[Diagnostics and treatment of insufficiency fractures of the pelvis]. / Diagnostik und Therapie von Beckeninsuffizienzfrakturen.

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X­rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

[Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]. / Operative Rekonstruktion der Thoraxwandinstabilität : Indikationen, Kontraindikationen und Operationszeitpunkt.

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

[Treatment strategy for severe implosion injuries of the lateral chest wall]. / Versorgungsstrategie bei schweren Implosionsverletzungen der lateralen Thoraxwand.

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

[Biomechanics of thoracic wall instability]. / Biomechanik der Thoraxwandinstabilität.

Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration; however, so far little is known about the biomechanics of the unstable thoracic wall and the optimal surgical fixation. This review article summarizes the current state of research regarding experimental models and previous findings. The thoracic wall is primarily burdened by complex muscle and compression forces during respiration and the mechanical coupling to spinal movement. Previous experimental models focused on the burden caused by respiration, but are mostly not validated, barely established, and severely limited with respect to the simulation of physiologically occurring forces. Nevertheless, previous results suggested that osteosynthesis of an unstable thoracic wall is essential from a biomechanical point of view to restore the native respiratory mechanics, thoracic shape and spinal stability. Moreover, in vitro studies also showed better stabilizing properties of plate osteosynthesis compared to intramedullary splints, wires or screws. The optimum number and selection of ribs to be fixated for the different types of thoracic wall instability is still unknown from a biomechanical perspective. Future biomechanical investigations should simulate respiratory and spinal movement by means of validated models.

The pelvic vascular injury score (P-VIS): a prehospital instrument to detect significant vascular injury in pelvic fractures.

PURPOSE: The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management. METHODS: To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient's charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012-2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7%): pelvic fracture with significant bleeding (> 20% of blood volume), Injury of the iliac or femoral artery or blood transfusion of ≥ 6 units (pRBC) prior to ICU admission. The multivariate analysis revealed nine items that constitute the pelvic vascular injury score (P-VIS). RESULTS: In study (1), 467 blunt pelvic trauma patients were included of which 24 (PVI) were presented with significant vascular injury (PVI, N = 24; control (C, N = 443). Patients with pelvic fractures and vascular injury showed a higher ISS, lower haemoglobin at admission and lower blood pressure. Their mortality rate was higher (PVI: 17.4%, C: 10.3%). In the defining and validating process of the score within the TR-DGU, 9227 patients met the inclusion criteria. 2090 patients showed significant peripelvic vascular injury (PVITR-DGU), the remaining 7137 formed the control group (CTR-DGU). Nine predictive parameters for peripelvic vascular injury constituted the peripelvic vascular injury score (P-VIS): age ≥ 70 years, high-energy-trauma, penetrating trauma/open pelvic injury, shock index ≥ 1, cardio-pulmonary-resuscitation (CPR), substitution of > 1 l fluid, intubation, necessity of catecholamine substitution, remaining shock (≤ 90 mmHg) under therapy. The multi-dimensional scoring system leads to an ordinal scaled rating according to the probability of the presence of a vascular injury. A score of ≥ 3 points described the peripelvic vascular injury as probable, a result of ≥ 6 points identified a most likely vascular injury and a score of 9 points identified an apparent peripelvic vascular injury. Reapplying this score to the study population a median score of 5 points (range 3-8) (PVI) and a median score of 2 points (range 0-3) (C) (p < 0.001). The OR for peripelvic vascular injury was 24.3 for the patients who scored > 3 points vs. ≤ 2 points. The TR-DGU data set verified these findings (median of 2 points in CTR-DGU vs. median of 3 points with in PVITR-DGU). CONCLUSION: The pelvic vascular injury score (P-VIS) allows an initial risk assessment for the presence of a vascular injury in patients with unstable pelvic injury. Thus, the management of these patients can be positively influenced at a very early stage, prehospital resuscitation performed safely targeted and further resources can be activated in the final treating Trauma Centre.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. / Bildgebung bei Kindern und Jugendlichen intraoperativ, bei ausgewählten Frakturen und im Verlauf nach konservativer und operativer Behandlung : Teil 2 der Ergebnisse einer bundesweiten Online-Umfrage der Sektion Kindertraumatologie der Deutschen Gesellschaft für Unfallchirurgie.

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair. METHODS: An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons. RESULTS: Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks. DISCUSSION: The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed. CONCLUSION: Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

[Imaging after trauma in clinics and practice for children and adolescents : Part 1 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. / Bildgebung nach Unfall in Klinik und Praxis bei Kindern und Jugendlichen : Teil 1 der Ergebnisse einer bundesweiten Online-Umfrage der Sektion Kindertraumatologie der Deutschen Gesellschaft für Unfallchirurgie.

BACKGROUND: The indication for radiography should strictly follow the ALARA (as low as reasonably achievable) principle in pediatric and adolescent trauma patients. The effect of radiation on the growing sensitive tissue of these patients should not be disregarded. QUESTION: The Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) wanted to clarify how the principle is followed in trauma care. METHODS: An online survey was open for 10 weeks. Target groups were trauma surgeons, pediatric surgeons, general surgeons, and orthopedic surgeons. RESULTS: From Nov. 15, 2019, to Feb. 29, 2020, 788 physicians participated: branch office 20.56%, MVZ 4.31%, hospital 75.13%; resident 16.62%, senior 38.07%, chief 22.59%. By specialist qualification, the distribution was: 38.34% surgery, 33.16% trauma surgery, 36.66% special trauma surgery, 70.34% orthopedics and trauma surgery, 18.78% pediatric surgery. Frequency of contact with fractures in the above age group was reported as 37% < 10/month, 27% < 20/M, 36% > 20/M. About 52% always request radiographs in 2 planes after acute trauma. X-ray of the opposite side for unclear findings was rejected by 70%. 23% use sonography regularly in fracture diagnosis. In polytrauma children and adolescents, whole-body CT is never used in 18%, rarely in 50%, and standard in 14%. DISCUSSION: The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. CONCLUSION: Comparing the results of the survey with the consensus findings of the SKT recently published in this journal, persuasion is still needed to change the use of radiography in primary diagnosis.

[Periprosthetic acetabular fractures and defects : Trauma meets ortho]. / Periprothetische acetabuläre Frakturen und Defekte : Trauma meets Ortho.

BACKGROUND: Periprosthetic acetabular fractures are considered to be a severe and challenging complication in total hip arthroplasty. To date, there are no internationally applicable standardized recommendations which can assist orthopedic surgeons and trauma surgeons in the treatment of patients. OBJECTIVE: The aim of this article is to report on the current state of knowledge on periprosthetic acetabular fractures, to present the commonly used classification systems and to demonstrate appropriate treatment algorithms together with personal experiences. MATERIAL AND METHODS: A selective search of the existing literature was carried out and the commonly used classification systems and treatment options for periprosthetic acetabular fractures were compiled and are discussed in relation to the in-house cases. RESULTS: The comparison of the classification systems showed that frequently only fractures which have a purely traumatic origin are included among periprosthetic acetabular fractures. Insufficiency fractures within the framework of acetabular defects, which also belong to the group of acetabular fractures, are frequently included in revision arthroplasty. The management of defects with appropriate implants represents a challenge. By the combination of osteosynthesis and implant replacement, the selection of implants can often be de-escalated. CONCLUSION: Periprosthetic acetabular fractures represent a complex operation for both trauma surgeons and for specially trained orthopedic surgeons, which necessitate a high level of expertise. By the cooperation between trauma surgeons and orthopedic surgeons good treatment results can be achieved and recommendations for the selection of implants can be made.

Prevention of severe injuries of child passengers in motor vehicle accidents: is re-boarding sufficient?

PURPOSE: The purpose of this study was to evaluate whether prolonged re-boarding of restraint children in motor vehicle accidents is sufficient to prevent severe injury. METHODS: Data acquisition was performed using the Trauma Register DGU® (TR-DGU) in the time period from 2010 to 2019 of seriously injured children (AIS 2 +) aged 0-5 years as motor vehicle passengers (MVP). Primarily treated and transferred patients where included. RESULTS: The study group included 727 of 2030 (35.8%) children, who were severely injured (AIS 2 +) in road traffic accidents, among them 268 (13.2%) as MVPs in the age groups: 0-1 years (42.5%), 2-3 years (26.1%) and 4-5 years (31.3%). The pattern of severe injury was head/brain (56.0%), thoracic (42.2%), abdominal (13.1%), fractures (extremities and pelvis, 52.6%) and spine/severe whiplash (19.8%). The 0-1-year-old MVPs showed the significantly highest proportion of brain injuries with Glasgow Coma Score (GCS) < 8 and severe injury to the spine. The 2-3-year-olds showed the significantly highest proportion of fractures especially the lower extremity and highest proportion of cervical spine injuries of all spine injuries, while the 4-5-year-olds, the significantly highest proportion of abdominal injury and second highest proportion of cervical spine injury of all spine injuries. MVPs of the 0-1-year-old and 2-3-year-old groups showed a higher median Injury Severity Score (ISS) of 21.5 and 22.1 points than the older children (17.0 points). They also suffered an AIS-6-injury significantly more often (9 of 21) of spine (p = 0.001). Especially the cervical spine was significantly more often involved. Passengers at the age of 0-1 years were treated with cardiopulmonary resuscitation (CPR) three times as often as older children in the prehospital setting and twice as often at admission in the Trauma Resuscitation Unit (TRU). Their survival rate was 7 out of 8 (0-1 years), 1 out of 6 (2-3 years) and 1 out of 4 (4-5 years). CONCLUSION: Although the younger MVPs are restraint in a re-boarding position, severe injury to the spine and head occurred more often, while older children as front-faced positioned MVPs suffered from significantly higher rates of abdominal and more often severe facial injury. Our data show, that it is more important to properly restrain children in their adequate car seats (i-size-Norm) and additionally consider the age-related physiological and anatomical specific risks of injury as well as co-factors in road traffic accidents, than only prolonging the re-boarding position over the age of 15 months as a single method.

Diagnostic value of chest radiography in the early management of severely injured patients with mediastinal vascular injury.

INTRODUCTION: Time is of the essence in the management of severely injured patients. This is especially true in patients with mediastinal vascular injury (MVI). This rare, yet life threatening injury needs early detection and immediate decision making. According to the ATLS guidelines [American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018], chest radiography (CXR) is one of the first-line imaging examinations in the Trauma Resuscitation Unit (TRU), especially in patients with MVI. Yet thorough interpretation and the competence of identifying pathological findings are essential for accurate diagnosis and drawing appropriate conclusion for further management. The present study evaluates the role of CXR in detecting MVI in the early management of severely injured patients. METHOD: We addressed the question in two ways. (1) We performed a retrospective, observational, single-center study and included all primary blunt trauma patients over a period of 2 years that had been admitted to the TRU of a Level-I Trauma Center. Mediastinal/chest (M/C) ratio measurements were calculated from CXRs at three different levels of the mediastinum to identify MVI. Two groups were built: with MVI (VThx) and without MVI (control). The accuracy of the CXR findings were compared with the results of whole-body computed tomography scans (WBCT). (2) We performed another retrospective study and evaluated the usage of sonography, CXR and WBCT over 15 years (2005-2019) in level-I-III Trauma Centers in Germany as documented in the TraumaRegister DGU® (TR-DGU). RESULTS: Study I showed that in 2 years 267 patients suffered from a significant blunt thoracic trauma (AIS ≥ 3) and met the inclusion criteria. 27 (10%) of them suffered MVI (VThx). Through the initial CXR in a supine position, MVI was detected in 56-92.6% at aortic arch level and in 44.4-100% at valve level, depending on different M/C-ratios (2.0-3.0). The specificity at different thresholds of M/C ratio was 63.3-2.9% at aortic arch level and 52.9-0.4% at valve level. The ROC curve showed a statistically random process. No significant differences of the cardiac silhouette were observed between VThx and Control (mean cardiac width was 136.5 mm, p = 0.44). Study II included 251,095 patients from the TR-DGU. A continuous reduction of the usage of CXR in the TRU could be observed from 75% in 2005 to 25% in 2019. WBCT usage increased from 35% in 2005 to 80% in 2019. This development was observed in all trauma centers independently from their designated level of care. CONCLUSION: According to the TRU management guidelines (American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018; Reissig and Kroegel in Eur J Radiol 53:463-470, 2005) CXR in supine position is performed to detect pneumothorax, hemothorax and MVI. Our study showed that sensitivity and specificity of CXR in detecting MVI was statistically and clinically not reliable. Previous studies have already shown that CXR is inferior to sonography in detecting pneumothorax and hemothorax. Therefore, we challenge the guidelines and suggest that the use of CXR in the early management of severely injured patients should be individualized. If sonography and WBCT are available and reasonable, CXR is unnecessary and time consuming. The clinical reality reflected in the usage of CXR and WBCT over time, as documented in the TR-DGU, seems to support our statement.

[Pipkin fractures]. / Pipkin-Frakturen.

Femoral head fractures a very rare emergency situation and occur in 4-17% of hip joint dislocations. Of femoral head dislocation fractures 3.7% occur in combination with acetabular fractures. Reduction of the dislocation should be immediately performed. Decisive for whether treatment should be conservative or surgical by resection of the fragments, reconstruction of the femoral head or prosthetic joint replacement, is the grading of the fracture type using the Pipkin classification. Surgical treatment appears to give a better outcome in Pipkin type 1 and Pipkin type 2 fractures than conservative treatment. The in-house cohort of patients showed a good long-term outcome after surgical reconstruction. The follow-up treatment is carried out with 6 weeks of floor contact and pharmaceutical ossification prophylaxis. The danger of secondary femoral head necrosis needs to be considered at all times. In patients aged > 65 years a primary endoprosthetic joint replacement is indicated.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®.

PURPOSE: In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay. METHODS: Data from the TraumaRegister DGU® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability. RESULTS: In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h. CONCLUSIONS: In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

Anatomic reduction of the sacroiliac joint in unstable pelvic ring injuries and its correlation with functional outcome.

PURPOSE: Reduction and percutaneous screw fixation of sacroiliac joint disruptions and sacral fractures are surgical procedures for stabilizing the posterior pelvic ring. It is unknown, however, whether smaller irregularities or the inability to achieve an anatomic reduction of the joint and the posterior pelvic ring affects the functional outcome. Here, the long-term well-being of patients with and without anatomic reduction of the posterior pelvis after sacroiliac joint disruptions is described. METHODS: Between 2011 and 2017, 155 patients with pelvic injuries underwent surgical treatment. Of these, 39 patients with sacroiliac joint disruption were examined by radiological images and computer tomography (CT) diagnostics and classified according to Tile. The functional outcome of the different surgical treatments was assessed using the short form health survey-36 (SF-36) and the Majeed pelvic score. RESULTS: Complete data sets were available for 31 patients, including 14 Tile type C and 17 type B injuries. Of those, 26 patients received an anatomic reduction, 5 patients obtained a shift up to 10 mm (range 5-10 mm). The SF-36 survey showed that the anatomic reduction was significantly better in restoring the patient's well being (vitality, bodily pain, general mental health and emotional well-being). Patients without this treatment reported a decrease in their general health status. CONCLUSIONS: Anatomic reduction was achieved in over 80% of patients in this study. When comparing the long-term well-being of patients with and without anatomic reduction of the posterior pelvis after sacroiliac joint disruptions, the results suggest that anatomical restoration of the joint is beneficial for the patients.

Analysis of trans-sacral corridors in stabilization of fractures of the pelvic ring.

Percutaneous screw fixation combined with pelvic reduction is a surgical technique used to stabilize fractures of the posterior pelvic ring. This is the standard surgical treatment of unstable posterior pelvic ring injuries. The primary goal of this treatment is an anatomic reduction and stable fixation. This has been shown to reduce pain and improve the patients' long-term well-being. The aim of this analysis was to determine the possible screw lengths and the positioning of the screws in the S1 and S2 sacral segments. A population of 697 pelvises from the Stryker Orthopaedic Modeling and Analytics database were analyzed. The dimensions of the S1 and S2 screw corridors were determined and after assessing for sacral dysmorphism, the correct screw placement was chosen to determine the necessary screw length for surgical treatment. The measurements of the screw lengths show a Gaussian distribution for the analyzed population. The percentage of dysmorphic pelvises for the S1 screw corridor was 31.3% and for the S2 corridor 8%. Average screw length for S1 was 163.8 ± 16.2 mm and for the S2 137.3 ± 9.5 mm. The results show that the S1/S2 axis cannot be used for a trans-sacral screw placement in every patient. The study shows that intraosseous screw corridors are present in 68.7% of the patients in the S1 position and in 92% at the S2 level where an intended implant can be placed fully intraosseous.

A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries.

BACKGROUND: Fragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment. METHODS: Between 2011-2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36). RESULTS: Thirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to "no pain" and 10 means "strongest pain". Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health. CONCLUSIONS: Patients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment. TRIAL REGISTRATION: Functional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768 .

Perioperative and posttraumatic anti-edematous decongestive device-based negative pressure treatment for anti-edematous swelling treatment of the lower extremity - a prospective quality study.

BACKGROUND: The perioperative management of trauma cases and orthopedic procedures is negatively influenced by tissue swelling and edema. They delay surgical treatment, extend stay in hospital and prolong the overall time of convalescence. In case of traumatic or postoperative edema the limited transport capacity (missing muscle pump and destruction of lymphatic channels) is casual. Edema mostly results in pain, limited function of the extremity, change in shape, higher infection rate and wound disorders. Manual lymph drainage (MLD) is a treatment option with respect to the complex physical decongestion (CPD). OBJECTIVE: To evaluate whether a device-based negative pressure lymph drainage (NPLD) is capable of reducing posttraumatic and perioperative swelling of the lower extremity effectively and sustainably. METHODS: Prospective quality study submitted to the Ethics Committee. The patients only received the procedures after signing the informed consent. The negative pressure was applied locally by using LymphaTouch® device (LT) (FDA approved) with a silicone-coated applicator. The lymphatic drainage had been either applied by a local stationary manner or by using the "Lift + Twist" technique. A negative pressure has been adjusted between 50-250 mm Hg depending on the skin and tissue texture. The frequency was chosen between 90-70 Hz. Type of application: pulsed or continuous negative pressure treatment. The procedure always began in the supraclavicular fossa and continued until reaching the area of surgery in the lower extremity. Duration approx. 30 min. The patient was encouraged to drink fluids after the LymphaTouch treatment (LTT). The results were documented by measurement of the girth and movement according to neutral-zero-method (NZM) and photographs. STATISTICS: Multi-variance, Wilcoxon test non-parametric. INCLUSION CRITERIA: Patients with injury to the lower extremity (LE), elective patients, age > 18 years, signed informed consent. RESULTS: 101 patients with injuries/surgical interventions to the lower extremity, age: 64.9 ± 13.17 years. The swelling was more pronounced at the knee. After 4 treatments, there was a measurable decrease in swelling of 11.6% at the lower extremity. In patients with trauma to the hip joint or hip interventions, the swelling at the femur was reduced by 8.6% between LTT 0 vs. 4. In patients with trauma to the knee joint and surgical interventions, significantly more female patients showed a positive effect to LTT. The mobility improved substantially, while the level of pain decreased. The patients reported immediate pain relief. No complications occurred. CONCLUSION: The perioperative and posttraumatic swelling at the lower extremity can be positively affected by the LT-NPLD within the first days. The preoperative duration until surgical intervention was decreased. The postoperative stage of wound and soft tissue swelling was reduced.

Biomechanical evaluation of self-cinching stitch techniques in rotator cuff repair: The single-loop and double-loop knot stitches.

In rotator cuff repair, strong and reliable suturing is necessary to decrease failure rates. The biomechanics of two self-cinching stitches - the single-loop knot stitch (SLKS) and the double-loop knot stitch (DLKS) - and the modified Mason-Allen stitch (mMAS) were compared. Twenty-seven porcine infraspinatus tendons were randomized among the three stitches. Each was cyclically loaded (10-80-200 N for 50 cycles each) while the gap formation was measured. Next, ultimate load to failure was tested. The gap widths after cyclic loading were 8.72 ± 0.93 mm for the DLKS, 8.65 ± 1.33 mm for the mMAS, and 9.14 ± 0.89 mm for the SLKS, without significant differences. The DLKS showed the highest ultimate load (350.52 ± 38.54 N) compared with the mMAS (320.88 ± 53.29 N; p = 0.304) and the SLKS (290.54 ± 60.51 N; p < 0.05). The DLKS showed similar reliability and better strength compared with the mMAS, while the SLKS showed a slight but not significant decrease in performance. In our experience, the DLKS and SLKS have clinical advantages, as they are easy to perform and the self-cinching loop knot allows the surgeon to grasp degenerative tendon tissue. Initial intraoperative tightening of the suture complex (preloading) before locking is important in order to decrease postoperative elongation.

[Osteosynthesis of the unstable thoracic wall]. / Osteosyntheseverfahren bei Thoraxwandinstabilität.

OBJECTIVE: Surgical stabilization of patients with flail chest, dislocated serial rib and sternal fractures, posttraumatic deformities of the thorax, symptomatic non-unions of the ribs and/or sternum, and weaning failure to biomechanically stabilize the thorax and avoid respirator-dependent complications. INDICATIONS: Combination of clinically and radiologically observed parameters, such as pattern of thoracic injuries, grade of fracture dislocation, pathological changes to breathing biomechanics, and failure of nonsurgical treatment. CONTRAINDICATIONS: Acute hemodynamical instability and signs of systemic infection. SURGICAL TECHNIQUE: Detailed preoperative planning. Open, minimally invasive reduction and osteosynthesis using precontoured, low-profile locking plates and/or intramedullary splints. Careful reduction drilling/implantation of screws due to proximity of the pleura, lungs and pericardium. POSTOPERATIVE MANAGEMENT: Weaning from respirator as early as possible and early therapy of pneumothorax perioperatively. Removal of implants usually not necessary. RESULTS: In a retrospective study, 15 polytraumatized patients with flail chest benefitted from an early interdisciplinary surgical treatment strategy within 24-48 h. Early osteosynthesis after severe thoracic trauma significantly reduced ventilator dependency and lowered the risk of pneumonia compared to patients who underwent surgery at a later time point. Patients with severe thoracic injury and life-threatening polytrauma, who meet the indication criteria for open reduction and surgical stabilization of the thorax, are in need of a throughly planned and interdisciplinary synchronized priorization and strategy. Longer intensive care unit stay, overall prolonged duration of admission in hospital, and higher level of respirator-associated complication should be expected in patients with life-threatening severe thoracic trauma (Abbreviated Injury Score (AIS) ≥ 3) compared to patients without thoracic trauma.