[Reconstruction of large osteochondral defects of the distal femur and proximal tibia : Adaptation of fresh frozen allografts using 3D-printed models]. / Rekonstruktion großer osteochondraler Defekte des distalen Femurs und der proximalen Tibia : Anpassung frisch gefrorener Allografts unter Zuhilfenahme 3D-gedruckter Kunststoffmodelle.

The reconstruction of large osteochondral defects is still a challenge in musculoskeletal surgery. Fresh frozen allografts are a frequently used resource for the treatment of such tissue defects. Furthermore, 3D-printed models enable multiple options in the preoperative planning and intraoperative adaptation of the allografts, so that healing is optimal and the best functional outcome for the patient is achieved.

Eradication of Acinetobacter baumannii/Enterobacter cloacae complex in an open proximal tibial fracture and closed drop foot correction with a multidisciplinary approach using the Taylor Spatial Frame®: a case report.

BACKGROUND: Multi-drug-resistant bacteria (e.g. Carbapenem-resistant Acinetobacter baumannii, extended-spectrum betalactamase or carbapenemase-producing enterobacteriaceae) are emerging in early-onset infections. So far, there is no report describing the eradication of these bacteria in a osseous infection of an open proximal tibial fracture in combination with the hexapod technology to address both osseous consolidation and closed drop foot correction. CASE PRESENTATION: After sustaining a proximal tibial fracture (Gustilo 3B), a 41-year-old man was primarily treated with open reduction and internal fixation by a locking plate and split-thickness skin graft in the home country. At the time of admission to our hospital there was a significant anterolateral soft tissue defect covered with an already-necrotic split-thickness graft and suspicious secretion. CAT and MRI scans revealed no signs of osseous healing, intramedullary distinctive osteomyelitis, as well as a large abscess zone in the dorsal compartment. Multiple wound smears showed multi-drug-resistant bacteria: Acinetobacter baumannii (Carbapenem resistant) as well as Enterobacter cloacae complex (AmpC overexpression). After implant removal, excessive osseous and intramedullary debridements using the Reamer Irrigator Aspirator (RIA®) as well as initial negative pressure wound therapy were performed. Colistin hand-modelled chains and sticks were applied topically as well as an adjusted systemic antibiotic scheme was applied. After repetitive surgical interventions, the smears showed bacterial eradication and the patient underwent soft tissue reconstruction with a free vascularized latissimus dorsi muscle flap. External fixation was converted to a hexapod fixator (TSF®) to correct primary varus displacement, axial assignment and secure osseous healing. A second ring was mounted to address the fixed drop foot in a closed fashion without further intervention. At final follow-up, 12 months after trauma, the patient showed good functional recovery with osseous healing, intact soft tissue with satisfactory cosmetics and no signs of reinfection. CONCLUSIONS: A multidisciplinary approach with orthopaedic surgeons for debridement, planning and establishing osseous and joint correction and consolidation, plastic surgeons for microvascular muscle flaps for soft tissue defect coverage as well as clinical microbiologists for the optimized anti-infective treatment is essential in these challenging rare cases. LEVEL OF EVIDENCE: Level IV.

Accidental hypothermia as an independent risk factor of poor neurological outcome in older multiply injured patients with severe traumatic brain injury: a matched pair analysis.

PURPOSE: Patients with multiple injuries are particularly susceptible to accidental hypothermia which is correlated with an increased risk of post-traumatic complications and mortality; however, its impact on neurological outcome in cases where there is concomitant traumatic brain injury is underexplored. METHODS: We analyzed severely injured patients (ISS ≥ 16) including a moderate-to-severe traumatic brain injury (AISHead ≥ 3). The primary endpoint was objective neurological recovery, expressed as Glasgow Outcome Scale (GOS) score at time of discharge. Secondary endpoints were mortality, systemic inflammatory response syndrome (SIRS), sepsis, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Statistical analysis included logistic regression (odds ratio). The significance level in all analyses was p = 0.05. RESULTS: We analyzed 278 patients (M age = 43 years, SD 19; M ISS = 32.8, SD 10.7). Mortality was 17% (n = 14). 102 patients (37%) were hypothermic on admission. Hypothermic patients were more severely injured (ISS 35.6 ± 11.1 vs. 31.2 ± 10.1, p = 0.001; APACHE II 18.1 ± 7.4 vs. 16.2 ± 7.3, p = 0.045) and had a higher transfusion requirement. Mortality rate in hypothermic patients was increased (23.5 vs. 13.1%, p = 0.03); however, hypothermia was not an independent predictor of mortality. Median GOS at discharge was 3 (IQR 3); in 47% of patients the outcome was favorable (GOS 4 or 5) and 36% it was poor (GOS 2 or 3). There were no differences in post-traumatic complications. Analysis of 73 matched pairs of hypothermic and normothermic patients could not prove hypothermia as an independent predictor of poor neurological outcome (OR 1.7, 95% CI 0.8-3.6, p = 0.1) in the total population. However, older patients (> 41 years) had a 4.2-times higher risk (95% CI 1.4-12.7; p = 0.01) of poor neurological outcome, if they were hypothermic on admission. CONCLUSIONS: Accidental hypothermia seems to have a negative impact on neurological recovery in older patients with multiple injuries including traumatic brain injury which outweighs potential benefits.

Injury severity in polytrauma patients is underestimated using the injury severity score: a single-center correlation study in air rescue.

PURPOSE: Prehospital estimation of injury severity is essential for prehospital therapy, deciding on the destination hospital and the associated emergency room care. The aim of this study was to compare prehospital estimates of the abbreviated injury scale (AIS) and the Injury Severity Score (ISS) by emergency physicians with the values of AIS and ISS of injury severity determined at the conclusion of diagnostics. METHODS: In this prospective study, the ISS was determined prehospital by emergency physicians. The validated AIS and ISS were analyzed based on final diagnoses. A Bland-Altman plot was used in analyzing the agreement between two different assays as well as sensitivity and specificity were determined. Confidence intervals were calculated for a Wilson score. Significance level was set at p ≤ 0.05. RESULTS: The prehospital ISS was estimated at 26.0 ± 13.0 and was 34.7 ± 16.3 (p < 0.001) after in-hospital validation. In addition, most of the AIS subgroups were significantly higher in the final calculation than preclinically estimated (p < 0.05). When analyzing subgroups of trauma patients (ISS < 16 vs. ISS ≥ 16), we were able to demonstrate a sensitivity of > 90% to identify a multiple-trauma patient. Diagnosing a higher injury severity group (ISS ≥ 25), sensitivity dropped to 61.1%. The Bland-Altman plot demonstrates that injury severity is underestimated in higher injury levels. CONCLUSION: Multiple-trauma patients can be identified using the ISS. Anatomic scores might be used for transport decisions; however, an accurate estimation of the injury severity should also be based on other criteria such as patient status, mechanism of injury, and other triage criteria.

Fractures of the transverse processes of the fourth and fifth lumbar vertebrae in patients with pelvic ring injuries: indicator of biomechanical instability but not shock.

Aims: This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent. Patients and Methods: The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014. Results: A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p < 0.001) had a fracture of a TP. Patients with a fracture of a TP of L4 and/or L5 had a 5.5-fold risk (odds ratio (OR)) of having a biomechanically unstable pelvic injury. TP fractures (OR 1.6, p = 0.2) could not be confirmed as an independent predictor of haemodynamic instability. Conclusion: This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214-19.

[Peri-implant femoral fracture following hip arthrodesis in adolescence]. / Periimplantäre Femurfraktur nach Hüftarthrodese im Jugendalter.

This article presents the case of an 83-year-old woman with a peri-implant femoral fracture after hip arthrodesis in adolescence. Due to the rarity of such operations, there is no standardized approach for these cases. In order to secure the treatment goal of rapid pain-adapted full weight bearing despite reduced bone quality, it was decided to perform a new osteosynthesis with a retrograde femoral nail after removal of some fixation screws of the existing arthrodesis plate. Due to this type of treatment, the preservation of activity and independence of an older trauma patient could be sustainably secured despite operative challenges. Taking an extended osteoporosis treatment into consideration, a bony fracture consolidation and complete convalescence of activity and autonomy were ultimately achieved.

Outcome after surgical treatment of fragility ankle fractures in a certified orthogeriatric trauma center.

INTRODUCTION: Orthogeriatric ankle fractures seem to play an essential role in terms of quality of life in the elderly. Knowledge of the outcome after orthogeriatric ankle fractures is sparse. The present study investigates the outcome after surgically treated ankle fractures at a certified orthogeriatric trauma center. MATERIAL & METHODS: A retrospective observational study was performed investigating the outcome of surgically treated ankle fractures in orthogeriatric patients between 2015-2017. Outcome parameters included but were not limited to the EQ-5D 3 L, Barthel Index, Karlsson Score and the Charlson Comorbidity Index. Housing situation and mobility were evaluated and potential associations to the fracture pattern and the related treatment strategy were investigated. RESULTS: In total, 58 patients were included (age 77.7 ±â€¯6,2 years). The majority were AO-44 B2 fractures (72%). General outcome was related to the Parker score; a Parker Score of 9 prior surgery was independently associated with an improved outcome according to the EQ-5D 3 L and Barthel Index. Patients under 80 years of age also had better results. Place of residence did not significantly change after surgery. Neither different types of implants nor initial use of an external fixator (e.g. open fractures) did influence outcome. A wound healing impairment was found in 10% of our patients whereas the overall unplanned reoperation rate was 7%. Overall complication rate was 20%, one-year mortality was 10%. CONCLUSIONS: Surgically treated ankle fractures in the elderly which are treated in a certified geriatric fracture center seem to have limited negative effect on their quality of life. We did not observe the otherwise often demonstrated high mortality rates, but still nearly half of the patients demonstrated perioperative complications, which emphasizes the need for optimal perioperative care at an orthogeriatric trauma center. Since there was a reasonable number of patients with wound healing issues this study supports the idea of a staged protocol using external fixation with secondary ORIF.

[Injury to the upper limbs and prevention in equestrian sports]. / Verletzungen der oberen Extremität und Prävention im Reitsport.

The upper limb is one of the most frequently injured body regions in equestrian sports, but it is unclear which injuries are involved, and there are no data on the associated accident mechanism. The present study is aimed at evaluating the accident mechanisms, injuries of the upper limbs, and the circumstances of the accident in equestrian sports. We included 218 patients who were all treated between 2006 and 2014 at the level I trauma center at the Medical University in Hannover because of equestrian-related accidents. The most frequent injuries were fractures and bruising in the shoulder area, fingers and hands, and the distal area of the lower arm, which were mostly caused by the horse kicking. To prevent hand injuries it is recommended that gloves are worn; the potential introduction of strengthened materials could protect the bones from severe bumping. Training in falling techniques to prevent serious injury to the upper limb would be useful. In general, primary prevention in equestrian sports should be extended to counteract the increasing neglect of protective equipment.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients.

AIMS: To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. PATIENTS AND METHODS: A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. RESULTS: In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. CONCLUSION: Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60.

[Accidents in equestrian sports : Analysis of injury mechanisms and patterns]. / Unfälle im Reitsport : Analyse von Verletzungsmechanismen und -mustern.

BACKGROUND: Equestrian sports are one of the most popular forms of sport in Germany, while also being one of the most accident-prone sports. Furthermore, riding accidents are frequently associated with a high degree of severity of injuries and mortality. Nevertheless, there are insufficient data regarding incidences, demographics, mechanisms of accidents, injury severity and patterns and outcome of injured persons in amateur equestrian sports. Accordingly, it was the aim of the present study to retrospectively analyze these aspects. METHODS: A total of 503 patients were treated in the emergency room of the Hannover Medical School because of an accident during recreational horse riding between 2006 and 2011. The female gender was predominantly affected with 89.5 %. The mean age of the patients was 26.2 ± 14.9 years and women (24.5 ± 12.5 years) were on average younger than men (40.2 ± 23.9 years). A special risk group was girls and young women aged between 10 and 39 years. The overall injury severity was measured using the injury severity score (ISS). RESULTS: Based on the total population, head injuries were the most common location of injuries with 17.3 % followed by injuries to the upper extremities with 15.2 % and the thoracic and lumbar spine with 10.9 %. The three most common injury locations after falling from a horse were the head (17.5 %), the upper extremities (17.4 %), the thoracic and lumbar spine (12.9 %). The most frequent injuries while handling horses were foot injuries (17.2 %), followed by head (16.6 %) and mid-facial injuries (15.0 %). With respect to the mechanism of injury accidents while riding were predominant (74 %), while accidents when handling horses accounted for only 26 %. The median ISS was 9.8 points. The proportion of multiple trauma patients (ISS > 16) was 18.1 %. Based on the total sample, the average in-hospital patient stay was 5.3 ± 5.4 days with a significantly higher proportion of hospitalized patients in the group of riding accidents. Fatal cases were not found in this study but the danger of riding is not to be underestimated. The large number of sometimes severe injuries with ISS values up to 62 points can be interpreted as an indication that recreational riding can easily result in life-threatening situations. CONCLUSION: Girls and young women could be identified as a group at particular risk. It has been demonstrated in this study that the three most common injury locations after falling from a horse were the head, the upper extremities, the thoracic and lumbar spine. The most frequent injury locations while handling horses were foot injuries, followed by head and mid-facial injuries.

[Cervical spine injury in equestrian sports]. / Halswirbelsäulenverletzungen im Breitenreitsport.

The cervical spine is considered fragile and vulnerable to injuries in equestrian sport. This retrospective study investigates the injury pattern and severity. Patients of the medical university in Hannover from the years 2006-2011, who had an equestrian accident, were identified. Patients who had been injured in the course of their work were excluded. Results counted with a p-value < 0.05 were considered significant. In 13.1% of patients, there were 71 cervical spine injuries (92.4% female; 7.6% male). The mean age was 27.1 ± 13.2 years. Of these, 86.4% associated the injury to the riding accident. In 56 cases, it concerned falls from the horse. In 13.6% of the cases, the injury was caused while handling the horse. Sprains were most common (70.4%). Fractures of the neck vertebrae were found in 22.5% of the cases. The mean ISS was 7.0 ± 5.8 pts. Polytrauma was identified in 6.1% of patients (ISS ≥ 16 Pkt). The most common accompanying injury presented was an injury to the head (29.2%; p = 0.003). Of the 30 hospitalized patients, 13.3% were admitted to intensive medical care for 2.3 ± 15.4 d. The mortality was 0%. Injuries of the cervical spine are not to be underestimated in their frequency and severity. It is shown that, especially with injuries of the head and thoracic and lumbar spine area, patients are at increased risk of concurrent cervical lesions. The prevention of neck injuries is currently done in the form of riding helmets, airbag jackets, riding behavior and education. Further study of the prevention of neck injuries is required.

A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing.

OBJECTIVE: Negative pressure wound therapy (NPWT) has become an established treatment of traumatic and infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a further development that combines the conventional NPWT with instillation of different fluids which continuously administer therapeutic reagents to the wound. The aim of this study was to compare the impact of additional saline instillation in NPWTi to NPWT alone. METHOD: Between January and July 2014, consecutive patients with acute wounds of the lower limb were treated with NPWTi with saline instillation. The number of revision surgeries, length of hospital stay, and duration of treatment until final healing were recorded and compared with matched patients undergoing NPWT without instillation. RESULTS: There were 10 patients recruited with 10 matched controls examined restrospectivley. Patients who received NPWTi were found to have decreased time of hospitalisation (21.5 versus 26.5 days, p=0.43), and accelerated wound healing (9.0 versus 12.5 days, p=0.36) than patients who received NPWT. However, the difference in the outcomes of the patients who received NPWTi and patients who received NPWT was not found to be statisticallly significant. CONCLUSION: NPWTi with instillation of saline is a promising method and its effectiveness needs to be tested in a randomised controlled trial compared with NPWT alone. DECLARATION OF INTEREST: This study obtained support by KCI (Wiebsaden, Germany) for the surgical material.

Is there a benefit for health care workers in testing HIV, HCV and HBV in routine before elective arthroplasty?

INTRODUCTION: Occupational infection of clinical health care workers with blood-borne viruses (BBVs) like human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) is a current and often emotionally discussed issue. HCV and especially HIV are still stigmatized. The consequence is a broad and maybe irrational fear of professional health care workers being infected occupationally. Therefore, we assessed preoperative screening to: (1) answer whether this can detect not previously diagnosed blood-borne virus infections to a great extent, (2) calculate a cost-benefit ratio to find out, if the screening's potential ability to prevent occupational transmission of BBVs to health care workers faces unjustifiable high costs. HYPOTHESIS: Preoperative routine screening is limited suitable for enhancement of detecting fomites compared to interview the patient. MATERIALS AND METHODS: Retrospective cohort study of preoperative screening for HIV, HBV and HCV (HBsAg, anti-HCV and HIV-Ab/Ag-Combination) for every patient who was admitted to the traumatologic department for elective arthroplasty between 01/01/1997 and 31/12/2008. RESULTS: Among the 1534 patients who underwent elective prosthetic surgery [total hip (879) and knee arthroplasty (508), followed by shoulder, elbow and upper ankle joint], 693 (45.2%) patients were male and 841 (54.8) female. Mean age was 64.2±13.8 years. Screening tests were available for 1373 patients (89.5%). Among all screened patients, we found 21 HCV, 10 HBV and 1 HIV infections. 5 HBV (0.5%) and 7 HCV infections (0.7%) were unknown before. Every newly detected infectious patient occasions screening costs about 7250€. Considering this data, the risk of HCV transmission from an index patient with unknown status of infectiousness to health care worker after percutaneous contact to blood is 0.08 ‰ and of HIV transmission is 0.00054 ‰ in our study population. DISCUSSION: Routine preoperative screening for BBVs of patients undergoing elective arthroplasty, who were asked for HBV, HCV and HIV, should be reconsidered and is, in times of sparse funds, overpriced. LEVEL OF EVIDENCE: IV.

Kinetic therapy in multiple trauma patients with severe blunt chest trauma: an analysis at a level-1 trauma center.

BACKGROUND AND OBJECTIVES: Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. METHODS: A retrospective analysis (2000-2009) of polytrauma patients (age > 16 years, ISS ⩾ 16) with severe chest trauma (AIS(Chest) ⩾ 3) was performed. Patients with AIS(Head) ⩾ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS(Chest), Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. RESULTS: Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS(Chest), age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. CONCLUSIONS: Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS(Chest), but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.

[Abdominal wall injury - risk of seat belt use]. / Bauchwandzerreißung - Risiko Sicherheitsgurt?

Abdominal seat belt marks can be an indication of abdominal wall rupture. The focused assessment with sonography for trauma (FAST) and computed tomography (CT) scanning are the diagnostic tools of choice in hemodynamically stable patients. The typical mechanism of trauma frequently leads to additional intra-abdominal injuries, spinal injuries and in some cases aortic rupture. Abdominal wall injuries of grade IV according to Dennis should be surgically treated. The increasing numbers of obese vehicle occupants and the resulting special risk of injury warrant optimization of technical restraint systems.

Effects of accidental hypothermia on posttraumatic complications and outcome in multiple trauma patients.

INTRODUCTION: Accidental hypothermia seems to predispose multiple trauma patients to the development of posttraumatic complications, such as Systemic Inflammatory Response Syndrome (SIRS), sepsis, Multiple Organ Dysfunction Syndrome (MODS), and increased mortality. However, the role of accidental hypothermia as an independent prognostic factor is controversially discussed. The aim of the present study was to evaluate the incidence of accidental hypothermia in multiple trauma patients and its effects on the development of posttraumatic complications and mortality. PATIENTS AND METHODS: Inclusion criteria for patients in this retrospective study (2005-2009) were an Injury Severity Score (ISS) ≥16, age ≥16 years, admission to our Level I trauma centre within 6h after the accident. Accidental hypothermia was defined as body temperature less than 35°C measured within 2 h after admission, but always before first surgical procedure in the operation theatre. The association between accidental hypothermia and the development of posttraumatic complications as well as mortality was investigated. Statistical analysis was performed with χ(2)-test, Student's t-test, ANOVA and logistic regression. Statistical significance was considered at p<0.05. RESULTS: 310 multiple trauma patients were enrolled in the present study. Patients' mean age was 41.9 (SD 17.5) years, the mean injury severity score was 29.7 (SD 10.2). The overall incidence of accidental hypothermia was 36.8%. The overall incidence of posttraumatic complications was 77.4% (SIRS), 42.9% (sepsis) and 7.4% (MODS), respectively. No association was shown between accidental hypothermia and the development of posttraumatic complications. Overall, 8.7% died during the posttraumatic course. Despite an increased mortality rate in hypothermic patients, hypothermia failed to be an independent risk factor for mortality in multivariate analysis. CONCLUSIONS: Accidental hypothermia is very common in multiply injured patients. However, it could be assumed that the increase of mortality in hypothermic patients is primarily caused by the injury severity and does not reflect an independent adverse effect of hypothermia. Furthermore, hypothermia was not shown to be an independent risk factor for posttraumatic complications.

Haematogenous abdominal wall metastasis of differentiated, alpha-fetoprotein-negative hepatocellular carcinoma after previous antiandrogen therapy within a site of lipoma manifestation since childhood.

BACKGROUND: Cases with subcutaneous metastasis of differentiated hepatocellular carcinoma to the abdominal wall without prior seeding as a consequence of local interventions with a negative or normal alpha-fetoprotein level in the serum are extremely rare. CASE REPORT: This is the first report of a case with AFP-negative, differentiated hepatocellular carcinoma metastasis to the abdominal wall within a pre-existing subcutaneous lipoma since childhood after antiandrogen therapy with leuprorelin and buserelin acetate for prostate cancer without seeding. METHODS: Clinical features including histology, immunohistochemistry, clinical course and surgical approach are presented. RESULTS: Histological examination revealed a hepatocellular carcinoma with a trabecular and pseudoglandular growth pattern with moderately atypical hepatocytes with multifocal bile formation within a lipoma. The postoperative course of abdominal wall reconstruction with a monocryl-prolene mesh and a local flap after potentially curative resection was uncomplicated. DISCUSSION AND CONCLUSION: It may be that previous antiandrogen treatment for prostate carcinoma contributed to the fact that our patient developed alpha-fetoprotein-negative and androgen receptor-negative subcutaneous abdominal wall metastasis within a pre-existing lipoma since childhood.

Systemic inflammatory effects of traumatic brain injury, femur fracture, and shock: an experimental murine polytrauma model.

OBJECTIVE: Despite broad research in neurotrauma and shock, little is known on systemic inflammatory effects of the clinically most relevant combined polytrauma. Experimental investigation in an animal model may provide relevant insight for therapeutic strategies. We describe the effects of a combined injury with respect to lymphocyte population and cytokine activation. METHODS: 45 male C57BL/6J mice (mean weight 27 g) were anesthetized with ketamine/xylazine. Animals were subjected to a weight drop closed traumatic brain injury (WD-TBI), a femoral fracture and hemorrhagic shock (FX-SH). Animals were subdivided into WD-TBI, FX-SH and combined trauma (CO-TX) groups. Subjects were sacrificed at 96 h. Blood was analysed for cytokines and by flow cytometry for lymphocyte populations. RESULTS: Mortality was 8%, 13% and 47% for FX-SH, WD-TBI and CO-TX groups (P < 0.05). TNFα (11/13/139 for FX-SH/WD-TBI/CO-TX; P < 0.05), CCL2 (78/96/227; P < 0.05) and IL-6 (16/48/281; P = 0.05) showed significant increases in the CO-TX group. Lymphocyte populations results for FX-SH, WD-TBI and CO-TX were: CD-4 (31/21/22; P = n.s.), CD-8 (7/28/34, P < 0.05), CD-4-CD-8 (11/12/18; P = n.s.), CD-56 (36/7/8; P < 0.05). CONCLUSION: This study shows that a combination of closed TBI and femur-fracture/ shock results in an increase of the humoral inflammation. More attention to combined injury models in inflammation research is indicated.

Effects of trauma-hemorrhage and IL-6 deficiency on splenic immune function in a murine trauma model.

Splenic immune function is known to be depressed following hemorrhage. The present study investigates the effects of femoral shaft fracture, isolated or in combination with hemorrhage, on early stage cytokine production capacity of splenocytes and observes the role of IL-6 under these conditions. Male IL-6 knockout (IL-6(-/-)) and wild-type mice (WT) were randomly divided into three groups: sham (S), isolated femoral fracture (Fx), and femoral fracture + volume controlled hemorrhage (TH-Fx) (n = 6 per group). Animals were sacrificed four hours after induction of hemorrhage and fracture. Cytokine release (TNF-α, IL-6, and IL-10) of isolated and LPS-stimulated splenocytes was determined by cytometric bead array. Femoral fracture with or without hemorrhage caused a suppression of in vitro cytokine production capacity of splenocytes at an early posttraumatic stage in WT and IL-6(-/-). In the absence of IL-6, the profile of splenic cytokine secretion is significantly altered, identifying this cytokine as a potential therapeutic target to modulate the posttraumatic immune response.

[Accidental hypothermia in multiple trauma patients]. / Akzidentelle Hypothermie beim Polytrauma.

BACKGROUND: Hypothermia, defined as a body core temperature below 35 °C, could be divided into an endogeneous, therapeutic and accidental hypothermia. At admission in the emergency room multiple trauma patients show a hypothermic core temperature in up to 66 %. A core temperature below 34 °C seems to be critical in these patients as this temperature limit has been demonstrated to be associated with an increased risk for post-traumatic complications and a decreased survival. In polytraumatised patients with a core temperature below 32 °C a mortality rate of 100 % has been described. MATERIAL AND METHODS: The main pathophysiological effects of hypothermia concern the haemo-dynamic, coagulatory and immune systems. Mild hypothermia (35-32 °C) leads to a vasoconstriction, tachycardia and increased cardiac output. After an increasing arrhythmia and bradycardia severe hypothermia (< 32 °C) finally results in a cardiac arrest. Hypothermia-induced coagulopathy comprises a dysfunction of the cellular and plasmatic coagulation with an increased blood loss. Due to the attenuation of the post-traumatic, pro-inflammatory immune response and enhancement of anti-inflammatory reactions, hypothermia counteracts an overwhelming systemic inflammation, concomitantly resulting in an increased susceptibility for infectious complications. RESULTS: Because of the negative effects of the -accidental hypothermia, effective rewarming is essential for adequate bleeding control and successful resuscitation. As aggressive rewarming (> 0.5 °C / h) has been reported to be associated with an increased mortality during the further course, this procedure should only be applied in hypothermic multiple trauma patients with haemorrhagic shock. CONCLUSION: Accidental hypothermia represents a serious problem in multiple trauma patients due to its frequency and negative pathophysiological effects. Therefore, early and effective re-warm-ing is essential in the treatment of hypothermic trauma patients. Possible protective effects of a therapeutic hypothermia in the treatment of trauma patients after initial resuscitation and operative bleeding control have to be clarified in further experimental and clinical studies.