Epidemiology, treatment and outcome after compartment syndrome of the thigh in 69 cases - Experiences from a level I trauma centre.

BACKGROUND: Compartment syndrome of the thigh (CST) is a rare condition, and its delayed diagnosis and therapy may lead to devastating adverse effects. Thus, the aim of this study was to present the amassed clinical experiences, regarding diagnosis and treatment of CST at a level I trauma centre. MATERIALS AND METHODS: The database was reviewed for all patients with a manifest CST treated surgically between 1995 and 2014. RESULTS: 69 patients (61 males and 8 females) met the inclusion criteria, with a mean age of 42.9 years (range: 11-87 years). Forty-four patients (64%) presented with an isolated CST. There was a significant association between complication rates and high impact vs. blunt trauma (12/32, 38% vs. 0/20, 0%; p = 0.0022; Fisher's exact test). The number of surgeries in patients with a concomitant femur fracture was significantly increased (in mean: 2.8 vs. 4.9 surgical interventions; p < 0.001; U test). CONCLUSION: Patients after high impact trauma showed the highest complication rate. Concomitant femur fractures were associated with an increased number of surgical interventions. The synopsis of trauma mechanism, clinical presentation, age, anticoagulation status and clinical experience of the trauma surgeon seem to be the best tools to correctly diagnose CST.

Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience.

INTRODUCTION: There remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA). HYPOTHESIS: There is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair. MATERIAL & METHODS: A retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome and costs for surgical intervention were evaluated. RESULTS: Minimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (i.e., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work & sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group (p=0.004). DISCUSSION: All reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results. LEVEL OF EVIDENCE: IV, a retrospective, comparative study.

Damage control surgery - experiences from a level I trauma center.

BACKGROUND: There is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The aim of this study was to determine parameters influencing the choice of treatment in clinical routine (DCO, ETC, or EF) in femoral or tibial shaft fractures in combination with multi-system-trauma, severe soft tissue damage or both. METHODS: Data of 236 patients with 280 fractures of long bones of the lower extremities treated at a level I trauma center were analysed. Clinical parameters on arrival (age, sex [m/f], ISS, fracture site [femur/tibia], soft tissue damage [closed or open fractures according to the Gustilo-Anderson classification], pulmonary injury [yes/no]) were collected and analysed whether they influence the choice of upcoming treatment (DCO/ETC/EF). RESULTS: Our findings showed that high ISS and severe soft tissue damage (grade III) significantly correlated with DCO. High ISS, old age, female sex and fracture site (tibia) correlated with EF. This group of sole use of external fixation had highest rate of complications, 69% were associated with at least one complication. CONCLUSION: Severely injured patients are treated significantly more often with DCO or EF. The presence of higher ISS (≥16) and of type III open fractures increased the use of DCO. However, ISS, fracture-site, patient's age, type III open fractures or sex (female) increased the use of EF compared to ETC.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb.

PURPOSE AND HYPOTHESIS: Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. METHODS: This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. RESULTS: In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9-90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. CONCLUSIONS: The results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.

Progression of function and pain relief as indicators for returning to sports after arthroscopic isolated type II SLAP repair-a prospective study.

BACKGROUND: One of the currently used surgical techniques in isolated type II SLAP lesions is arthroscopic SLAP repair. Postoperatively, patients tend to suffer from a prolonged period of pain and are restricted in their sports activities for at least 6 months. The aim of this study was to prospectively evaluate the clinical outcome as well as the postoperative course of pain after arthroscopic type II SLAP repair. METHODS: Outcome measures were assessed using the Individual Relative Constant Score (CSindiv), the American Shoulder and Elbow Surgeons (ASES) Score, the Visual Analogue Scale (VAS), and the Short Form 36 (SF-36). Data were collected preoperatively, as well as at 3, 6, 12 and >24 months postoperatively. RESULTS: Eleven patients with an average age of 31.8 years (range: 22.8-49.8 years) underwent arthroscopic repair of isolated type II SLAP lesions. Mean follow-up time was 41.9 months (range: 36.1-48.4 months). 6 months after surgery, there was a statistically significant improvement of function according to the CSindiv (p = 0.004), the ASES Score (p = 0.006), and the SF-36 subscale "physical functioning" (p = 0.014) and a statistically significant decrease of pain according to the VAS (p = 0.007) and the SF-36 subscale "bodily pain" (p = 0.022) compared to preoperative levels. CONCLUSIONS: Arthroscopic repair of isolated type II SLAP lesions with suture anchors leads to a satisfactory functional outcome and return to pre-injury sports levels, with delayed, but significant pain relief observed 6 months after surgery. Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength. TRIAL REGISTRATION: Researchregistry1761 (UIN).

Osteoporosis associated vertebral fractures-Health economic implications.

INTRODUCTION: Osteoporosis-associated vertebral fractures represent an increasing clinical and public health problem, one with important socioeconomic effects within western countries. The purpose of this study was to analyse demographic, medical, gender and socioeconomic aspects of osteoporotic vertebral fractures of the thoracic or lumbar spine over a period of at least 10-years. MATERIAL AND METHODS: Included for analysis were 694 patients who had suffered a vertebral fracture due to primary or secondary osteoporosis, and who were treated at our Level-I trauma center between 2000 and 2013. Collected data included demographic, medical and socioeconomic aspects. RESULTS: Clinical results revealed that 669 patients (96%) were treated conservatively. The remaining 25 patients (4%) underwent surgical therapy: 4 were treated with vertebroplasty, 15 with kyphoplasty and 6 patients with posterior stabilization. The mean age was 75.6 years (range: 50-98), with the vast majority of patients being female (n = 515). A statistically significant demographic difference (i.e., increase) in fractures was observed between the age groups 60-69 and 70-79 (p = 0.041). Concerning socioeconomic aspects, statistical analysis showed that the number of sick leaves and the need for professional domestic help was higher in female patients. Concerning treatment costs, statistical analysis did not reveal any significant differences between female and male patients. CONCLUSION: Significant gender differences-to the detriment of the female population-could be demonstrated within this study. A regrettably low rate of adequate treatment after diagnosis of osteoporosis and its associated fractures-specifically relating to primary and secondary prevention-could also be identified. To prospectively avoid complications and consequential cost increases, more awareness of the necessity for prevention, early diagnosis and adequate treatment of osteoporosis and its related fractures should be considered.

Displaced Neer Type IIB distal-third clavicle fractures-Long-term clinical outcome after plate fixation and additional screw augmentation for coracoclavicular instability.

BACKGROUND: Unstable Neer Type IIB fractures require meticulous surgical treatment. Thus, the aim of this study was to present long-term outcomes after plate fixation and minimally invasive coracoclavicular (CC) stabilization using screw fixation. METHODS: A consecutive series of patients with unstable Neer Type IIB displaced clavicle fractures, treated by open reduction and internal fixation (ORIF) with a plate and additional screw fixation for coracoclavicular ligament instability, was reviewed in order to determine long-term clinical and radiological outcome. RESULTS: Seven patients, six males and one female, with a mean age of 37 ± 8 years (median: 36 years; range, 28-51 years), were evaluated. At latest follow-up, after a mean of 67 months (range, 11-117 months), patients presented with the following mean scores: DASH: 0.57, ASES: 98.81, UCLA: 34.29, VAS: 0.43, Simple Shoulder Test: 11.57. However, two complications were observed: one case of implant loosening and one non-union. There were no differences observed between the CC distances comparing postoperative X-rays to those in final follow-up. In 25% of our patients early postoperative complications occurred. In all patients reoperation was necessary to remove the implanted screw. CONCLUSION: The results of the present study indicate that the treatment of Neer Type IIB lateral clavicle fractures with ORIF using a plate and additional CC screw fixation, leads to satisfying clinical and radiological outcomes in the long-term. However, considering an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw does not seem to justify this technique anymore.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND: The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS: We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS: We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4-92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3-22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION: We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Tracheostomy following anterior cervical spine fusion in trauma patients.

PURPOSE: Traumatic injuries to the cervical spine are frequently accompanied by cervical spinal cord injuries-often necessitating tracheostomy. The purpose of this study was to evaluate patient characteristics and outcomes after undergoing anterior cervical spine fusion (ACSF) with tracheostomy. METHODS: All patients with cervical spine injury (CSI) who underwent ACSF and tracheostomy between December 1992 and June 2014 were included in this retrospective data analysis. The study group consisted of 32 men (84 %) and six women (16 %), with an average age of 47 ± 20 years. Blunt trauma to the cervical spine was the cause of CSI in all 38 patients. RESULTS: The mean Injury Severity Score (ISS) was 30.50 ± 6.25. Eighteen patients sustained severe concomitant injuries related to the spinal injury. In 15 patients (39.5 %), traumatic brain injury (TBI) with fractures of the cranium and/or intracranial lesions were observed. The mean Glasgow Coma Scale (GCS) score was 11 ± 4.5 (range 3-15). Two tracheostomies (5.3 %) were performed simultaneously with ACSF. The remaining 36 were performed with an average "delay" of 15 ± ten days. We observed no difference in time to tracheostomy among patients initially presenting with an American Spinal Injury Association (ASIA) score of either A, B, C or D. Only two patients (5.3 %) were identified as having an infection at the site of ACSF after placement of a tracheostomy. There were no deaths directly related to airway difficulties in our cohort. CONCLUSIONS: Our data show that tracheostomy is safely performed after an average of 15 days post-ACSF, thereby being associated with a very low rate of complications. However, future prospective randomised studies are needed to identify the optimal timing of tracheostomy placement after ACSF. LEVEL OF EVIDENCE: IV; retrospective case series.

Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures.

AIM: The aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures-in particular, general risk factors that exist independent of fracture type. MATERIALS AND METHODS: This study included patients (n=154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out. RESULTS: A total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19-91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out - as well as overall complication rate - and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher. CONCLUSION: The older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patient's age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.

A New Method of Airway Management in Patients Undergoing Gasserian Ganglion Thermal Coagulation: Preliminary Results.

BACKGROUND: Airway management in patients undergoing neurosurgical interventions for trigeminal neuralgia can often prove difficult. This is because the patient's assistance is required during this neurosurgical intervention, and moreover, the site of puncture lies within the working area of the anesthesiologists. An obvious alternative for airway management is the use of a nasopharyngeally placed tube. The purpose of the present study was to objectify the gas exchange in patients during this new ventilation technique. METHODS: In 5 patients, a tube with a 5 mm internal diameter was placed nasopharyngeally after induction of general anesthesia and ventilation was then manually assisted. The intraoperative partial pressure values of CO(2) (pvCO(2)) and O(2) (pvO(2)) in the venous blood were then compared with their respective patient's preoperative baseline pvCO(2) and pvO(2) levels. Blood pressure, heart rate, and SpO(2) were continuously and noninvasively monitored. During the entire surgical intervention, patients were ventilated with a fraction of inspired oxygen (FiO(2)) of 1.0 and a fresh gas flow of 18 L per minute. RESULTS: All patients exhibited sufficient oxygenation during the entire procedure under manual ventilation. There were no excessive deviations in pvCO(2) from baseline levels. Furthermore, no incidents of hemodynamic instability occurred. Mean duration of the neurosurgical procedure was 54 minutes. Impairment of intraoperative verbal communication was not observed with the nasopharyngeal tube in situ. CONCLUSIONS: This preliminary study suggests that manually assisted ventilation with pure oxygen using a nasopharyngeally placed tube seems to be a sufficient airway management technique during thermal coagulation of the Gasserian ganglion.

A novel protocol of continuous navigation guidance for endoscopic third ventriculostomy.

BACKGROUND: Although considered a standard neurosurgical procedure, endoscopic third ventriculostomy (ETV) is associated with a relatively high complication rate that is predominantly related to malpositioning of the trajectory. OBJECTIVE: To develop an advanced navigation protocol for ETV, assess its possible benefits over commonly used ETV trajectories, and apply this protocol during surgery. METHODS: After development of our advanced protocol, the imaging data of 59 patients who underwent ETV without navigation guidance was transferred to our navigation software. An individualized endoscope trajectory was created according to our protocol in all cases. This trajectory was compared with 2 standard trajectories, especially with regard to the distance to relevant neuronal structures: a trajectory manually measured on preoperative radiological images, as performed in all 59 cases, and a trajectory resulting from a commonly used fixed coronal burr hole. Subsequently, we applied the protocol in 15 ETVs to assess the feasibility and procedural complications. RESULTS: Our individualized trajectory resulted in a significantly greater distance to the margins of the foramen of Monro, and the burr hole was located more posteriorly from the coronal suture in comparison with the standard trajectories. The advanced ETV technique was feasible in all 15 procedures, and no major complications occurred in any procedure. In 1 patient, a fornix contusion without clinical correlation was observed. CONCLUSION: Our data indicate that the proposed navigation protocol for ETV optimizes the distance of the endoscope to important neuronal structures. Continuous endoscope and puncture device guidance may further add to the safety of this procedure.

Alterations of the biomarker S-100B and NSE in patients with acute vertebral spine fractures.

BACKGROUND CONTEXT: Although several publications concerning the use of the biomarkers S100B and neuron-specific enolase (NSE) in vertebral spine fractures in animal experimental studies have proven their usefulness as early indicators of injury severity, there are no clinical reports on their effectiveness as indicators in patients with spinal injuries. As these biomarkers have been examined, with promising results, in patients with traumatic brain injury, there is a potential for their implementation in patients with vertebral spine fractures. PURPOSE: To investigate the early serum measurement of S100B and NSE in patients with vertebral spine fractures compared with those in patients with acute fractures of the proximal femur. STUDY DESIGN: Prospective longitudinal cohort study. PATIENT SAMPLE: A cohort of 34 patients admitted over an 18-month period to a single medical center for suspected vertebral spine trauma. Twenty-nine patients were included in the control group. OUTCOME MEASURES: S100B and NSE serum levels were assessed in different types of vertebral spine fractures. METHODS: We included patients older than 16 years with vertebral spine fractures whose injuries were sustained within 24 hours before admission to the emergency room and who had undergone a brief neurologic examination. Spinal cord injuries (SCIs) were classified as being paresthesias, incomplete paraplegias, or complete paraplegias. Blood serum was obtained from all patients within 24 hours after the time of injury. Serum levels of S100B and NSE were statistically analyzed using Wilcoxon signed-rank test. RESULTS: S100B serum levels were significantly higher in patients with vertebral spine fractures (p=.01). In these patients, the mean S100B serum level was 0.75 µg/L (standard deviation [SD] 1.44, 95% confidence interval [CI] 0.24, 1.25). The mean S100B serum level in control group patients was 0.14 µg/L (SD 0.11, 95% CI 0.10, 0.19). The 10 patients with neurologic deficits had significantly higher S100B serum levels compared with the patients with vertebral fractures but without neurologic deficits (p=.02). The mean S100B serum level in these patients was 1.18 µg/L (SD 1.96). In the 26 patients with vertebral spine fractures but without neurologic injury, the mean S100B serum level was 0.42 µg/L (SD 0.91, 95% CI 0.08, 0.76). The analysis revealed no significant difference in NSE levels. CONCLUSIONS: We observed a significant correlation not only between S100B serum levels and vertebral spine fractures but also between S100B serum levels and SCIs with neurologic deficit. These results may be meaningful in clinical practice and to future studies.

Iron deficiency alters megakaryopoiesis and platelet phenotype independent of thrombopoietin.

Iron deficiency is a common cause of reactive thrombocytosis, however, the exact pathways have not been revealed. Here we aimed to study the mechanisms behind iron deficiency-induced thrombocytosis. Within few weeks, iron-depleted diet caused iron deficiency in young Sprague-Dawley rats, as reflected by a drop in hemoglobin, mean corpuscular volume, hepatic iron content and hepcidin mRNA in the liver. Thrombocytosis established in parallel. Moreover, platelets produced in iron deficient animals displayed a higher mean platelet volume and increased aggregation. Bone marrow studies revealed subtle alterations that are suggestive of expansion of megakaryocyte progenitors, an increase in megakaryocyte ploidy and accelerated megakaryocyte differentiation. Iron deficiency did not alter the production of hematopoietic growth factors such as thrombopoietin, interleukin 6 or interleukin 11. Megakaryocytic cell lines grown in iron-depleted conditions exhibited reduced proliferation but increased ploidy and cell size. Our data suggest that iron deficiency increases megakaryopoietic differentiation and alters platelet phenotype without changes in megakaryocyte growth factors, specifically TPO. Iron deficiency-induced thrombocytosis may have evolved to maintain or increase the coagulation capacity in conditions with chronic bleeding.

Reconstruction of cavernous nerves by nerve grafts to restore potency: contemporary review of technical principles and basic anatomy.

PURPOSE OF REVIEW: The review discusses the efficacy of reconstructing the neurovascular bundle to regain sexual function if nerve-sparing prostatectomy is unfeasible. RECENT FINDINGS: Eleven studies could be found describing the reconstruction of neurovascular bundles. All reconstructive procedures displayed technical inadequacies. The effectiveness of unilateral neurovascular bundle reconstruction remains statistically insignificant when compared with procedures without reconstruction. The efficacy of reconstructing both neurovascular bundles ranges between 0 and 43%. Concerning basic anatomy, the neurovascular bundle contains fibers innervating the cavernous nerves, prostate, rectum, and levator ani muscle. The terms cavernous nerve and neurovascular bundle have often been wrongly considered synonymous. The pelvic splanchnic nerves probably do not join the neurovascular bundle proximal to the bladder/prostate junction but rather at variable distances from 10 to 20 mm distal to it. Therefore, described proximal coaptation sites at the bladder/prostate junction possibly encompass only the hypogastric nerve. SUMMARY: Modest clinical results are partly due to inadequate surgical techniques and are mainly due to the anatomical and topographical complexity of the cavernous nerves. Contemporary nerve grafting techniques probably do not allow for the regeneration of all cavernous nerves.