[Analysis of a differentiated resuscitation room activation at a national trauma center]. / Analyse einer differenzierten Schockraumalarmierung an einem überregionalen Traumazentrum.

BACKGROUND: In order to continue to efficiently provide both personnel-intensive and resource-intensive care to severely injured patients, some hospitals have introduced individually differentiated systems for resuscitation room treatment. The aim of this study was to evaluate the concept of the A and B classifications in terms of practicability, indications, and potential complications at a national trauma center in Bavaria. METHODS: In a retrospective study, data from resuscitation room trauma patients in the year 2020 were collected. The assignment to A and B was made by the prehospital emergency physician. Parameters such as the injury severity score (ISS), Glasgow outcome scale (GOS), upgrade rate, and the indication criteria according to the S3 guidelines were recorded. Statistical data comparisons were made using t­tests, χ2-tests, or Mann-Whitney U­tests. RESULTS: A total of 879 resuscitation room treatments (A 473, B 406) met the inclusion criteria. It was found that 94.5% of resuscitation room A cases had physician accompaniment, compared to 48% in resuscitation room B assignments. In addition to significantly lower ISS scores (4.1 vs. 13.9), 29.8% of B patients did not meet the treatment criteria defined in the S3 guidelines. With a low upgrade rate of 4.9%, 98% of B patients had a GOS score of 4 or 5. CONCLUSION: The presented categorization is an effective and safe way to manage the increasing number of resuscitation room alerts in a resource-optimized manner.

Deltoid Muscle Tension Alterations Post Reverse Shoulder Arthroplasty: An Investigation Using Shear Wave Elastography.

INTRODUCTION: This study aimed to evaluate the utility of shear wave elastography (SWE) in assessing changes in deltoid muscle properties following reverse shoulder arthroplasty (RSA). METHODS: Our cohort consisted of 18 patients who underwent RSA due to various conditions, including osteoarthritis, cuff arthropathy, and irreducible proximal humeral fractures. Pre- and postoperative muscle elasticity and stiffness were measured using SWE and were compared with functional outcomes and radiological parameters. RESULTS: Our results showed significant changes in deltoid muscle elasticity after RSA, particularly in the anterior and middle portions. However, these alterations were not correlated with postoperative functional outcomes or specific radiological parameters. The study also underscored the potential of SWE for future applications, including the preoperative assessment of deltoid function, postoperative monitoring, and intraoperative use for optimal component positioning during RSA. CONCLUSION: Further research, involving larger, more homogeneous patient cohorts is needed to confirm these findings and to explore the potential influence of these changes on the biomechanical design of implants and prosthesis positioning in RSA.

Experimental magnesium phosphate cement paste increases torque of trochanteric fixation nail advanced™ blades in human femoral heads.

BACKGROUND: The use of polymethylmethacrylate cement for in-situ implant augmentation has considerable disadvantages: it is potentially cytotoxic, exothermic and non-degradable. Therefore, the primary aim of this study was to develop a magnesium phosphate cement which meets the requirements for in-situ implant augmentation as an alternative. Secondly, this experimental cement was compared to commercial bone cements in a biomechanical test set-up using augmented femoral head blades. METHODS: A total of 40 human femoral heads were obtained from patients who underwent total hip arthroplasty. After bone mineral density was quantified, specimens were assigned to four treatment groups. A blade of the Trochanteric Fixation Nail Advanced™ was inserted into each specimen and augmented with either Traumacem™ V+, Paste-CPC, the experimental magnesium phosphate cement or no cement. A rotational load-to-failure-test (0° to 90°) was performed. FINDINGS: A conventional two-component magnesium phosphate cement failed in-situ implant augmentation consistently due to filter pressing. Only a glycerol-based magnesium phosphate paste was suitable for the augmentation of femoral head blades. While the blades augmented with Traumacem™ V+ yielded the highest maximum torque overall (22.1 Nm), the blades augmented with Paste-CPC and the magnesium phosphate paste also showed higher maximum torque values (15.8 and 12.8 Nm) than the control group (10.8 Nm). INTERPRETATION: This study shows for the first time the development of a degradable magnesium phosphate cement paste which fulfills the requirements for in-situ implant augmentation. Simultaneously, a 48% increase in stability is demonstrated for a scenario where implant anchorage is difficult in osteoporotic bone.

"Mother and baby plate": a strategy to improve stability in proximal fractures of the ulna.

INTRODUCTION: Proximal ulna fractures with a large zone of comminution, such as in the context of Monteggia injuries, require mechanically strong osteosyntheses as they occur in regions with high physiological joint load. Consequently, implant failure and pseudarthrosis are critical and devastating complications, especially with the background of mainly young patients being affected. An effective solution could be provided by adding a small second plate 90° angulated to the standard dorsal plate in the area of non-union. Thus, this study investigates whether, from a biomechanical point of view, the use of such a mini or baby plate is worthwhile. MATERIALS AND METHODS: Comminuted fractures distal to the coronoid process, equivalent to Jupiter type IIb fractures, are generated on artificial Sawbones® of the ulna and stabilized using two different plate osteosyntheses: in the first group, a dorsal locking compression olecranon plate is used (LCP group). In the second group, a small, ulnar 5-hole olecranon plate is added as a baby plate in addition to the mother plate at the level of the fracture zone (MBP group). Dynamic biomechanical loading in degrees of flexion from 0° to 90° is carried out to determine yield load, stiffness, displacement, and changes in fracture gap width as well as bending of the dorsal plate. RESULTS: The "mother-baby-plate" osteosynthesis had a significantly higher yield load (p < 0.01) and stiffness (p = 0.01) than the LCP group. This correlates with the increased movement of the proximal fracture element during cyclic testing for the LCP group compared to the MBP group as measured by an optical metrology system. CONCLUSIONS: Here, we show evidence that the addition of a small plate to the standard plate is highly effective in increasing the biomechanical stability in severe fractures equivalent to Jupiter type IIb. As it hopefully minimizes complications like pseudarthrosis and implant failure and as the additional preparatory effort leading to compromised blood supply is regarded to be negligible, this justifies and highly advises the use of a mother-baby-plate system.

Impact of a Femoral Fracture on Outcome after Traumatic Brain Injury-A Matched-Pair Analysis of the TraumaRegister DGU®.

Traumatic brain injury (TBI) is the leading cause of death and disability in polytrauma and is often accompanied by concomitant injuries. We conducted a retrospective matched-pair analysis of data from a 10-year period from the multicenter database TraumaRegister DGU® to analyze the impact of a concomitant femoral fracture on the outcome of TBI patients. A total of 4508 patients with moderate to critical TBI were included and matched by severity of TBI, American Society of Anesthesiologists (ASA) risk classification, initial Glasgow Coma Scale (GCS), age, and sex. Patients who suffered combined TBI and femoral fracture showed increased mortality and worse outcome at the time of discharge, a higher chance of multi-organ failure, and a rate of neurosurgical intervention. Especially those with moderate TBI showed enhanced in-hospital mortality when presenting with a concomitant femoral fracture (p = 0.037). The choice of fracture treatment (damage control orthopedics vs. early total care) did not impact mortality. In summary, patients with combined TBI and femoral fracture have higher mortality, more in-hospital complications, an increased need for neurosurgical intervention, and inferior outcome compared to patients with TBI solely. More investigations are needed to decipher the pathophysiological consequences of a long-bone fracture on the outcome after TBI.

Retroperitoneal arterial bleeding caused by an undisplaced conservatively treated hyperextension injury of the lumbar spine - A case report.

Background: Hyperextension fractures of the thoracolumbar spine are commonly seen in ankylotic disorders due to the rigidity of the spine. The known complications include instability, neurological deficits and posttraumatic deformity but there is no report of a hemodynamic relevant arterial bleeding in undisplaced hyperextension fractures. An arterial bleeding poses a life-threatening complication and may be difficult to recognize in an ambulatory or clinical setting. Case presentation: A 78-year-old male was brought to the emergency department after suffering a domestic fall with incapacitating lower back pain. X-rays and a CT scan revealed an undisplaced L2 hyperextension fracture which was treated conservatively. 9 days after admission, the patient complained about unprecedented abdominal pain with a CT scan disclosing a 12 × 9 × 20 cm retroperitoneal hematoma on grounds of an active arterial bleeding from a branch of the L2 lumbar artery. Subsequently, access via lumbotomy, evacuation of the hematoma and insertion of a hemostatic agent was performed. The therapy concept of the L2 fracture remained conservatively. Conclusions: A secondary, retroperitoneal arterial bleeding after a conservatively treated undisplaced hyperextension fracture of the lumbar spine is a rare and severe complication that has not been described in literature yet and may be difficult to recognize. An early CT scan is recommended in case of a sudden onset of abdominal pain in these fractures to fasten treatment and hence decrease morbidity and mortality. Thus, this case report contributes to the awareness of this complication in a spine fracture type with increasing incidence and clinical relevance.

[The severely injured older cyclist-Evaluation of the TraumaRegister DGU® : Retrospective, multicenter cross-sectional study based on the TraumaRegister DGU®]. / Der schwer verletzte ältere Fahrradfahrer ­ Auswertung des TraumaRegister DGU® : Retrospektive, multizentrische Querschnittstudie anhand des TraumaRegister DGU®.

BACKGROUND: Contrary to the trend of decreasing traffic fatalities, the number of cyclists killed in Germany has been steadily increasing in recent years. With the increasing popularity of cycling in all age groups, the number of accidents with sometimes serious injuries is rising. In the course of this, the question arises what influence age has on the type and severity of injuries, the probability of survival and the length of hospital stay in seriously injured cyclists. METHODS: A retrospective analysis of data from the TraumaRegister DGU® (TR-DGU) from 2010 to 2019 was performed. All severely injured cyclists with a maximum abbreviated injury scale (MAIS) of 3+ (n = 14,651) in the TR-DGU were included in this study and the available parameters were evaluated. A subdivision into three age groups (60-69, 70-79, and ≥ 80 years) and a control group (20-59 years) was carried out. RESULTS: Injuries to the head were by far the most common, accounting for 64.2%. There was a marked increase in severe head injuries in the 60-plus years age group. Furthermore, with increasing age, the probability of prehospital intubation, catecholamine requirement, intensive care and hospital length of stay, and mortality increased. CONCLUSION: Head injuries represent the most common serious injury, especially among older cyclists. As helmet wearing was not recorded in the TraumaRegister DGU® during the evaluation period, no conclusion can be drawn about its effect. Furthermore, a higher age correlates with a longer hospital stay and a higher mortality, but does not represent an independent risk factor for death in severely injured patients.

Gantry-Free High-Resolution Cone-Beam CT: Efficacy for Distal Radius and Scaphoid Fracture Detection and Characterization.

OBJECTIVES: Gantry-free cone-beam CT (CBCT) allows for comfortable patient positioning due to an open scanner architecture. Since CBCT without gantry is not yet established for clinical wrist trauma imaging, this study's aim was to investigate its diagnostic value in the preoperative workup of patients with distal radius and scaphoid fractures. METHODS: Within a 12-month period, 113 patients with severe wrist trauma underwent both radiography and CBCT with the same gantry-free multi-use scanner before surgery. Two radiologists retrospectively analyzed all datasets for the morphology of distal radius (n = 95) and scaphoid fractures (n = 20). In all 115 wrists (two bilateral injuries), surgical reports served as the standard of reference. RESULTS: While accuracy for distal radius fractures was comparable among CBCT and radiographs, the former was superior with regard to scaphoid fractures (Reader 1: 100.0% vs. 75.0%; Reader 2: 100.0% vs. 65.0%). Accuracy for multi-fragmentary radius injuries (100.0% vs. 90.5%; 100.0% vs. 93.7%), and articular affliction (99.0% vs. 84.2%; 100.0% vs. 83.2%) was also higher in CBCT. Regarding scaphoid fractures, CBCT proved superior for diagnosis of proximal pole or waist involvement (100.0% vs. 70.0%; 100.0% vs. 65.0%) and comminuted patterns (100.0% vs. 70.0%; 100.0% vs. 75.0%). Median effective dose of CBCT was as low as 3.65 µSv compared with 0.16 µSv for standard radiography. CONCLUSION: Gantry-free CBCT allows for excellent diagnostic accuracy in the assessment of distal radius and scaphoid fracture morphology. Even in patients with limited mobility, very low radiation dose is sufficient to maintain high image quality.

Development and preclinical evaluation of a cable-clamp fixation device for a disrupted pubic symphysis.

BACKGROUND: Traumatic separation of the pubic symphysis can destabilize the pelvis and require surgical fixation to reduce symphyseal gapping. The traditional approach involves open reduction and the implantation of a steel symphyseal plate (SP) on the pubic bone to hold the reposition. Despite its widespread use, SP-fixation is often associated with implant failure caused by screw loosening or breakage. METHODS: To address the need for a more reliable surgical intervention, we developed and tested two titanium cable-clamp implants. The cable served as tensioning device while the clamp secured the cable to the bone. The first implant design included a steel cable anterior to the pubic symphysis to simplify its placement outside the pelvis, and the second design included a cable encircling the pubic symphysis to stabilize the anterior pelvic ring. Using highly reproducible synthetic bone models and a limited number of cadaver specimens, we performed a comprehensive biomechanical study of implant stability and evaluated surgical feasibility. RESULTS: We were able to demonstrate that the cable-clamp implants provide stability equivalent to that of a traditional SP-fixation but without the same risks of implant failure. We also provide detailed ex vivo evaluations of the safety and feasibility of a trans-obturator surgical approach required for those kind of fixation. CONCLUSION: We propose that the developed cable-clamp fixation devices may be of clinical value in treating pubic symphysis separation.

Life-threatening pelvic injuries are often associated with disruption of a joint within the hip bones, called the pubic symphysis. Disruption can lead to a gap and subsequent instability of the pelvis. The current treatment is to stabilize the joint with a steel plate and screws, however this often becomes unstable soon after the operation. In this study, we analyzed two alternatives for stabilization that use cables and clamps instead of the plate. Further, we tested a surgical approach for implantation. The cables and clamps were as stable as a steel plate so offer an alternative approach to stabilize the pubic symphysis.

Plate osteosynthesis combined with bone cement provides the highest stability for tibial head depression fractures under high loading conditions.

Older patients sustaining tibial head depression fractures often cannot follow the post-operative rehabilitation protocols with partial weight-bearing of the affected limb, leading to osteosynthesis failure, cartilage step-off and arthritis development. Therefore, the aim of this study was to analyse the biomechanical performance of different types of osteosyntheses alone and in combination with bone cement simulating cyclically high loading conditions of tibial head depression fractures. Lateral tibial head depression fractures (AO: 41-B2.2; Schatzker type III) were created in synthetic bones and stabilized using three different osteosyntheses alone and in combination with a commonly used bone cement (chronOS™): 2 screws, 4 screws in the jail technique and a lateral angle-stable buttress plate. After fixation, the lateral tibial plateau was axially loaded in two, from each other independent testing series: In the first test protocol, 5000 cycles with 500 N and in the end load-to-failure tests were performed. In the second test protocol, the cyclic loading was increased to 1000 N. Parameters of interest were the displacement of the articular fracture fragment, the stiffness and the maximum load. The osteosyntheses revealed a higher stiffness in combination with bone cement compared to the same type of osteosynthesis alone (e.g., 500 N level: 2 screws 383 ± 43 N/mm vs. 2 screws + chronOs 520 ± 108 N/mm, increase by 36%, p < 0.01; 4 screws 368 ± 97 N/mm vs. 4 screws + chronOS 516 ± 109 N/mm, increase by 40%, p < 0.01; plate: 509 ± 73 N/mm vs. plate + chronOs 792 ± 150 N/mm, increase by 56%, p < 0.01). Bone cement reduced the displacement of the plate significantly (500 N level: plate: 8.9 ± 2.8 mm vs. plate + chronOs: 3.1 ± 1.4 mm, reduction by 65%, p < 0.01; 1000 N level: 16.9 ± 3.6 mm vs 5.6 ± 1.3 mm, reduction by 67%, p < 0.01). Thus, the highest stiffness and lowest displacement values were found when using the plate with bone cement in both loading conditions (500 N level: 2 screws + chronOs 3.7 ± 1.3 mm, 4 screws + chronOs 6.2 ± 2.4 mm; 1000 N level: 2 screws + chronOs 6.5 ± 1.2 mm, 4 screws + chronOs 5.7 ± 0.8 mm). From a biomechanical perspective, plate osteosynthesis of tibial head depression fractures should always be combined with bone cement, provides higher stability than 2-screw and 4-screw fixation and is a valid treatment option in cases where extraordinary stability is required.

Surgical Fixation of Calcaneal Beak Fractures-Biomechanical Analysis of Different Osteosynthesis Techniques.

The calcaneal beak fracture is a rare avulsion fracture of the tuber calcanei characterized by a solid bony fragment at the Achilles tendon insertion. Treatment usually requires osteosynthesis. However, lack of biomechanical understanding of the ideal fixation technique persists. A beak fracture was simulated in synthetic bones and assigned to five different groups of fixation: A) 6.5-mm partial threaded cannulated screws, B) 4.0-mm partial threaded cannulated screws, C) 5.0-mm headless cannulated compression screws, D) 2.3-mm locking plate, and E) 2.8-mm locking plate. Different traction force levels were applied through an Achilles tendon surrogate in a material-testing machine on all stabilized synthetic bones. Outcome measures were peak-to-peak displacement, total displacement, plastic deformation, stiffness, visual-fracture-line displacement, and mode of implant failure. The 2.3- and 2.8-mm plating groups showed a high drop-out rate at 100 N tension force and failed under higher tension levels of 200 N. The fracture fixation using 4.0-mm partial threaded screws showed a significantly higher repair strength and was able to withhold cyclic loading up to 300 N. The lowest peak-to-peak displacement and the highest load-to-failure and stiffness were provided by fracture fixation using 6.5-mm partial threaded cannulated screws or 5.0-mm headless cannulated compression screws. As anticipated, large 6.5-mm screw diameters provide the best biomechanical fixation. Surprisingly, the 5.0-mm headless cannulated compression screws yield reliable stability despite the absent screw head and washer. When such large screws cannot be applied, 4.0-mm screws also allow reasonable fixation strength. Plate fixation should be implemented with precaution and in combination with a restrictive postoperative motion protocol. Finally, clinical cases about the surgical application and recovery are included.

[Pedicled anterolateral thigh flap reconstruction in the region of the lower abdomen, groin, perineum, and hip]. / Die gestielte, anterolaterale Oberschenkellappenplastik zur Weichteilrekonstruktion im Bereich von Unterbauch, Leiste, Perineum und Hüfte.

OBJECTIVE: Soft tissue reconstruction of complex defects of the lower abdomen, groin, the perineum and the hip region present a reconstructive challenge. Besides free tissue transfer, pedicled flaps may also be utilized. Harvest of the vertical rectus abdominis flap causes a functional deficit by weakening the abdominal wall. Pedicled, perforator-based flaps minimize functional deficits by preserving muscle. INDICATIONS: Soft tissue defects with exposed vital structures, prosthetic devices or irradiated wound beds. CONTRAINDICATIONS: Previous surgery at the donor site, peripheral vascular disease at the pelvic and thigh region, previous vascular interventions at the donor site. SURGICAL TECHNIQUE: After preoperative localization of the perforators, a retrograde, intramuscular dissection of the pedicle allows sufficient length to be gained in order to transpose the flap into the defect. Tunneling of the flap beneath the rectus femoris muscle and Sartorius muscle is often required for tension-free inset. POSTOPERATIVE MANAGEMENT: Five days of bed-rest postoperatively followed by ambulation. RESULTS: No complete flap loss was encountered in 13 cases. In 2 cases a partial tip necrosis required secondary skin grafting.

Interobserver reliability of scapula fracture classifications in intra- and extra-articular injury patterns.

BACKGROUND: Morphology and glenoid involvement determine the necessity of surgical management in scapula fractures. While being present in only a small share of patients with shoulder trauma, numerous classification systems have been in use over the years for categorization of scapula fractures. The purpose of this study was to evaluate the established AO/OTA classification in comparison to the classification system of Euler and Rüedi (ER) with regard to interobserver reliability and confidence in clinical practice. METHODS: Based on CT imaging, 149 patients with scapula fractures were retrospectively categorized by two trauma surgeons and two radiologists using the classification systems of ER and AO/OTA. To measure the interrater reliability, Fleiss kappa (κ) was calculated independently for both fracture classifications. Rater confidence was stated subjectively on a five-point scale and compared with Wilcoxon signed rank tests. Additionally, we computed the intraclass correlation coefficient (ICC) based on absolute agreement in a two-way random effects model to assess the diagnostic confidence agreement between observers. RESULTS: In scapula fractures involving the glenoid fossa, interrater reliability was substantial (κ = 0.722; 95% confidence interval [CI] 0.676-0.769) for the AO/OTA classification in contrast to moderate agreement (κ = 0.579; 95% CI 0.525-0.634) for the ER classification system. Diagnostic confidence for intra-articular fracture patterns was superior using the AO/OTA classification compared to ER (p < 0.001) with higher confidence agreement (ICC: 0.882 versus 0.831). For extra-articular fractures, ER (κ = 0.817; 95% CI 0.771-0.863) provided better interrater reliability compared to AO/OTA (κ = 0.734; 95% CI 0.692-0.776) with higher diagnostic confidence (p < 0.001) and superior agreement between confidence ratings (ICC: 0.881 versus 0.912). CONCLUSIONS: The AO/OTA classification is most suitable to categorize intra-articular scapula fractures with glenoid involvement, whereas the classification system of Euler and Rüedi appears to be superior in extra-articular injury patterns with fractures involving only the scapula body, spine, acromion and coracoid process.

Augmentation of suture anchors with magnesium phosphate cement - Simple technique with striking effect.

BACKGROUND: Suture anchors have a large field of application in orthopedic trauma surgery like the refixation of patellar, quadriceps and Achilles tendon or the treatment of rotator cuff tears. The fixation of suture anchors in osteoporotic bone is difficult, a problem that becomes increasingly relevant in the elderly. METHODS: Two types of suture anchors: 1.) Titanium CorkScrew Fast Track II with a knotted eyelet and 2.) polyether ether ketone (PEEK) SwiveLock C with a knotless eyelet were chosen for evaluation in open cell bone blocks with densities of 5-20 pcf supplied by Sawbones AB. A pilot hole of 7 mm diameter and 20 mm depth was drilled in the bone blocks and filled with an experimental drillable magnesium phosphate cement (powder: 92.5 wt% Mg3(PO4)2, 7.5 wt% MgO, liquid: 25 wt% phytic acid (C6H18O24P6)). Anchors were then inserted into the cement and allowed to cure for 24 h (37 °C, 100% humidity) before pullout testing was conducted with a material testing machine. Suture anchors inserted in the blocks after predrilling and tapping served as control. RESULTS: Through augmentation with magnesium phosphate cement pullout strength and stiffness of the suture anchors could be significantly increased in all bone blocks up to 22-fold. CorkScrew anchors failed by rupture of the eyelet with higher pullout strengths, whereas no failure of SwiveLock C anchors could be observed when reinforced with additional FibreWire at the tip. CONCLUSIONS: We present a simple technique, whereby pullout strength of suture anchors can be significantly increased in bone with compromised density. The experimental resorbable and drillable magnesium phosphate cement proved to be effective in resisting tensile load, dispersing in the adjacent bone, and thus increasing the bone-anchor contact surface. Therefore, the experimental magnesium phosphate cement is a promising candidate for clinical application in the numerous scenarios mentioned.

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury.

PURPOSE: To evaluate the clinical benefit of surgical stabilization of rib fractures (SSRF) in polytrauma patients with serial rib fractures. METHODS: Retrospective single-center cohort analysis in trauma patients. Serial rib fracture was defined as three consecutive ribs confirmed by chest computer tomography (CT). Study cohort includes 243 patients that were treated conservatively and 34 patients that underwent SSRF. Demographic patient data, trauma mechanism, injury pattern, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and hospital course were analyzed. Two matched pair analyses stratified for ISS (32 pairs) and GCS (25 pairs) were performed. RESULTS: The majority of patients was male (74%) and aged 55 ± 20 years. Serial rib fractures were associated with more than 6 broken ribs in average (6.3 ± 3.7). Other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). Visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). Average ISS was 22 ± 7.3. Overall hospital stay was 15.9 and ICU stay 7.4 days. In hospital, mortality was 13%. SSRF did not improve hospital course or postoperative complications in the complete study cohort. However, patients with a significantly reduced GCS (7.6 ± 5.3 vs 11.22 ± 4.8; p = 0.006) benefitted from SSRF. Matched pair analysis stratified for GCS showed shorter ICU stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003). CONCLUSION: Patients with serial rib fractures and simultaneous moderate or severe traumatic brain injury benefit from surgical stabilization of rib fractures.

[Vascular diagnostics before microvascular tissue transfer on the lower extremities : An algorithm]. / Gefäßdiagnostik vor mikrovaskulärem Gewebetransfer an der unteren Extremität : Ein Algorithmus.

Microsurgical free flap transfer plays a key role in soft tissue reconstruction of the lower extremities. Through close cooperation between plastic and orthopedic surgery, great progress and success in limb salvage could be achieved over the last decades. The risk for extremity malperfusion is especially high in older patients and after trauma. To maximize the success rate for free flap transfer there is need for interdisciplinary clinical examination and diagnostics. In addition to clinical methods radiological procedures are necessary to evaluate and optimize lower extremity perfusion before surgery.Vascular ultrasound provides important information about the arterial and venous status; however, DSA, CTA and MRA are well-established and exact methods to evaluate arterial inflow. The use of less invasive methods makes it much more feasible, economic and comfortable to perform preoperative selection of patients requiring interventional procedures.In the case of intraluminal stenosis without any option for PTA, a vascular surgeon can be involved at an early stage to evaluate further surgical options. In some cases, similar surgical revascularization and free flap transfer can be performed in a single surgery. The aim of this study is to implement a standardized algorithm for preoperative examination and radiological diagnostics before reconstructive surgery of the lower extremity.

Anterior deltoid muscle tension quantified with shear wave ultrasound elastography correlates with pain level after reverse shoulder arthroplasty.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) leads to medialization and distalization of the centre of rotation of the shoulder joint resulting in lengthening of the deltoid muscle. Shear wave ultrasound elastography (SWE) is a reliable method for quantifying tissue stiffness. The purpose of this study was to analyse if deltoid muscle tension after RSA correlates with the patients' pain level. We hypothesized that higher deltoid muscle tension would be associated with increased pain. MATERIAL AND METHODS: Eighteen patients treated with RSA were included. Constant score (CS) and pain level on the visual analogue scale (VAS) were analysed and SWE was performed on both shoulders. All three regions of the deltoid muscle were examined in resting position and under standardized isometric loading. RESULTS: Average patient age was 76 (range 64-84) years and average follow-up was 15 months (range 4-48). The average CS was 66 points (range 35-89) and the average pain level on the VAS was 1.8 (range 0.5-4.7). SWE revealed statistically significant higher muscle tension in the anterior and middle deltoid muscle region in patients after RSA compared to the contralateral non-operated side. There was a statistically significant correlation between pain level and anterior deltoid muscle tension. CONCLUSION: SWE revealed increased tension in the anterior and middle portion of the deltoid muscle after RSA in a clinical setting. Increased tension of the anterior deltoid muscle portion significantly correlated with an increased pain level. SWE is a powerful, cost-effective, quick, dynamic, non-invasive, and radiation-free imaging technique to evaluate tissue elasticity in the shoulder with a wide range of applications. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer.

BACKGROUND: Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. OBJECTIVE: Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. METHODS: 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. RESULTS: Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. CONCLUSION: The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.

Efficacy of Zoledronic Acid in the Treatment of Nonmalignant Painful Bone Marrow Lesions: A Triple-Blind, Randomized, Placebo-Controlled Phase III Clinical Trial (ZoMARS).

Bone marrow lesions (BML) represent areas of deteriorated bone structure and metabolism characterized by pronounced water-equivalent signaling within the trabecular bone on magnetic resonance imaging (MRI). BML are associated with repair mechanisms subsequent to various clinical conditions associated with inflammatory and non-inflammatory injury to the bone. There is no approved treatment for this condition. Bisphosphonates are known to improve bone stability in osteoporosis and other bone disorders and have been used off-label to treat BML. A randomized, triple-blind, placebo-controlled phase III trial was conducted to assess efficacy and safety of single-dose zoledronic acid (ZOL) 5 mg iv with vitamin D 1000 IU/d as opposed to placebo with vitamin D 1000 IU/d in 48 patients (randomized 2:1) with BML. Primary efficacy endpoint was reduction of edema volume 6 weeks after treatment as assessed by MRI. After treatment, mean BML volume decreased by 64.53% (±41.92%) in patients receiving zoledronic acid and increased by 14.43% (±150.46%) in the placebo group (p = 0.007). A decrease in BML volume was observed in 76.5% of patients receiving ZOL and in 50% of the patients receiving placebo. Pain level (visual analogue scale [VAS]) and all categories of the pain disability index (PDI) improved with ZOL versus placebo after 6 weeks but reconciled after 6 additional weeks of follow-up. Six serious adverse events occurred in 5 patients, none of which were classified as related to the study drug. No cases of osteonecrosis or fractures occurred. Therefore, single-dose zoledronic acid 5 mg iv together with vitamin D may enhance resolution of bone marrow lesions over 6 weeks along with reduction of pain compared with vitamin D supplementation only. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Comparing porous tantalum fusion implants and iliac crest bone grafts for spondylodesis of thoracolumbar burst fractures: Prospectice Cohort study.

The aim of this study was to compare two different techniques of performing one-level spondylodesis for thoracolumbar burst fractures using either an autologous iliac crest bone graft (ICBG) or a porous tantalum fusion implant (PTFI). In a prospective nonrandomized study, 44 patients (20 women, 24 men; average age 43.1 ± 13.2 years) suffering from severe thoracolumbar burst fractures were treated with combined anterior-posterior stabilization. An ICBG was used in 21 cases, and a PTFI was used in the other 23 cases. A two-year clinical and radiographic follow-up was carried out. There were no statistically significant differences in age, sex, localization/classification of the fracture, or visual analog scale (VAS) before injury between the two groups. All 44 patients were followed up for an average period of 533 days (range 173-1567). The sagittal spinal profile was restored by an average of 11.1° (ICBG) vs. 14.3° (PTFI) (monosegmental Cobb angle). Loss of correction until the last follow-up tended to be higher in the patients treated with ICBG than in those treated with PTFI (mean: 2.8° vs. 1.6°). Furthermore, significantly better restoration of the sagittal profile was obtained with the PTFI than with the iliac bone graft at the long-term follow-up (mean: ICBG 7.8°, PTFI 12.3°; p < 0.005). Short-segment posterior instrumentation combined with anterior one-level spondylodesis using either an ICBG or a PTFI resulted in sufficient correction of posttraumatic segmental kyphosis. PTFI might be a good alternative for autologous bone grafting and prevent donor site morbidities.