 101 BMP-7 treatments in 101 nonunions of 98 patients. The average age of the patients was 50 years (18-88 years). The gender composition was 29 women (30%) and 69 men (70%). Before BMP-7 application, patients had already underwent surgical treatement an average of 3.3 times (median 3, 1- to 13-times). We used BMP-7 "off-label" in all long bones. RESULTS: In 93 cases (92%), we observed proper bone healing. The average healing time was 4.8 months (range 1.5-11 months). The average time from injury to BMP-7 application was 18.4 months (3-84 months). In 65 cases, BMP-7 application was combined with re-osteosynthesis and autologous bone grafting. Serious side effects were not observed. CONCLUSIONS: BMP-7 should not be used as general treatment of nonunion in all patients, but appears to be effective for the treatment of complex cases. In clinical practice, the decision to proceed with off-label use of BMP-7 should be made on a case-by-case basis.

Use of Medihoney as a non-surgical therapy for chronic pressure ulcers in patients with spinal cord injury.

STUDY DESIGN: Prospective, observational study of 20 spinal cord-injured (SCI) patients with chronic pressure ulcers (PUs) using Medihoney. OBJECTIVES: To determine the effects of Medihoney by bacterial growth, wound size and stage of healing in PUs. METHODS: We treated 20 SCI adult patients with chronic PUs using Medihoney. In all, 7 patients (35%) were female, and 13 (65%) were male. The average patient age was 48.7 years (30-79). In all, 6 patients (30%) were tetraplegic and 14 (70%) were paraplegic. Also, 5 patients (25%) had grade IV ulcers and 15 patients (75%) had grade III ulcers according to the National Pressure Ulcer Advisory Panel. RESULTS: After 1 week of treatment with Medihoney, all swabs were void of bacterial growth. Overall 18 patients (90%) showed complete wound healing after a period of 4 weeks, and the resulting scars were soft and elastic. No negative effects were noted from the treatment using Medihoney. No blood sugar level derailment was documented. CONCLUSION: The medical-honey approach to wound care must be part of a comprehensive conservative surgical wound-care concept. Our study indicates the highly valuable efficacy of honey in wound management and infection control as measured by bacterial growth, wound size and healing stage.

[Arthrodesis of the elbow joint. Indications, surgical technique and clinical results]. / Ellenbogengelenkarthrodese. Indikation, Operationsverfahren und klinische Ergebnisse.

Arthrodesis of the elbow joint (EA) is a rare salvage procedure which is disliked by both surgeons and patients. The aim of this study was to analyze the indications, the operation techniques and the outcome of EA in patients treated at our clinic. Between January 1997 and December 2005 a total of 20 patients with a mean age of 55 years (range 27-85 years) were treated with EA at our clinic. In 18 patients a compression plate was used as surgical technique. In 18 out of the 20 patients the operation was performed post-traumatically after infection, bone and tissue defects and painful loss of motion. Of these patients, 16 could be followed up for an average time of 66 months. The outcome was evaluated based on the degree of pain, range of motion, radiographic findings and grip strength measured with the Jamar dynamometer. All patients had a solid and fused EA, the average angle was 89 degrees (range 80-110 degrees) and the grip strength was reduced by 27% compared to the unaffected side. The patients achieved 56 points in the Morrey score, 38.29 points in the DASH (disabilities of the arm, shoulder and hand) score and 80 points in the Constant-Murley score. The indication of EA depends on several factors, therefore it is essential to take the patients' functional requirements into consideration and the best arthrodesis angle should be validated pre-operatively. In these cases the patients can regain good grip strength and a high level of stability within defined functional limitations.

[Kinematic investigations of the talocrural joint in human cadaver specimens. Basic studies for the development of a hinged fixator]. / Biomechanische Untersuchungen der Achsenkinematik an menschlichen Sprunggelenken Grundlagenuntersuchungen für die Entwicklung eines Bewegungsfixateurs.

To determine the specifications of a hinged fixator for the upper ankle joint, biomechanical investigations were performed on 20 human cadaver specimens and the talocrural axis was recorded by X-ray cinematography in all levels of the space. The results showed a medium variation of the axis in zero position (mean: 5.8 degrees ) from 3 degrees to 10 degrees in the anterior-posterior view. The span of the axis migration around zero position amounted to a minimum of 3 degrees and a maximum value of 10 degrees (mean: 7.2 degrees ). It could be ascertained that the axis kinetics does not move linearly in all cases. The talus rotation (the axle deviation from the sagittal plane) amounted to a minimum value of 2 degrees and a maximum value of 12 degrees (mean: 5.3 degrees ). In the transverse level, the axis kinetics was tracked by separate X-ray markings of the lateral and medial cortical of the talus in the zero point of the talocrural axis. The results were typical migration curves of the X-ray markings, demonstrating a ventral convex curve at the medial and lateral cortex. This migration of the cortex crossing point of the axis was geometrically entered in a coordinate system. The variance of the axis cortex crossing point at the medial cortical was X(M)=4.2 mm (min: 2 mm, max: 7 mm) and Y(M)=4.7 mm (2-7 mm), at the lateral cortical X(L)=3.7 mm (1-9 mm) and Y(L) =4.1 mm (1-8 mm). Regarding the clinical relevance for the development of a hinged fixator for the upper ankle joint, the results indicate that an external axis guidance of these axoids is not possible, but that an adjusted axis is necessary taking into consideration the values measured using ligamentotaxis.

Interganglionic segregation of distinct vagal afferent fibre phenotypes in guinea-pig airways.

1. The present study addressed the hypothesis that jugular and nodose vagal ganglia contain the somata of functionally and anatomically distinct airway afferent fibres. 2. Anatomical investigations were performed by injecting guinea-pig airways with the neuronal tracer Fast Blue. The animals were killed 7 days later, and the ganglia were removed and immunostained with antisera against substance P (SP) and neurofilament protein (NF). In the nodose ganglion, NF-immunoreactive neurones accounted for about 98% of the Fast Blue-labelled cells while in the jugular ganglion they accounted for approximately 48%. SP and NF immunoreactivity was never (n = 100) observed in the same cell suggesting that the antisera labelled distinct populations. 3. Electrophysiological investigations were performed using an in vitro guinea-pig tracheal and bronchial preparation with intact afferent vagal pathways, including nodose and jugular ganglia. Action potentials arriving from single airway afferent nerve endings were monitored extracellularly using a glass microelectrode positioned near neuronal cell bodies in either ganglion. 4. The nodose ganglion contained the somata of mainly fast-conducting tracheal A delta fibres whereas the jugular ganglion contained equal numbers of C fibre and A delta fibre tracheal afferent somata. The nodose A delta neurones adapted rapidly to mechanical stimulation, had relatively low mechanical thresholds, were not activated by capsaicin and adapted rapidly to a hyperosmotic stimulus. By contrast, jugular A delta and C fibres adapted slowly to mechanical stimulation, were often activated by capsaicin, had higher mechanical thresholds and displayed a slow adaptation to a hyperosmotic stimulus. 5. The anatomical, physiological and pharmacological data provide evidence to support the contention that the vagal ganglionic source of the fibre supplying the airways ultimately dictates its neurochemical and physiological phenotype.