The role of sarcopenia in fragility fractures of the pelvis - is sarcopenia an underestimated risk factor?

BACKGROUND: Fragility fractures of the pelvis (FFPs) represent a significant health burden, particularly for the elderly. The role of sarcopenia, an age-related loss of muscle mass and function, in the development and impact of these fractures is not well understood. This study aims to investigate the prevalence and impact of osteoporosis and sarcopenia in patients presenting with FFPs. METHODS: This retrospective study evaluated 140 elderly patients with FFPs. The diagnosis of sarcopenia was assessed by psoas muscle area (PMA) and the height-adjusted psoas muscle index (PMI) measured on computed tomography (CT) scans. Clinical data, radiological findings and functional outcomes were recorded and compared with the presence or absence of sarcopenia and osteoporosis. RESULTS: Our study cohort comprised 119 female (85.0%) and 21 (15.0%) male patients. The mean age at the time of injury or onset of symptoms was 82.26 ± 8.50 years. Sarcopenia was diagnosed in 68.6% (n = 96) patients using PMA and 68.8% (n = 88) using PMI. 73.6% (n = 103) of our study population had osteoporosis and 20.0% (n = 28) presented with osteopenia. Patients with sarcopenia and osteoporosis had longer hospital stays (p < 0.04), a higher rate of complications (p < 0.048) and functional recovery was significantly impaired, as evidenced by a greater need for assistance in daily living (p < 0.03). However, they were less likely to undergo surgery (p < 0.03) and the type of FFP differed significantly (p < 0.04). There was no significant difference in mortality rate, pre-hospital health status, age or gender. CONCLUSION: Our study highlights the important role of sarcopenia in FFPs in terms of the serious impact on health and quality of life in elderly patients especially when osteoporosis and sarcopenia occur together. Identifying and targeting sarcopenia in older patients may be an important strategy to reduce pelvic fractures and improve recovery. Further research is needed to develop effective prevention and treatment approaches that target muscle health in the elderly.

Neutrophil Gene Expression Patterns in Multiple Trauma Patients Indicate Distinct Clinical Outcomes.

INTRODUCTION: Patients after polytrauma suffer from posttraumatic immune system dysregulation and multiple organ dysfunction. Genome-wide microarray profiling in monocytes revealed a regulatory network of inflammatory markers around the transcription factor AP-1 in severely injured patients. Recent research focuses on the role of neutrophils in posttraumatic inflammation. The aim of this study was, therefore, to evaluate the impact of this inflammatory network in neutrophils. MATERIALS AND METHODS: Blood sampling and neutrophil separation were performed on admission of the patient and at 6 h, 12 h, 24 h, 48 h, and 72 h after trauma. Neutrophil expression levels of the target genes c-Jun, c-Fos, BCL2A, MMP-9, TIMP-1, ETS-2, IL-1ß, and MIP-1ß were quantified by RT-qPCR. Patients were assorted into groups according to distinct clinical parameters like massive transfusion (>10 RBC units/24 h), injury severity (ISS), 90-d survival, and the presence of traumatic brain injury (defined by ICI on head CT). Statistics were calculated by Mann-Whitney Rank-Sum Test, Receiver Operating Curves, and binary multiple logistic regression. RESULTS: Forty severely injured patients (mean ISS 36 ± 14) were included. BCL2A, MMP-9, TIMP-1, and ETS2 levels showed a significant correlation to 90-d-survival in the early posttraumatic period (6 h-24 h). Furthermore, differential BCL2A, IL-1ß, MIP-1ß, and MMP-9 regulation was observed in patients requiring massive transfusion. We could further show a significant TIMP-1 response in trauma PMN associated with traumatic brain injury. CONCLUSIONS: This study of seriously injured patients highlights very early posttraumatic transcriptional changes in PMNs, which were clearly associated with posttraumatic events and outcomes.

Dysregulation of Wnt signaling in bone of type 2 diabetes mellitus and diabetic Charcot arthropathy.

BACKGROUND: Type 2 diabetes mellitus (T2DM) patients show a markedly higher fracture risk and impaired fracture healing when compared to non-diabetic patients. However in contrast to type 1 diabetes mellitus, bone mineral density in T2DM is known to be normal or even regionally elevated, also known as diabetic bone disease. Charcot arthropathy is a severe and challenging complication leading to bone destruction and mutilating bone deformities. Wnt signaling is involved in increasing bone mineral density, bone homeostasis and apoptotic processes. It has been shown that type 2 diabetes mellitus is strongly associated with gene variants of the Wnt signaling pathway, specifically polymorphisms of TCF7L2 (transcription factor 7 like 2), which is an effector transcription factor of this pathway. METHODS: Bone samples of 19 T2DM patients and 7 T2DM patients with additional Charcot arthropathy were compared to 19 non-diabetic controls. qPCR analysis for selected members of the Wnt-signaling pathway (WNT3A, WNT5A, catenin beta, TCF7L2) and bone gamma-carboxyglutamate (BGLAP, Osteocalcin) was performed and analyzed using the 2-ΔΔCt- Method. Statistical analysis comprised one-way analysis of variance (ANOVA). RESULTS: In T2DM patients who had developed Charcot arthropathy WNT3A and WNT5A gene expression was down-regulated by 89 and 58% compared to healthy controls (p < 0.0001). TCF7L2 gene expression showed a significant reduction by 63% (p < 0.0001) and 18% (p = 0.0136) in diabetic Charcot arthropathy. In all diabetic patients BGLAP (Osteocalcin) was significantly decreased by at least 59% (p = 0.0019). CONCLUSIONS: For the first time with this study downregulation of members of the Wnt-signaling pathway has been shown in the bone of diabetic patients with and without Charcot arthropathy. This may serve as future therapeutic target for this severe disease.

Treatment of vascular graft infections: gentamicin-coated ePTFE grafts reveals strong antibacterial properties in vitro.

Vascular graft infections (VGI) are severe complications in prosthetic vascular surgery with an incidence ranging from 1 to 6%. In these cases, synthetic grafts are commonly used in combination with antimicrobial agents. Expanded polytetrafluoroethylene (ePTFE) is in clinical use as a synthetic graft material and shows promising results by influencing bacterial adhesion. However, the literature on antibiotic-bound ePTFE grafts is scarce. Gentamicin is a frequently used antibiotic for local treatment of surgical site infections, but has not been evaluated as antimicrobial agent on ePTFE grafts. In this study, we examine the antimicrobial efficacy and biocompatibility of novel types of gentamicin-coated ePTFE grafts in vitro. ePTFE grafts coated with gentamicin salt formulations with covalently-bound palmitate were evaluated in two drug concentrations (GP1.75% and GP3.5%). To investigate effects from types of formulations, also suspensions of gentamicin in palmitate as well as polylactide were used at comparable levels (GS + PA and GS + R203). Antibacterial efficacies were estimated by employing a zone of inhibition, growth inhibition and bacterial adhesion assay against Staphylococcus aureus (SA). Cytotoxicity was determined with murine fibroblasts according to the ISO standard 10993-5. Gentamicin-coated ePTFE grafts show low bacterial adherence and strong antibacterial properties in vitro against SA. Bactericidal inhibition lasted until day 11. Highest biocompatibility was achieved using gentamicin palmitate GP1.75% coated ePTFE grafts. ePTFE grafts with gentamicin-coating are effective in vitro against SA growth and adherence. Most promising results regarding antimicrobial properties and biocompatibility were shown with chemically bounded gentamicin palmitate GP1.75% coatings. Graphical abstract.

Does implant removal of superior clavicle plate osteosynthesis affect the functional outcome: a prospective trial.

BACKGROUND: Elective implant removal (IR) accounts for up to 30% of all orthopaedic surgeries. While there is general acceptance about the need of implant removal for obvious reasons, such as infections or implant failure, little is known about the beneficial aspects in cases of minor reasons such as patients' wish for IR. Therefore, we initiated this study to define patients' benefit of elective implant removal following plate osteosynthesis of displaced clavicle fractures. PATIENTS AND METHODS: Prospective evaluation of patients was conducted before implant removal and 6 weeks postoperative. Subjective and objective criteria included pain rating on a visual analogue scale (VAS) and active range of motion (ROM) pre- and 6 weeks postoperative. Functional scoring included Constant-Murley Score, DASH (Disabilities of Arm, Shoulder and Hand Score), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index). RESULTS: 37 patients were prospectively enrolled in this study and implant removal was performed after 16 ± 6.1 months. No re-fractures nor other complications were detected during routine follow up. Functional outcome increased through all scores (Constant score 73.3 ± 14.6 preoperative to 87.4 ± 12.0 postoperative (p = 0.000), MSQ 85.0 ± 7.3 preoperative to 91.8 ± 9.0 postoperative (p = 0.005), DASH Score 7.4 ± 8.2 preoperative to 5.7 ± 9.5 postoperative (p = 0.414), SPADI 93.4 ± 6.6 preoperative to 94.0 ± 10.1 postoperative (p = 0.734). CONCLUSIONS: Discomfort during daily activities or performing sports as well as limited range of motion were the main reasons for patients' wish for implant removal. We found increased functional outcome parameters and decreased irritation after implant removal. Therefore we suggest implant removal in case of patients' wish and completed fracture consolidation. TRIAL REGISTRATION: Trial registration no: NCT04343118, Retrospective registered: www.clinicaltrials.gov .

[Functional outcome of 111 metatarsal fractures following conservative in comparison to operative treatment]. / Funktionelles Outcome nach konservativer im Vergleich zu operativer Therapie von 111 Mittelfußfrakturen.

BACKGROUND: Fractures of the metatarsal bones are common injuries of the foot and particularly occur in patients aged 40-50 years. Especially multiple metatarsal fractures can lead to permanent limitations. Therefore, the aim of this study was to investigate the functional outcome of metatarsal fractures after conservative and surgical treatment using a validated self-reported patient-based outcome questionnaire. MATERIAL AND METHODS: All patients suffering from metatarsal fractures between 2003 and 2015 were enrolled in this retrospective analysis. The following data were collected: demographic data, AO classification, treatment, reoperation rate and the foot and ankle outcome score (FAOS). For outcome analysis, the nonparametric Mann-Whitney U­test and Fisher's exact test were performed. RESULTS: In total the functional outcome of 111 patients with metatarsal fractures were analyzed, 81 patients suffered of an isolated metatarsal fracture and 30 of multiple fractures. The mean age of the patients was 45 ± 15.2 years with a total of 48 men (43%) and 63 women (57%). Patients with an isolated metatarsal fracture had an FAOS of 88 ± 17.1, while patients with multiple metatarsal fractures achieved an FAOS of 78 ± 17.7 (p = 0.046). In the group of isolated metatarsal fractures 43 patients (53%) were surgically treated and of these 36 patients showed a type C fracture (84%). In the group of multiple metatarsal fractures 16 patients (53%) underwent operative treatment. CONCLUSION: Overall, the functional outcome of isolated metatarsal fractures following operative as well as conservative treatment is good to very good. Simple fractures can be successfully treated conservatively and complex multifragment fractures can be safely managed surgically. If more than one metatarsal bone is fractured, the functional outcome is significantly worse with patients reporting lasting limitations involving the range of motion and stiffness.

The Clinical Impact of Platelets on Post-Injury Serum Creatinine Concentration in Multiple Trauma Patients: A Retrospective Cohort Study.

Background and objective: Platelets contribute to the immunological response after multiple trauma. To determine the clinical impact, this study analyzes the association between platelets and creatinine concentration as an indicator of kidney function in polytraumatized patients. Methods: We investigated all patients presenting an Injury Severity Score (ISS) ≥16 for a 2-year period at our trauma center. Platelet counts and creatinine concentrations were analyzed, and correlation analysis was performed within 10 days after multiple trauma. Results: 83 patients with a median ISS of 22 were included. Platelet count was decreased on day 3 (p ≤ 0.001) and increased on day 10 (p ≤ 0.001). Platelet count was elevated on day 10 in younger patients and diminished in severely injured patients (ISS ≥35) on day 1 (p = 0.012) and day 3 (p = 0.011). Creatinine concentration was decreased on day 1 (p = 0.003) and day 10 (p ≤ 0.001) in female patients. Age (p = 0.01), male sex (p = 0.004), and injury severity (p = 0.014) were identified as factors for increased creatinine concentration on day 1, whereas platelets (p = 0.046) were associated with decreased creatinine concentrations on day 5 after multiple trauma. Conclusions: Kinetics of platelet count and creatinine concentration are influenced by age, gender, and trauma severity. There was no clear correlation between platelet counts and creatinine concentration. However, platelets seem to have a modulating effect on creatinine concentrations in the vulnerable phase after trauma.

Is the Use of Segways or E-Scooters in Urban Areas a Potential Health Risk? A Comparison of Trauma Consequences.

Background and objectives: Electromobility has become increasingly popular. In 2001, Segway personal transporters (Segway) were established for tourists, and e-scooters have been in use since their approval in 2019. The aim of this study was to analyze and compare the types of injuries directly related to the use of Segways and e-scooters, respectively, in a German city and to phrase potential safety advice. Materials and Methods: All patients presenting to our emergency department after Segway incidents were retrospectively analyzed and compared with the prospectively collected cohort of patients following e-scooter incidents. Presented injuries were analyzed by body region and injury severity score (ISS). Epidemiological data were collected. Results: Overall, 171 patients were enrolled. The Segway group included 56 patients (mean age 48 years), and the e-scooter group consisted of 115 patients (mean age 33.9 years). Head injuries (HI) occurred in 34% in the Segway group compared to 52% in the e-scooter group. The ISS was approximately equal for both groups (mean ISS Segway group: 6.9/e-scooter group: 5.6). Conclusions: Since the e-scooter group presented a high number of HI along with a higher likelihood and greater severity of HI, mandatory use of helmets is suggested.

Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System.

Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the 'Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries' (UPPS) score for easier prediction of GUI in the emergency setting.

Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial.

BACKGROUND: The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes. METHODS: This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon's experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups. RESULTS: Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome. CONCLUSIONS: The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers. TRIAL REGISTRATION: Retrospectively registered 21.12.2020. Registration number NCT04680247 .

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures.

BACKGROUND: Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures. METHODS: Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score. RESULTS: Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months. CONCLUSION: Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results. TRIAL REGISTRATION: No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

Patient reported outcome of 33 operatively treated talar fractures.

BACKGROUND: Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures. METHODS: A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed. RESULTS: In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145). CONCLUSIONS: Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

BACKGROUND: In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome. METHODS: In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively. RESULTS: Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22-64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II. CONCLUSIONS: The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery. TRIAL REGISTRATION: Registered 20 April 2020, retrospectively on ClinicalTrails.gov ( NCT04370561 ).

Medical drones: Disruptive technology makes the future happen.

Trauma surgery has always been driven forward by innovative technological advancements. The recent appearance of "advanced air mobility" (AAM) represents one of the next steps in these technological developments. These innovative flying systems have major implications for all of the various healthcare stages in trauma surgery: Unmanned aircraft systems, or drones, can deliver critical supplies on demand, just in time, without physical contact, within the "last mile delivery" concept, such as AEDs, critical medication, blood for transfusion etc. Electric vertical take-off and landing (eVTOL) devices add new horizons for healthcare thanks to the smallest take-off and landing areas. These eVTOLs are not only new aircraft but, thanks to the autonomous flying options, they are flying computers with novel technological opportunities on board. With these new, flying operation systems, the whole rescue chain will be completely revolutionized by much faster response intervals, patient transportation times, telemedical applications, optimized emergency medical services, laboratory transportation etc. Hence, this article aims to provide a tentative overview of these new exciting technological developments in the field of trauma surgery for the benefit of our patients.

[E-scooter accidents and their consequences : First prospective analysis of the injury rate and injury patterns in the urban area of a German city with over 1 million residents]. / E-Scooter-Unfälle und deren Folgen : Erste prospektive Analyse der Verletzungsrate und Verletzungsmuster im urbanen Raum einer deutschen Millionenstadt.

BACKGROUND: Since their approval in Germany in June 2019 e­scooters have become increasingly more popular; however, with growing popularity and easy access for everybody the number of accidents has increased, sometimes even resulting in severe injuries. OBJECTIVE: The purpose of this study was to collect demographic data and analyze injury patterns of accidents due to e­scooter use in a large German city and to give suggestions on future safety concepts and rules of conduct. METHODS: All patients who presented at the interdisciplinary emergency room of the Klinikum rechts der Isar, University hospital of the Technical University in Munich between 1 July 2019 and 1 April 2020 after suffering an e­scooter accident were included in this study. Demographic data as well as information with respect to the trauma mechanism were prospectively collected. RESULTS: During the study period 60 patients were identified of which 34 (56.7%) were male with an average age of 34.7 years (range 18-73 years) at the time of the accident. Of the patients 22 rode the e­scooter under the influence of alcohol and only 1 wore a helmet. The head was the most injured body region, followed by the upper and lower extremities and 2 (3.3%) patients were severely injured with an injury severity score (ISS) ≥16. CONCLUSION: Due to the growing popularity of e­scooter use more injuries have been registered. The head was the most affected body region, therefore emphasis should be put on wearing a helmet. Furthermore, strict rules and more police controls should take place to identify and reduce the number of accident victims under the influence of alcohol.

The posttraumatic response of CD4+ regulatory T cells is modulated by direct cell-cell contact via CD40L- and P-selectin-dependent pathways.

CD4+ FoxP3+ regulatory T cells (CD4+ Tregs) are important for the posttraumatic anti-inflammatory host response. As described previously, platelets are able to modulate CD4+ Treg activity in a reciprocally activating interaction following injury. The underlying mechanisms of the posttraumatic interaction between platelets and CD4+ Tregs remain unclear. We investigated the potential influence of CD40L and P-selectin, molecules known to be involved in direct cell contact of these cell types. In a murine burn injury model, the potential interaction pathways were addressed using CD40L- and P-selectin-deficient mice. Draining lymph nodes were harvested following trauma (1 h) and following a sham procedure. Early rapid activation of CD4+ Tregs was assessed by phospho-flow cytometry (signaling molecules (p)PKC-δ and (p)ZAP-70). Platelet function was analyzed performing rotational thromboelastometry (ROTEM). We hypothesized that disruption of the direct cell-cell contact via CD40L and P-selectin would affect posttraumatic activation of CD4+ Tregs and influence the hemostatic function of platelets. Indeed, while injury induced early activation of CD4+ Tregs in wild-type mice (ZAP-70: p = 0.13, pZAP-70: p < 0.05, PKC-δ: p < 0.05, pPKC-δ: p < 0.05), disruption of CD40L-dependent interaction (ZAP-70: p = 0.57, pZAP-70: p = 0.68, PKC-δ: p = 0.68, pPKC-δ: p = 0.9) or P-selectin-dependent interaction (ZAP-70: p = 0.78, pZAP-70: p = 0.58, PKC-δ: p = 0.81, pPKC-δ: p = 0.73) resulted in reduced posttraumatic activation. Furthermore, hemostatic function was impaired towards hypocoagulability in either deficiency. Our results suggest that the posttraumatic activation of CD4+ Tregs and hemostatic function of platelets are affected by direct cell-cell-signaling via CD40L and P-selectin.

Treatment of fracture-related infection of the lower extremity with antibiotic-eluting ceramic bone substitutes: case series of 35 patients and literature review.

INTRODUCTION: The current treatment concepts of fracture-related infection (FRI) [Consensus Conference (Anti-Infection Task Force (AITF)) on the definition of acute or chronic osteomyelitis (cOM)] are associated with unsolved challenges and problems, underlining the need for ongoing medical research. METHOD: Literature review of treatments for FRI and description of own cases. RESULTS: We could include eight papers with 394 patients reporting treatments and outcome in FRI. The infection was resolved in 92.9% (mean) of all treatments. The mean follow-up was 25 months with a persistent non-union in 7% of the patients. We diagnosed 35 (19f/16m; 56.4 ± 18.6 years) patients with bone infections anatomically allocated to the proximal and distal femur (12×), the pelvis (2×), distal tibia (3×), tibial diaphysis (11×), the ankle joint (4×) and calcaneus (3×). These 35 patients were treated (1) with surgical debridement; (2) with antibiotic-eluting ceramic bone substitutes; (3) bone stabilization (including nail fixation, arthrodesis nails, plates, or external ring fixation), (4) optionally negative pressure wound therapy (NPWT) and (5) optionally soft tissue closure with local or free flaps. The mean follow-up time was 14.9 ± 10.6 months (min/max: 2/40 month). The overall recurrence rate is low (8.5%, 3/35). Prolonged wound secretion was observed in six cases (17.1%, 6/35). The overall number of surgeries was a median of 2.5. CONCLUSION: The results in the literature and in our case series are explicitly promising regarding the treatment of posttraumatic fracture-related infection.

The influence of foehn winds on the incidence of severe injuries in southern Bavaria - an analysis of the TraumaRegister DGU®.

BACKGROUND: Foehn describes a wind which occurs in areas with close proximity to mountains. The presence of foehn wind is associated with worsening health conditions. This study analyzes the correlation between a foehn typical circulation and the incidence for suffering a severe trauma. METHODS: This is a retrospective, multicentre observational register study. The years from 2013 to 2016 were analyzed for the presence of foehn winds. A logistic regression analysis with the number of daily admitted trauma patients as the primary target value was performed in dependence of foehn winds. Southern Bavaria is a typical foehn wind region. Individuals were treated in 37 hospitals of Southern Bavaria which participate in the TraumaRegister DGU®, an international register that includes all severe trauma patients, mainly in Germany. We analyzed patients with an Injury Severity Score (ISS) of at least nine with admission to intensive care units or prior death in the emergency room. RESULTS: 6215 patients were enrolled in this study. A foehn-typical circulation was present on 65 days (4.5%). 301 patients (5%) suffered a trauma with an ISS ≥ 9 on a foehn day. The mean ISS was 20.2 (9-75). On average, 4.3 patients (0-15 patients) were admitted on a daily basis due to a severe trauma. The multivariate regression analysis revealed a daily increase of 0.87 individuals (p = 0.004; 95% CI 0.23-1.47) on foehn days. During spring 1.07 patients (p = < 0.001; 95% CI 0.72-1.42), in summer 1.98 patients (p = < 0.001; 95% CI 1.63-2.32), in fall 0.63 (p = < 0.001; 95% CI 0.28-0.97) and on Saturdays, 0.59 patients (p = < 0.001; 95% CI 0.24-0.93) were additionally admitted due to severe trauma. CONCLUSION: Foehn winds are significantly associated with severe trauma in trauma centers of the TraumaNetzwerk DGU®.

[Distal femoral fractures]. / Distale Femurfrakturen.

With a prevalence of approximately 0.4%, distal femoral fractures are a rare entity. Nevertheless, due to the high mortality rates, which are comparable to proximal femoral fractures, these fractures are highly important. The clinical symptoms are often quite striking. In combination with preoperative computed tomography (CT) and if necessary, supplemented by CT angiography, the morphological situation can be assessed and the decision making facilitated. There are several different treatment options and the appropriate one should be selected for each individual case. The use of external fixation of the complete knee joint in the sense of damage control surgery, is useful. For definitive treatment retrograde intramedullary nailing and locking plates with angle stable screws are the main options. Modern angle stable and anatomically preformed implants enable surgical treatment using minimally invasive approaches to protect the soft tissues, with a better overall outcome.

[Delayed occurrence of compartment syndrome of the upper arm after shovelling snow by a patient under oral anticoagulation]. / Verzögert auftretendes Oberarmkompartmentsyndrom nach Schneeschaufeln unter oraler Antikoagulation.

This article reports the case of an 81-year-old male patient under treatment with oral anticoagulation who suffered delayed compartment syndrome of the upper arm from arterial capillary hemorrhage after shovelling snow. The diagnosis was made 48 h after the initial symptoms in the emergency surgical department of the Klinikum rechts der Isar (München) with the presence of clear neurological deficits. Following computed tomography angiography (CTA) imaging an emergency dermatofasciotomy was carried out as well as a vascular ligature via a medial approach. Compartment syndromes are the result of pathologically elevated tissue pressure and as a rule with a rapid clinical course. A delayed diagnosis can therefore lead to irreversible tissue and nerve damage up to the loss of the extremity. Compartment syndromes are particularly frequent in the lower extremities whereas those of the upper extremities are rare. This case report is intended to raise awareness for an insidiously occurring compartment syndrome of the upper arm due to repetitive microtrauma (in this case shovelling snow) and arterial peripheral vascular hemorrhage with simultaneous anticoagulation. The necessary diagnostic and treatment steps are also elucidated.