Evaluation of two different semi-automated homogenization techniques in microbiological diagnosis of periprosthetic joint infection: disperser vs. bead milling method.

BACKGROUND: In microbiological diagnosis of periprosthetic joint infection (PJI) there is no consensus regarding the most suitable and optimal number of specimens to be cultured or the most effective technique of tissue processing. This comparative study analysed the accuracy of two semi-automated homogenization methods with special focus on the volume and exact origin of each sample. METHODS: We investigated a total of 722 periprosthetic tissue samples. PJI was defined according to the new scoring system for preoperative and intraoperative criteria. We compared the performance of our routinely used single tissue processing by disposable high-frequency disperser with the bead milling method. RESULTS: Eighty patients were included. Among forty classified PJIs, 34 patients yielded positive culture results. In 23 cases (68%) exact concordant results were generated with both techniques. However, in seven cases (20%) processing by the disperser and in four cases (12%) by bead milling provided additional positive samples, but without significant difference since the major definition criteria were met in all cases. The percentage of positive results was influenced by the volume and origin of the tissue samples. Results for small tissue samples tended to be better using the bead milling method. This might lead to improved preoperative arthroscopic diagnosis, as the volume of biopsies is generally limited. Six patients had negative results due to previous antimicrobial therapy. Forty other patients were classified as aseptic failures. Neither procedure resulted in any contamination. CONCLUSION: Both methods enable reliable processing of tissue samples for diagnosis of PJI and are suitable for routine use.

Standards for external fixation application: national survey under the auspices of the German Trauma Society.

INTRODUCTION: External fixation is widely accepted as a provisional or sometimes definitive treatment for long-bone fractures. Indications include but are not limited to damage control surgery in poly-traumatized patients as well as provisional bridging to definite treatment with soft tissue at risk. As little is known about surgeon's habits in applying this treatment strategy, we performed a national survey. METHODS: We utilized the member database of the German Trauma Society (DGU). The questionnaire encompassed 15 questions that addresses topics including participants' position, experience, workplace, and questions regarding specifics of external fixation application in different anatomical regions. Furthermore, we compared differences between trauma centre levels and surgeon-related factors. RESULTS: The participants predominantly worked in level 1 trauma centres (42.7%) and were employed as attendings (54.7%). There was widespread consensus for planning and intra-operative radiographical control of external fixation. Surgeons appointed at a level I trauma centre preferred significantly more often supra-acetabular pin placement in external fixation of the pelvis rather than the utilization of iliac pins (75.8%, p = 0.0001). Moreover, they were more likely to favor a mini-open approach to insert humeral pins (42.4%, p = 0.003). Overall, blunt dissection and mini-open approaches seemed equally popular (38.2 and 34.1%). Department chairmen indicated more often than their colleagues to follow written pin-care protocols for minimization of infection (16.7%, p = 0.003). CONCLUSION: Despite the fact that external fixation usage is widespread and well established among trauma surgeons in Germany, there are substantial differences in the method of application.

Return to Sports After Multiple Trauma: Which Factors Are Responsible?-Results From a 17-Year Follow-up.

OBJECTIVE: We hypothesize that the majority of polytraumatised patients are unable to maintain their preinjury level of sporting activity, and that musculoskeletal injuries are a major contributing factor. We assessed the impact of such injuries on sporting prowess, with a focus on isolating, particularly debilitating musculoskeletal trauma. METHODS: We conducted a cohort study of 637 patients at a level 1 trauma centre, to assess the long-term outcome of severe trauma on return to sporting activities (RTS). Data collated on the multiply injured patient included preinjury physical activity, standardized outcome scores (SF-12, GOS, HASPOC), and clinical follow-up of at least 10 years duration. The return to preinjury sports participation was defined as a primary outcome parameter. Regression analyses were performed to identify specific injuries interfering with the RTS. STUDY DESIGN: Prognostic study; Level of evidence, II. RESULTS: Mean follow-up was 17 ± 5 years. We included 465 patients, including 207 athletic and 258 nonathletic individuals. Mean age at the time of injury was 26 ± 11.5 years and injury severity was comparable between the 2 cohorts. The deleterious effects on quality of life and the total duration of the rehabilitation process were also similar in athletes and nonathletes. Athletes were more likely to be unable to return to preinjury activities, or to return to a lower level of sporting prowess posttrauma. We identified knee injuries as the type of musculoskeletal trauma most likely to be career ending for the athlete (odds ratio 3.4, 95% confidence interval, 1.4-8.3; P = 0.008). CONCLUSION: Our results demonstrate an enforced shift from high-impact and team sports to low-impact activities after multiple trauma. Injuries of the lower extremities, especially around the knee joint, seem to have the highest lifechanging potential, preventing individuals from returning to their previous sporting activities.

Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient: Case Report and Review of the Literature.

BACKGROUND: Life-threatening arterial bleeding from fragility fractures of the pelvis are very rare but associated with significant mortality, especially in anticoagulated patients. CASE DESCRIPTION: We report the successful interdisciplinary management of a 78-year-old woman under anticoagulation and antiplatelet therapy who had life-threatening arterial hemorrhage from the pubic rami following a fragility fracture of the pelvis. Our management strategy included early hemorrhage control by means of selective arterial embolization followed by surgical fracture stabilization and surgical hematoma evacuation. LITERATURE REVIEW: We identified 6 cases within the English literature, all involving females older than 70 years. All patients under anticoagulation developed hemorrhagic shock, and in 2 cases selective embolization contributed to survival of the patient. However, a combined management including fracture stabilization and hematoma evacuation has not been reported, allowing an excellent clinical outcome and discharge to geriatric rehabilitation. CLINICAL RELEVANCE: This case illustrates that elderly patients with apparently benign pelvic fragility fractures might develop severe hemorrhage due to arterial injury, especially when under dual anticoagulation, and stresses the importance of a high index of suspicion. If bleeding is suspected, detailed imaging studies are necessary to determine the source of bleeding and immediate angiographic or surgical interventions in combination with volume resuscitation and coagulation therapy should be readily available.

Classification of soft-tissue injuries in open femur fractures: Relevant for systemic complications?

BACKGROUND: A broad range of systemic complications has been described to occur in patients with open major fractures. Various causes have been claimed to play a role. We therefore surveyed a nationwide trauma registry to assess risk factors associated with closed and various types of open femur fractures. METHODS: This was a cohort study in a nationwide population-based prospective database. Inclusion criteria for selection from database are as follows: individuals with femur fracture, age 16 years or older, and survival until primary admission. Main groups included closed and open femur fracture. Patient demographics, injury severity (New Injury Severity Score), surgical fracture management, length of stay, and systemic complications (e.g., multiple organ failure [MOF], sepsis, mortality) were collected and statistically analyzed using SPSS statistics. Multivariate regression analysis was performed to stratify subgroups for the degree of open soft-tissue injury according to Gustilo and Anderson. RESULTS: Among 32,582 documented trauma victims (January 1, 2002, to December 31, 2010), a total of 5,761 met the inclusion criteria. Main groups: 4,423 closed (76.8%) and 1,338 open femur fractures (23.2%). Open fractures subgroups were divided into I° (334, 28.1%), II° (526, 44.3%), and III° (328, 27.6%). Open fractures were associated with an increased risk of prehospital hemorrhagic shock (p = 0.01), higher resuscitation requirements (p < 0.001), MOF (p = 0.001), and longer in-hospital (p < 0.001) and intensive care stay (p = 0.001). While New Injury Severity Score values showed a minor increase per subgroup, the prevalence of MOF, sepsis, and mortality multiplied with the degree of open soft-tissue injury. Especially patients with Type III open femur fractures received mass transfusions (28.2%, p < 0.001), and mass transfusions were identified as independent predictor for sepsis (odds ratio [OR], 2.393; 95% confidence interval [CI], 1.821-3.143; p < 0.001) and MOF (OR, 2.966; 95% CI, 2.409-3.651; p < 0.001). Our data also indicate an increased mortality in patients with open femur managed outside Level I trauma centers (OR, 1.358; 95% CI, 1.018-1.812; p = 0.037). CONCLUSION: Open femur fractures are associated with higher in-hospital complications related to incidence of MOF, associated intensive care unit stay, and hospital days when compared with closed femur fractures. For prevention of in-hospital complications, prompt hemorrhage control, surgical fracture fixation, cautious blood management, and triage to a Level I trauma center must be considered. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level II.

Assessment of pelvic injuries treated with ilio-sacral screws: injury severity and accuracy of screw positioning.

PURPOSE: The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement. METHODS: Cohort study, level I trauma centre. INCLUSION CRITERIA: (1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement. EXCLUSION CRITERIA: (1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2 mm; grade 2, perforation from 2 to 4 mm; grade 3, ≥4 mm perforation. RESULTS: Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4 years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6 % (120) were placed satisfactory (<2 mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1 % vs single screw 7.0 %; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred. CONCLUSIONS: We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.

Collagen Type I Conduits for the Regeneration of Nerve Defects.

To date, reliable data to support the general use of biodegradable materials for bridging nerve defects are still scarce. We present the outcome of nerve regeneration following type I collagen conduit nerve repair in patients with large-diameter nerve gaps. Ten patients underwent nerve repair using a type I collagen nerve conduit. Patients were re-examined at a minimal follow-up of 14.0 months and a mean follow-up of 19.9 months. Regeneration of nerve tissue within the conduits was assessed by nerve conduction velocity (NCV), a static two-point discrimination (S2PD) test, and as disability of arm shoulder and hand (DASH) outcome measure scoring. Quality of life measures including patients' perceived satisfaction and residual pain were evaluated using a visual analog scale (VAS). No implant-related complications were observed. Seven out of 10 patients reported being free of pain, and the mean VAS was 1.1. The mean DASH score was 17.0. The S2PD was below 6 mm in 40%, between 6 and 10 mm in another 40% and above 10 mm in 20% of the patients. Eight out of 10 patients were satisfied with the procedure and would undergo surgery again. Early treatment correlated with lower DASH score levels. The use of type I collagen in large-diameter gaps in young patients and early treatment presented superior functional outcomes.

Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion.

External fixation has become an important tool in orthopedic surgery. Technology has improved the design and material as well as the construct of the fixator. As most patients are converted from external fixation to definite stabilization during later clinical course, prevention of complications such as infection is of high importance. Based on the current literature, principles of temporary external fixation were summarized. We focused on minimizing the risk of infection and introduce a standardized algorithm how to proceed when converting from external to internal fixation, which also was examined for effectiveness.

Fracture of the lesser trochanter as a sign of undiagnosed tumor disease in adults.

Isolated avulsion fractures of the pelvic ring are rare and occur predominantly in adolescent athletes. Isolated fractures of the lesser trochanter are reported to be pathognomic for tumor diseases in adults. We present a case of a female patient with an isolated avulsion of the lesser trochanter after treatment by her chiropractor. After staging examination, we determine the diagnosis of a left-sided carcinoma of the mamma. Additional imaging shows multiple metastases in liver, spine and pelvis. Palliative therapy has started over the course of time. We suggest, on suspicion of a malignant metastatic process, further investigation.

Plate osteosynthesis versus hemiarthroplasty in proximal humerus fractures--does routine screening of systemic inflammatory biomarkers makes sense?

BACKGROUND: Increases in C-reactive protein (CRP) and white blood cell (WBC) counts after orthopedic surgical procedures can give evidence of postoperative infection. However, there is a lack of knowledge about the kinetics of these biomarkers in cases with an uneventful clinical course after osteosynthesis of upper limb fractures. This study investigated CRP and WBC serum levels after osteosynthesis or hemiarthroplasty of humeral head fractures. METHODS: A retrospective study on patients with humeral head fractures who had open reduction and internal fixation via plate osteosynthesis (PO) (n = 64) or hemiarthroplasty (HA) (n = 28) without any complications in the postoperative clinical course. C-reactive protein serum levels (mg/l) and leukocyte counts (g/l) were assayed at several time points. Multiple regression analysis was performed to evaluate the influence of several confounding variables (the surgical procedure, duration of surgery, patient's health status, and comorbidities) on the kinetics of CRP and WBC. RESULTS: Our data showed that CRP levels were statistically significantly higher in the HA cohort when compared to the PO cohort (p = 0.003). Moreover, daily measurement of CRP levels during the postoperative course showed that CRP peaked on the 2nd and 3rd days postoperatively in both cohorts and started to decrease afterward, reaching normal values on day 8 to 10. However, WBCs did not show any significant differences between the HA and PO cohorts. Finally, the choice of surgical procedure and the patient's health status were associated with higher peak levels of CRP. CONCLUSIONS: After osteosynthesis or hemiarthroplasty of humeral head fractures, CRP is a responsive serum parameter in the postoperative course of an uneventful inflammatory response. Abnormalities from these values should be interpreted carefully as they may give a hint as to postoperative complications such as infection.

Is percutaneous suturing superior to open fibrin gluing in acute Achilles tendon rupture?

PURPOSE: Open fibrin gluing is reported to enable anatomical reconstruction with less soft tissue compromise than suture repair. Our main objective was to compare the complication rate, function, pain and disability of the two operative approaches of percutaneous suture using the Paessler technique and open fibrin gluing. METHODS: Sixty-four patients (two centres, retrospective cohort study, 2000-2009) who had undergone acute Achilles tendon repair with either percutaneous suture (n = 27; 44 years) or open fibrin glue (n = 37; 45 years) took part in a follow-up examination after a median of 63 months (range, six to 180). Ankle range of motion, calf and ankle circumferences and return to work and sports activities were evaluated. Isokinetic und sonographic evaluation results were retrieved. RESULTS: Complications were noted in 22 patients (34 %). Delayed wound healing without evidence of surgical site infection was found in three patients in the fibrin group and two patients in the suture group. Postoperative scar tenderness described as pain at the rim of the shoe was significantly more frequent in the suture group (p = 0.03). Re-rupture requiring re-operation occurred in one patient. Transient paresthesia of the heel occurred in 12 patients. No sural nerve lesions were reported. There was no significant difference between groups regarding lower leg circumference, disability, or function. Ultrasound and isokinetic measurements did not reveal a significant difference between the two methods. CONCLUSIONS: The present study suggests that open fibrin gluing is a reasonable alternative to percutaneous repair of acute ruptures of the Achilles tendon and both techniques can yield reliably good results.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Percutaneous screw placement in acetabular posterior column surgery: gender differences in implant positioning.

Percutaneous reduction and periarticular screw implantation techniques have been successfully introduced in acetabular surgery. Image guided navigation techniques might be beneficial in increasing accuracy. However, a thorough understanding of standard values is needed to oversee pitfalls. This cadaver study was designed to identify reliable angulation values for screw implantation in the posterior acetabular column and to provide knowledge of the bony thickness for the periarticular corridor. Gender differences were specifically addressed. 27 embalmed cadaveric hemipelvic specimens (13 male, 14 female) were used. After soft-tissue removal posterior column acetabular screw placement was conducted by one experienced orthopaedic trauma surgeon under visibility. Radiographic verification of ideal screw placement was followed by radiographic assessment in three standard views and angulation values were assessed. Through bony dissection the maximal periarticular canal width was assessed. Various angulation values with regard to anatomical landmarks could be determined in the anteroposterior radiograph, as well as in the iliac oblique and the obturator oblique view. Gender differences were significant for all reference points with the pubic rami involved. The minimal canal width was 1.1cm in female and 1.6 cm in male specimen. The findings provide standard values for safe passages in percutaneous posterior column acetabular surgery. Gender differences have to be taken in consideration when planning the drill corridor. By adherence to standard values, screw placement can be performed safely.

Risk stratification by injury distribution in polytrauma patients - does the clavicular fracture play a role?

BACKGROUND: Thoracic and extremity injuries are common in polytraumatized patients. The clavicle limits the upper thoracic cage and connects the body and upper extremities. It is easy to examine and is visible on standard emergency room radiographs. We hypothesize that clavicular fracture in polytrauma patients indicates the presence of further injuries of the upper extremities, head, neck and thorax. MATERIAL AND METHODS: Retrospective study including patients admitted between 2008 and 2012 to a level-I trauma center. INCLUSION CRITERIA: ISS > 16, two or more injured body regions, clavicular fracture. CONTROL GROUP: patients admitted in 2011, ISS > 16, two or more injured body regions, no clavicular fracture. Patient information was obtained from the patients' charts; evaluation of radiographic findings was performed; scoring was based on the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) AIS/ISS; data were analyzed using Pearson's correlation and the Mann-Whitney U-test in SPSS (version 11.5.1); graphs were drawn using EXCEL®. RESULTS: Thirty-four patients with clavicular fracture (C+) and 40 without (C-) were included; the mean ISS was 25 (range 16-57), m = 70%, f = 30%; age 43.3 years (range 9-88); clavicular fractures were positively correlated with severe thoracic (p = 0.011, OR 4.5: KI 1.3-15.3), external (p < 0.001, OR 9.2: KI 2.7-30.9) and upper extremity injuries (p < 0.001, OR 33.2: KI 6.9-16.04 resp. p = 0.004, OR 12.5: KI 1.5-102.9). C + showed a lower head/neck AIS (p = 0.033), higher thorax AIS (p = 0.04), arm/shoulder AIS (p = 0.001) and external AIS (0.003) than C-. Mean hospital stay and ICU treatment time were longer in the C + group (p = 0.001 and p = 0.025 respectively). CONCLUSION: A clavicular fracture can be diagnosed easily and may be used as a pointer for further thoracic and upper extremity injuries in polytrauma patients that might have been otherwise missed. Special attention should be paid on second and tertiary survey.

Operative treatment of acute acromioclavicular joint injuries graded Rockwood III and IV: risks and benefits in tight rope technique vs. k-wire fixation.

BACKGROUND: Operative treatment of acromioclavicular joint injuries is recommended for higher degree dislocations. Recently a new option has become available with the minimally-invasive tight rope technique. Whereas clinical studies justify the medical use, risks and benefits remain unclear. Therefore, this study analyzed these facts associated with this procedure and compared them to K-wire fixation. MATERIAL AND METHODS: A retrospective analysis was performed of patients surgically treated either with the TightRope™-technique (TR) or K-wires (KW) for a first event isolated Rockwood type III or higher acromioclavicular joint dislocation between 2004 and 2011. Timing for surgery, surgical duration, length of hospital stay, costs, complications and outpatient visits were recorded. RESULTS: 41 patients were included (TR: n = 18; KW: n = 23) with comparable demographics and injury severity. A trend towards shorter operation time was seen in the TR group (TR: 64.3 ±19.8 min. vs. KW: 80.9 ±33.7 min., n.s.) A tendency for lower total operation theater costs was seen in the TR group (TR: 474 ±436.5€ vs. KW: 749.1 ±31.2€, n.s.). Patients from the TR group left hospital earlier (TR: 2 ±1d vs. KW: 3.6 ±1.8d, p = 0.002). Severe complications (i.e. a fracture of the clavicle or nerve damage) occurred in neither of the groups. Early loss of reduction (n = 1) and impaired wound healing (n = 2) was seen in the TR group. Migrating K-wires (n = 4), loss of reduction (n = 1) and impingement syndrome (n = 1) were recorded in the KW group. CONCLUSION: Usage of the tight rope technique offered advantages, such as being a safe minimally-invasive technique and showed a tendency towards shorter operation time, and lower physician- and total operation and theater costs. Material costs were significantly higher for this device but patients were discharged earlier. The influence of different clinical long-term results on the financial outcome needs to be evaluated in further studies.

Trauma care in Germany: an inclusive system.

BACKGROUND: Development of trauma systems is a demanding process. The United States and Germany both have sophisticated trauma systems. This manuscript is a summary of political, economic, and medical changes that have led to the development of both trauma systems and the current high-quality standards. QUESTIONS/PURPOSES: We specifically asked three questions: (1) What tasks are involved in developing a modern trauma system? (2) What is the approach to achieve this task? (3) Do these systems work? METHODS: We conducted a systematic review of relevant articles by searching electronic databases (PubMed, Embase, Cochrane library) using the following search terms: "trauma system", "polytrauma", "trauma networks", and "trauma registry". Of 2573 retrieved manuscripts, the authors made a personal selection of studies. A personal study selection from our experiences was added when their contribution to the topic was judged important. RESULTS: Worldwide, similar tasks concerning trauma care have to be addressed. In most societies, traffic accidents and firearm-related injuries contribute to a high number of trauma victims. The German approach has been to decrease the number of accidents through injury prevention and to provide better care by establishing an emergency medical system. For in-hospital treatment, clinical care has constantly improved and a close interaction with members from the American Association for the Surgery of Trauma and the Orthopaedic Trauma Association has helped a great deal to achieve these improvements. The German healthcare system was developed as a powerful healthcare tool covering patients from injury to rehabilitation. In addition, trauma and injury research has been strengthened to deal with various questions of trauma care. CONCLUSIONS: Organized injury prevention programs and systematized professional patient care can address the issues associated with the global burden of trauma. These trauma systems require constant monitoring and improvement.

Type I collagen nerve conduits for median nerve repairs in the forearm.

PURPOSE: To evaluate patients with median nerve damage in the distal forearm treated with type 1 collagen nerve conduits. METHODS: Nine patients with damage to the median nerve in the distal forearm underwent treatment with a type 1 collagen nerve conduit. The nerve gaps ranged between 1 and 2 cm. An independent observer reexamined patients after treatment at a minimal follow-up of 14 months and a mean follow-up of 21 months. Residual pain was evaluated using a visual analog scale. Functional outcome was quantified by assessing static 2-point discrimination, nerve conduction velocity relative to the uninjured limb, and Disabilities of the Arm, Shoulder, and Hand outcome measure scoring. We also recorded quality of life measures including patients' perceived satisfaction with the results and return to work latency. RESULTS: We observed no implant-related complications. Of 9 patients, 7 were free of pain, and the mean visual analog scale was 0.6. The mean Disabilities of the Arm, Shoulder, and Hand score was 6. The static 2-point discrimination was less than 6 mm in 3 patients, between 6 and 10 mm in 4 patients, and over 10 mm in 2 patients. Six patients reached a status of M4 or higher. Eight patients were satisfied with the procedure and would undergo surgery again. CONCLUSIONS: This study indicates that purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Stem cell-based tissue-engineering for treatment of meniscal tears in the avascular zone.

Meniscal tears in the avascular zone have a poor self-healing potential, however partial meniscectomy predisposes the knee for early osteoarthritis. Tissue engineering with mesenchymal stem cells and a hyaluronan collagen based scaffold is a promising approach to repair meniscal tears in the avascular zone. 4 mm longitudinal meniscal tears in the avascular zone of lateral menisci of New Zealand White Rabbits were performed. The defect was left empty, sutured with a 5-0 suture or filled with a hyaluronan/collagen composite matrix without cells, with platelet rich plasma or with autologous mesenchymal stem cells. Matrices with stem cells were in part precultured in chondrogenic medium for 14 days prior to the implantation. Menisci were harvested at 6 and 12 weeks. The developed repair tissue was analyzed macroscopically, histologically and biomechanically. Untreated defects, defects treated with suture alone, with cell-free or with platelet rich plasma seeded implants showed a muted fibrous healing response. The implantation of stem cell-matrix constructs initiated fibrocartilage-like repair tissue, with better integration and biomechanical properties in the precultured stem cell-matrix group. A hyaluronan-collagen based composite scaffold seeded with mesenchymal stem cells is more effective in the repair avascular meniscal tear with stable meniscus-like tissue and to restore the native meniscus.

A minimally invasive approach for total hip arthroplasty does not diminish early post-operative outcome in obese patients: a prospective, randomised trial.

PURPOSE: The benefits of minimally invasive surgical techniques in total hip arthroplasty (THA) are well known, but concerns about applying those techniques in obese patients are controversial. We prospectively compared patients with increased body mass index (BMI ≥ 30) undergoing THA with normal weight patients. METHODS: A total of 134 patients admitted for unilateral THA were randomised to have surgery through either a transgluteal or a minimally invasive approach (MicroHip). In each group a BMI ≥ 30 was used to define obese patients. Pre- and early post-operative demographics, intraoperative data, baseline haematological values, hip function (Harris Hip Score, Oxford Hip Score) and quality of life (EQ-5D) were assessed with follow-up at three months. RESULTS: Duration of surgery, blood loss, C-reactive protein levels, radiographic measurements and complication rates were comparable in all groups. There was a tendency for lower serum creatine kinase levels in the MicroHip group. Intraoperative fluoroscopic time and dose area products were significantly elevated in patients with a BMI exceeding 30 regardless of the approach used. Time points of mobilisation, length of hospital stay and functional outcome measurements were similar in the different weight groups. CONCLUSIONS: Our data suggest that obese patients gain similar benefit from MicroHip THA as do non-obese patients. The results of this study should be further investigated to assess long-term survivorship.

Do parameters used to clear noncritically injured polytrauma patients for extremity surgery predict complications?

BACKGROUND: In multiply injured patients, definitive stabilization of major fractures is performed whenever feasible, depending on the clinical condition. QUESTIONS/PURPOSES: We therefore asked whether (1) any preoperative indicators predict major complications after major extremity surgery; (2) perioperative routine parameters other than those indicative of hemorrhagic shock predict postoperative complications; and (3) any postoperative clinical findings can predict major complications in the further course of the patient. METHODS: We prospectively followed patients with femoral midshaft fracture, Injury Severity Score (ISS) > 16 points, or three fractures and Abbreviated Injury Scale (AIS) ≥ 2 points and another injury (AIS ≥ 2 points), and age 18 to 65 years. We recorded multiple clinical parameters. End points were pneumonia, sepsis, acute respiratory distress syndrome, acute lung injury, and multiple organ failure. RESULTS: Forty-three of 165 patients developed complications. (1) Patients with complications had a decreased initial Glasgow Coma Scale and tended to have a lower ISS. (2) None of the assessed perioperative parameters was able to sufficiently predict postoperative complications. (3) The presence of a lung contusion and ventilation > 48 hours were associated with complications in the further course. CONCLUSIONS: In stable multiply injured patients, none of the individual routine clinical parameters was able to predict complications. Severe head and thoracic injuries seem to be important drivers for the development postoperative complications.