Preliminary findings on biomarker levels from extracerebral sources in patients undergoing trauma surgery: Potential implications for TBI outcome studies.

BACKGROUND: Despite several experimental studies on the role of S100B and NSE in fractures, no studies on the influence of surgery on the biomarker serum levels have been performed yet. METHODS: The serum levels of S100B and NSE were analysed in patients with fractures that were located in the spine (group 1, n = 35) or in the lower extremity (group 2, n = 32) pre- and post-operatively. RESULTS: The mean S100B serum level showed a significant increase (p = 0.04) post-surgery in the patients of group 1. In patients undergoing acute surgery (< 24 hours) the mean S100B serum level was 0.23 ± 0.22 µg L(-1) pre-operatively and 1.24 ± 1.38 µg L(-1) post-operatively. Likewise, the mean S100B serum level significantly increased in group 2 after surgery (p < 0.0001). In this group patients undergoing acute surgery showed a mean S100B serum level of 0.23 ± 0.14 µg L(-1) and 1.11 ± 0.73 µg L(-1) pre- and post-operatively. CONCLUSION: This study demonstrates significant alterations of the biomarker S100B serum levels in patients undergoing surgery. Higher S100B serum levels were found within 24 hours and might be related to the acute fracture. The NSE serum levels were unchanged and this biomarker may offer the probability to serve as a future outcome predictor in studies with patients with traumatic brain injury and additional extracerebral injuries.

Analysis of factors predicting success and failure of treatment after type B periprosthetic humeral fractures: a case series study.

PURPOSE: The purpose of this study was to investigate which factors predict the failure and success of treatment of periprosthetic type B humeral fractures that have occurred traumatically. METHODS: The institutional admission database and the trauma registry were retrospectively reviewed. A total of 8 patients suffering from periprosthetic humeral fractures were included. The time span was 10 years (2000-2010). RESULTS: The average age at the time of the fracture was 77 years. Surgery was performed at an average of 5.6 days after injury. In three patients with a well-fixed and one with an unstable humeral component, open reduction and internal fixation with the use of a plate and screws was performed. Two patients with a Delta prosthesis had an unstable humeral component. A proximal humeral resection and an implantation of an HMRS prosthesis was performed in one patient. The other patient received a Delta revision stem prosthesis, cable and plate fixation. Two patients were treated conservatively. CONCLUSIONS: Early surgical treatment with angular stable implants in fractures with a stable stem and replacement with a revision long-stem component in fractures with a loose prosthesis is recommended. Special attention should be paid to bone quality and anatomical proximity to the radial nerve. Conservative treatment of type B fractures is not sufficient to achieve union, especially in short oblique or transverse fractures.

Minimally invasive ilioinguinal approach to the acetabulum.

The classic ilioinguinal approach is a gold standard in acetabular surgery. We developed a modification, a minimally invasive method that entails a median lower abdominal approach with extraperitoneal dissection and exposure of the pubic symphysis. The second incision is lateral, next to the iliac crest. This allows an easy, safe and quick exposure of the anterior iliac ring as well as easy access to the posterior column and wall towards the sacroiliac joint. The iliac vessels and nerves are thereby protected, and no preparation of neurovascular structures is required. The technique was applied in 23 clinical cases and compared with the classic ilioinguinal approach in 9 similar cases over the same period.

Treatment of talar neck fractures: clinical results of 50 patients.

Fractures of the neck and body of the talus present as one of the most challenging and rare injuries. These fractures are often associated with other ankle, foot, and skeletal injuries, which complicate their treatment. The clinical course of 50 patients with a mean age of 29 years with a severe talus fracture between 1992 and 1997 is presented. According to the Hawkins classification there were 16 (32%) of type I, 14 (28%) of type II, 9 (18%) of type III, and 11 (22%) of type IV. Forty-three patients (86%) underwent operative treatment: 27 (63%) by open reduction and internal fixation with screws, seven (16%) by external fixation, five (12%) with percutaneous screws, and four (9%) by closed reduction with K-wire fixation. Mild osteoarthritis of the talocrural joint was seen in 14 patients (28%) and severe osteoarthritis in 10 patients (20%), five of whom required subsequent arthrodesis of the ankle joint. Arthrodesis of the subtalar joint was observed in 4 cases. Avascular necrosis with collapse of the talar body was seen in four patients (8%). The function of the ankle joint was evaluated according to the Weber score. Patients with talus fractures of Hawkins' type I and II had considerably better outcomes (with 95% being excellent or good) than individuals suffering dislocated fractures with involvement of the articulating surface with 70% good results in Hawkins' type III and 10% good results in Hawkins' type IV fractures. For the evaluation of the vitality of the talus body in cases with titanium implants, the authors used magnetic resonance imaging and intraosseous phlebography in cases with stainless steel implants. The displaced talus fractures must be treated by closed and, if necessary, open reduction with internal fixation. The initial postoperative management should consist of ambulation without weightbearing until radiographic appearance of trabecular bone in the fracture zone, indicating revascularization, can be manifested.

Pressure changes during reaming with different parameters and reamer designs.

Reaming increases intramedullary pressure and can cause fat intravasation. This study investigated the influence of reaming parameters on pressure changes using the AO, Gray, and Howmedica reamers. Silicone cylindrical shells with 10-, 11-, 16-, 19-, and 20-mm inner diameters were filled with a 1:2 ratio of paraffin and petroleum jelly. The 10- and 11-mm shells were reamed using a 9-mm reamer, the 16-mm shells with a 14-mm reamer, and the 19- and 20-mm shells with an 18-mm reamer. Each experiment was performed seven times while singularly varying driving speeds of 15, 30, and 50 mm per second, with a revolution rate of 150, 250, and 500 revolutions per minute. Using stepwise linear regression analysis, driving speed was the most significant parameter. The lowest pressure increases occurred at the lowest driving speed and the highest revolution rate in all cylinders. The model used for this study did not take into consideration the interaction between the cortical shell and reamer head. The results of this study suggest that reaming should be done at a low driving speed and a high revolution rate using a small cored reamer head, especially during the first reaming steps.

Acetabular fractures: operative management and long term results.

INTRODUCTION: While the undisplaced acetabular fractures have a good prognosis after conservative treatment, the management of the displaced fractures has been a controversial issue over the last decades with variable results in their treatment and prognosis. Anatomical reduction can be only achieved operatively. The long term outcome of 209 patients with displaced acetabular fractures treated by open reduction and internal fixation was presented. MATERIAL AND METHODS: Between 1972 and 1996, 209 patients with a mean age of 38 years (15-62a) were treated for displaced acetabular fractures operatively. 161 patients could be followed up over a period of 2 to 20 years. The function of the hip joint in correlation with radiological results was evaluated according to the scheme of Merle d'Aubinge. RESULTS: Patients with single column fractures showed 90% good or excellent results followed by 55% good or excellent results in patients with transverse fractures. The highest rates of complication (20% osteoarthritis, 6% femoral head necrosis, 9% heterotopic ossification) were observed in both column fractures and in transverse and posterior wall fractures. Deep infection was observed in 6 cases (4%), superficial wound infection in 8 cases (5%). Primary sciatic nerve palsy was seen in 10 cases (6%) and postoperative peroneal nerve palsy in 6 cases (4%), all of which improved during the rehabilitation period. CONCLUSION: Displaced acetabular fractures of the weight bearing part of the dome, i.e. transtectal fractures, should be treated operatively. The operation should preferably be performed within one week after the injury.

[Concomitant intra-abdominal injuries in pelvic trauma]. / Intraabdominelle Begleitverletzungen beim Beckentrauma.

A pelvic fracture combined with abdominal injury and soft tissue damage, defined as complex pelvic trauma, is an expression of severe trauma and requires specific procedures in terms of diagnosis and treatment. The clinical course and outcome of 75 patients (56 males and 19 females) with complex pelvic injuries from 1985 to 1996 are presented in this follow-up study. There were 33 (44%) Type A (stable pelvic ring fracture), 10 (13%) Type B (rotationally unstable pelvic ring fracture) and 32 (43%) Type C (rotationally and vertically unstable pelvic ring fracture). Concomitant abdominal injuries included: 14 liver lacerations (19%), 28 splenic lesions (37%), 7 ruptures of the kidney (9%), 18 ruptures of the bladder (24%), 13 urethra lesions (17%), 13 intestinal lesions (17%) and 16 ruptures of the diaphragm (21%). The mean Hannover polytrauma score was 22 points. Twelve patients (16%) died within 6 hours after associated head and/or chest injury with hemorrhage, and 3 patients (4%) died in the intensive care unit from sepsis and multiorgan failure within 2 weeks after injury. The priority of the steps taken is of utmost importance in the diagnosis and treatment of such injuries. Immediate control of hemorrhage by surgical or minimally invasive radiological techniques, stabilization of pelvic fractures and inter-disciplinary cooperation are important requirements for management and successful treatment.

Tibial avulsion fracture of the posterior cruciate ligament: K-wire or screw fixation? A retrospective study of 26 patients.

Although the posterior cruciate ligament (PCL) is not frequently injured, a greater understanding of its role in stabilizing the knee joint, mechanism of injury and treatment has developed. Isolated avulsion injuries constitute only a subgroup of PCL injuries, but nevertheless several operative techniques have been described for the fixation of the avulsed bony fragment. In order to investigate whether K-wire or screw fixation yields better long-term results, we examined 26 patients at an average of 10.5 years after the initial operation. Clinical examination, activity level, radiographic evaluation and instrumented measurements did not reveal any significant differences. All the patients had an excellent functional result. Thus, both K-wire and screw fixation are recommended for bony PCL avulsion injuries.