Damage control orthopaedics in polytraumatized patients- current concepts.

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the "first hit"). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the "second hit" and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality. The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the "Safe Definitive Surgery" (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey.

OBJECTIVES: The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. BACKGROUND: The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). METHODS: Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. RESULTS: Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". CONCLUSION: This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

Long-term outcome of total knee arthroplasty in patients with morbid obesity.

INTRODUCTION: Patients with morbid obesity and advanced painful knee osteoarthritis are considered as poor candidates for total knee replacement. Our aims were to evaluate the outcomes of TKR surgery and the risks for post-operative complications in patients with morbid obesity (BMI > 40 kg/m2) as compared with obese patients (30 < BMI ≤ 40 kg/m2) and non-obese patients, BMI < 30 kg/m2); to evaluate if there are differences between morbid-obese patients (BMI 40-49.99 kg/m2) and extreme morbid obese patients (BMI > 50 kg/m2); and to present some surgical tips which can improve the TKR outcomes in morbid obese patients. MATERIALS AND METHODS: There were successive 333 patients, of them 39 patients (11.7%) were lost for follow-up. So, this series included 292 patients - 82 with bilateral TKR- and 374 TKR. The mean age was 64.3 years old (48-83 years) and the mean follow-up 10.8 years (4-17 years). The KSS and FKSS scores were calculated at the end of the follow-up period and compared to the pre-operative evaluation. Radiographic assessment at the end of follow-up included evaluation of implant position, alignment, and presence of radiolucent lines around the implants and was compared with the immediate post-operative radiographs. Statistical analysis was performed using SPSS v 22.0. RESULTS: Our findings showed marked improvement following TKR of non-obese, obese, and morbid obese patients, regarding the KSS and FKSS. Significant change was observed between the non-obese and obese patients as compared to morbid obese patients. There were no significant differences between morbid obese patients with BMI > 40 versus those with BMI > 50. There was a slight increased risk of early complications following TKR in morbid obese patients such as skin necrosis and infection around the surgical incision. CONCLUSIONS: Marked improvement was observed in the three groups of patients after TKR, although non-obese and obese groups had better mean scores of KSS and FKSS than morbid obese patients. No significant differences were found within the morbid obese patients themselves. Therefore, we believe that morbid obese patients are appropriate candidates and can enjoy the benefits of total knee arthroplasty done with careful use of some surgical tips presented in our study.

Surgical treatment of periprosthetic femoral fractures following hip arthroplasty: our institutional experience.

PURPOSE: Periprosthetic fractures are one of the most serious complications after hip replacement. The aim of this retrospective study was to evaluate the clinical outcome of surgical treatment of periprosthetic femoral fractures following total hip arthroplasty using treatment algorithm of the Vancouver classification. MATERIALS AND METHODS: Fifty six periprosthetic femoral fractures operated on during the period December 2004-September 2013 were followed-up retrospectively. There were 40 women and 16 men with mean age at the time of surgery 64.7 years (41-88 years). The mean follow-up for the group was 5 years (range, 1-10 years). Periprosthetic fractures were classified according to the Vancouver classification. The clinical evaluation was performed with the Harris hip score, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Short Form 8 (SF-8). Bone healing, implant survival, pain, function and complications were recorded. Bone healing and implant stability were evaluated clinically and on plain radiographs. RESULTS: Uneventful bone healing was achieved in 52 cases. In two fractures (one type B1, one type C) nonunion and plate failure occurred. Two cemented stems were revised for aseptic loosening 6.5 and 7 years after fracture fixation. Uncontrollable prosthesis infection and sepsis in a rheumatoid (immunocompromised) patient required disarticulation of the involved extremity. DISCUSSION AND CONCLUSIONS: Periprosthetic femoral fractures are difficult to treat and require complex treatment approach according to risk assessment, fracture type, implant stability, bone stock and medical status of the patient. Using a treatment protocol of the Vancouver classification we obtained satisfactory outcome.

Cytokine levels (IL-4, IL-6, IL-8 and TGFß) as potential biomarkers of systemic inflammatory response in trauma patients.

PURPOSE: Much research is now being conducted in order to understand the role of cytokines in the development of the inflammatory response following trauma. The purpose of this study was to evaluate whether serum levels of certain cytokines, measured immediately after initial injury, can be used as potential biomarkers for predicting the development and the degree of severity of the systemic inflammatory response (SIRS) in patients with moderate and severe trauma. METHODS: We conducted a prospective study with 71 individuals of whom 13 (18.3 %) were healthy controls and 58 (81.7 %) were traumatized orthopaedic patients who were categorized into two groups: 31 (43.6 %) with moderate injuries and 27 (38.1 %) patients with severe orthopaedic trauma. Thirty cc of heparinized blood were drawn from each individual within a few hours after the injury. Serum levels of pro-inflammatory, regulatory and anti-inflammatory cytokines were measured in each individual participant. RESULTS: High levels of pro-inflammatory cytokines IL-1ß,-6,-8,-12, tumour necrosis factor alpha and interferon gamma were found in all injured patients compared to healthy controls. Only IL-6 and IL-8 were significantly higher in the injured patients. Levels of the regulatory cytokines, transformed growth factor beta (TGF-ß) and IL-10 were higher in the injured patients, but significant only for TGF-ß. Levels of IL-4 were significantly lower in the injured groups as compared to the controls. CONCLUSIONS: Secretion of large amounts of pro-inflammatory cytokines and decreased level of anti-inflammatory cytokines during the acute phase of trauma may lead to the development of systemic inflammatory response syndrome (SIRS) in unstable polytraumatized patients. SIRS may result in life threatening conditions as acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF). High levels of IL-6, IL-8, TGFß and low levels of IL-4 were found to be reliable markers for the existence of immune reactivity in trauma patients. More research is needed to study pattern of cytokine levels along the acute period of injury, after surgical interventions and during recovery.

Antithrombotic prophylaxis in major orthopaedic surgery: an historical overview and update of current recommendations.

The risk of venous thromboembolism following major orthopaedic procedures, such as joint arthroplasty and hip fracture surgery, are well recognised and represent one of the major challenges in orthopaedic practice, having in mind the increasing number of arthroplasties of the hip and knee done worldwide per year and their successful outcome. This potentially fatal complication remains a challenge in orthopaedic practice. The percentage of patients in whom antithrombotic prophylaxis has not been administrated or has been inadequate may reach 50%. Until recently, anticoagulant prophylaxis with low molecular weight heparins (LMWHs) has been a "gold standard". LMWHs are indirect inhibitors of the clotting factors Xa and thrombin and are administered by daily subcutaneous injection. Their efficacy has been proven in numerous clinical trials and the rate of complications with their use is relatively low. However these compounds are associated with a failure rate and are inconvenient to administer, requiring subcutaneous injection, leading to inadequate compliance. For these reasons postoperative thrombembolism continues to occur in up to 10% of this patient population. Recently, novel oral anticoagulants have been introduced into practice for thromboprophylaxis after joint arthroplasy and hip fracture surgery. These drugs are direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban). These oral drugs have the same efficacy as the LMWHs with the same or slightly more clinically significant haemorrhage as their main side effect. Their ease of administration and favourable clinical profile makes them an important addition to the therapeutic armamentarium available for venous thromboprophylaxis. In this paper we review the aetiology and pathogenesis of venous thromboembolism and present the various alternatives for its prevention after major orthopaedic surgical procedures with emphasis on the new oral drugs.

Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children.

BACKGROUND: Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. METHODS: A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. RESULTS: All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. CONCLUSIONS: Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. LEVEL OF EVIDENCE: Level IV.

Possible association of Toll-like receptor 9 polymorphisms with cytokine levels and posttraumatic symptoms in individuals with various types of orthopaedic trauma: early findings.

BACKGROUND: Although TLR9 polymorphisms may be associated with cytokine dysregulation, its role in regulation of cytokines due to bodily trauma or in relation to acute stress symptoms or posttraumatic stress symptoms (ASS/PTS) has not been evaluated. AIMS: To assess serum cytokine levels and levels of ASS and PTS in relation to four common TLR9 single-nucleotide polymorphisms (SNPs) in individuals with various types of orthopaedic trauma. METHODS: Forty-eight accident-injured individuals, aged 20-60 years were studied. Serum cytokine levels and TLR9 SNPS (1486T/C, 1237T/C, 1174G/A and 2848G/A) were assessed together with intensity of ASS and PTS symptoms. RESULTS: Statistically significant higher serum levels of IL-12 and IL-1ß (p<.05) were found in individuals heterozygous for TLR9-1237 (TC) than in individuals expressing the most common TLR9-1237 type (TT), while differences in levels of IL-6 were not significant. Also, marginally significant levels of IL-6 were found in individuals expressing the common TLR9-1174 (GG) compared with individuals homozygous (AA) or heterozygous (GA) for this SNP. They also had non-significant higher intensity of ASS symptoms. A trend of higher PTS levels in individuals expressing the most common type TLR9-1174 (GG) was found, contrary to homozygous (AA) and heterozygous individuals (GA). CONCLUSIONS: The results of this pilot study suggest that accident-injured individuals with certain TLR9 polymorphisms express higher levels of pro-inflammatory cytokines (IL-1ß, IL-6 and IL-12). The associations of TLR9 SNPSs with increased risk of ASS or PTS should be further studied in larger groups of such patients.

[What are the recommendations for sport activity following total hip or total knee arthroplasty?].

Total hip and knee arthroplasty are surgical procedures usually performed in older adults aged 65-70 years and more, who suffer from arthritic joint degeneration, in order to relieve pain and improve functioning. In the past decade there have been more and more documentations of younger people, 50-60 years old and even less, who expect to participate in physical activity following these procedures. The trend today is to recommend activities which exert mild pressure on the implants such as swimming, cycling, golf, bowling, walking and cycling. It is not recommended to participate in sports activities that place greater pressure on the implants such as soccer, football, volleyball, handball, basketball, hockey and jogging. Such high-stress activities may cause early loosening of implants, as described in the article by Keren et al. in this issue: "Sport activity after hip and knee arthroplasty".

Cytokine levels as potential biomarkers for predicting the development of posttraumatic stress symptoms in casualties of accidents.

BACKGROUND: Traumatic injuries are usually associated with increased secretion of pro-inflammatory cytokines, and are sometimes followed by the development of acute stress symptoms (ASS) and posttraumatic stress symptoms (PTSS). AIMS: To measure serum pro- and anti-inflammatory cytokines in accident casualties and to associate it with ASS at hospitalization, and with PTSS 1 month later. METHODS: Participants were 48 patients, aged 20-60, hospitalized following various orthopedic injuries including bone fractures, and 13 healthy volunteers matched for gender. At hospitalization (Time 1), 30 ml heparinized venous blood were drawn and cytokines levels in serum were assessed; participants filled out the Acute Stress Disorder Inventory (ASDI), COPE, and injury-related questionnaires. One month later (Time 2), 26 participants filled out the Posttraumatic Disorder Symptom Scale (PDS). RESULTS: High serum levels of IL-6, IL-8, and TGF-beta and low levels of serum IL-4 and IL-10 were found in injured patients as compared with controls, When controlling for age and severity of injury in the regression analysis, higher levels of IL-6 and IL-8 and lower TGF-beta were predicted by higher ASS and higher use of and emotion-focused coping. Higher PTSS scores at Time 2 were predicted by higher levels of IL-8, lower levels of TGF-beta, and higher ASS measured at Time 1. CONCLUSIONS: High levels of the pro-inflammatory cytokine IL-6 and IL-8 and lower levels of the regulatory cytokine TGF-beta should be further assessed as a possible risk factor or a bio-marker of PTSS in accident casualties.

[Fat embolism syndrome following injuries and limb fractures].

Fat embolism syndrome is a clinical entity characterized by varying degrees of cerebral dysfunction, pulmonary changes and petechial rash that usually develop within 24-48 hours in a small percentage of victims after trauma and Long bone fractures. Deterioration can occur within a few hours Leading to unconsciousness or acute respiratory insufficiency, similar to adult respiratory distress syndrome (ARDS). The pathophysiology is still not clearly understood and there are two theories--the mechanical and biochemical cascade of events. It seems that the most significant diagnostic sign is hypoxemia with relatively normaL values of PaCO2 leading to development of radiographic "snow-like appearance" of the Lungs, resulting from the typical interstitial lung edema. Treatment consists of early fracture fixation, volume replacement, respiratory support and analgesia carefully managed since some of the patients may develop acute respiratory distress. The role of steroids and other drugs is still under debate. The vast majority of patients may heal without any complications, while 5%-10% of the patients may develop some neurological complications manifesting as behavior disturbances. The aim of this review is to update the clinical and pathophysiological aspects of fat embolism syndrome and to describe the various aspects of prevention and treatment.

Treatment of articular cartilage lesions of the knee.

Treatment of articular cartilage lesions in the knee remains a challenge for the practising orthopaedic surgeon. A wide range of options are currently practised, ranging from conservative measures through various types of operations and, recently, use of growth factors and emerging gene therapy techniques. The end result of these methods is usually a fibrous repair tissue (fibrocartilage), which lacks the biomechanical characteristics of hyaline cartilage that are necessary to withstand the compressive forces distributed across the knee. The fibrocartilage generally deteriorates over time, resulting in a return of the original symptoms and occasionally reported progression to osteoarthritis. Our purpose in this study was to review the aetiology, pathogenesis and treatment options for articular cartilage lesions of the knee. At present, autologous cell therapies, growth factor techniques and biomaterials offer more promising avenues of research to find clinical answers.

[Utilization of prosthesis in patients who underwent below-knee amputation].

BACKGROUND: Thirty-two patients, among them 25 men (78.1%) and 7 women (21.9%), underwent surgery for below-knee amputation at the Western Galilee hospital, Nahariya, received a prosthesis and began rehabilitation treatment at the same hospital. Of these, 27 patients--21 men (77.8%) and 6 women (22.8%) responded to the authors request to complete the questionnaire. Four of these underwent bilateral below-knee amputation. The authors had no previous information about routine use of prosthesis after the termination of the rehabilitation process. METHODS: All patients who underwent a below-knee amputation between the years 2000 and 2004 and received a prosthesis thereafter, were surveyed. Each one was asked to complete a detailed questionnaire. The patients were asked about the use of prosthesis during daily activities, their mobility inside and outside the home, the possibility of returning to work, the influence on their social activity, the various complications caused by the prosthesis, the use of a walking aid, their ability to drive a car or to use public transport, and their ability to accomplish some physical tasks. The questionnaire included information about the patient's age, sex, level of education, civil status and familial support, in order to evaluate their influence on the use of the prosthesis. RESULTS AND CONCLUSIONS: The statistically significant results were all dependent upon the amputee's age. With an increase in age, the patient wears the prosthesis fewer hours per day inside and outside the home, has difficulty in walking quickly, tires earlier while walking and has a reduced quality of life.

Low back pain.

This study attempts to define the validity of radiographic imaging for the diagnosis of low back pain.

[Osteoid osteoma of the wrist joint resembling tenosynovitis].

Osteoid osteoma of bones of the wrist joint is a relatively rare lesion. This article presents a series of three patients, one with osteoid osteoma of the styloid process of the radius and two with osteoid osteoma of the capitate bone. All of them had clinical symptoms resembling those of stenosing tenosynovitis of the wrist joint. X-rays, tomography and bone scan revealed the characteristic findings of osteoid osteoma. Histological examination confirmed the diagnosis. Treatment consisted of "en bloc" excision of these tumors. Following surgery patients were asymptomatic and had normal mobility of the affected wrist. In the first patient this has been maintained for the succeeding 27 years. It is suggested that in any case of persistent unexplained pain of the wrist or clinical symptoms resembling those of tenosynovitis, osteoid osteoma of the styloid process of the radius or of the carpal bones should also be included in the differential diagnosis. The recommended treatment of osteoid osteoma is "en bloc" excision of this tumour in the affected bone, resulting in complete relief of pain and absence of functional disturbances.

[Limb fractures in organ transplanted patients].

Patients that have had organ transplantation receive immunosuppressive therapy to prevent organ rejection. Along with this therapy comes a higher incidence of osteoporosis, which may lead to an increased frequency of fractures in post-transplant patients. This article presents three patients who underwent organ transplantation and had subsequent fractures: subcapital fracture of the femoral neck treated with hemiarthroplasty of the hip, in a patient 8 years post cardiac transplantation; minimally displaced intertrochanteric fracture treated by percutaneous pinning, in a patient one year post lung transplantation; minimally displaced subcapital fracture treated by percutaneous pinning, in a patient 3 months post liver transplantation. Each patient was operated upon successfully and without complications. The three patients were able to resume their activities of sitting and walking after only a few days. In our opinion, preventive treatment for osteoporosis is crucial for candidates of solid organ transplantation. This treatment should be initiated prior to surgery and continued after as well. Transplant patients receiving immunosupression therapy with subsequent osteoporotic fractures of the extremities should undergo early surgical intervention in order to enable a short and quick rehabilitation and early return to normal activities of daily living.