Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals.

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.

Coralline hydroxyapatite reinforced with polylactide fibres in lumbar interbody implantation.

Porous hydroxyapatite HA blocks reinforced with poly-l/dl-lactide fibres were used to maintain the lumbar disc space and to start to create intercorporeal fusion in 23 growing pigs. In four pigs two emptied non adjacent disc spaces were left open. After 3, 6, 12 and 16 weeks the implanted disc blocks were studied radiologically, histologically, histomorphometrically, microradiographically, and with oxytetracycline fluorescence. In plain films slight to moderate ossification of the implanted disc spaces was detected at 12 and 16 weeks. Resorption of the implants was seen radiologically from 3 weeks and fragmentation from 12 weeks onwards. In microradiographs disintegration of the coralline inner structure started at 3 weeks. Histologically, connective tissue ingrowth was seen inside the porous structure from three weeks onwards. Small amounts of new bone were visible and connective tissue inside the implant increased from a mean of 65.6% at 3 weeks to a mean of 79.4% at 16 weeks histomorphometrically. The bone ingrowth varied from 0.7 to 1.7%. A loss of height in the implanted disc spaces was seen (p < 0.05, linear regression analysis). In control pigs the emptied disc spaces lost their height similarly. The implants used were not strong enough to maintain the lumbar disc height.

Bioabsorbable fixation in orthopaedic surgery and traumatology.

Bioabsorbable internal fixation devices were introduced clinically in the treatment of fractures and osteotomies of the extremities at the Department of Orthopaedics and Traumatology, Helsinki University, in 1984. Since November 5, 1984, a total of 3200 patients were managed using bone or ligament fixation devices made of self-reinforced (matrix and fibres of the same polymer) bioabsorbable alpha-hydroxy polyesters. The devices used included cylindrical rods, screws, tacks, plugs, arrows, and wires. The most common indication for the use of bioabsorbable implants was the displaced malleolar fracture of the ankle. Transphyseal fixation with small-diameter, mainly polyglycolide pins was used in children. The postoperative clinical course was uneventful in more than 90% of the patients. The complications included bacterial wound infection in 4% and failure of fixation in 4%. In one-fifth of the latter cases, however, re-operation was not necessary. The occurrence of non-infectious foreign-body reactions two to three months postoperatively has been observed in 2% of the patients operated in the last few years with polyglycolide implants but none of the patients managed with polylactide implants. This inflammatory tissue response often required aspiration with a needle but did not influence the functional or radiologic result of the treatment. Owing to the biodegradability of these internal fixation devices, implant removal procedures were avoided. This results in financial benefits and psychological advantages. Bioabsorbable implants can also be used in open fractures and infection operations.

Absorbable devices in the fixation of fractures.

Totally absorbable internal fracture fixation devices were introduced clinically in the treatment of fractures and osteotomies of the extremities at our department in 1984. A total of 2,500 patients were managed using bone or ligament fixation devices made of self-reinforced (matrix and fibers of same polymer) absorbable alpha-hydroxy polyesters between November 5, 1984, and January 12, 1994. The devices used included cylindrical rods or pins, screws, tacks, plugs, and wires. The most common indication for the use of absorbable implants was displaced malleolar fracture of the ankle. Transphyseal fixation with small-diameter polyglycolide pins was used in children. The postoperative clinical course was uneventful in over 90% of the patients. The complications included bacterial wound infection in 3.6% and failure of fixation in 3.7%. In one-fifth of these cases, however, reoperation was not necessary. The occurrence of noninfectious foreign-body reactions 2 to 3 months postoperatively has been observed in 2.3% of the patients operated in the last years with polyglcolide implants but in none of the patients with polylactide implants. This inflammatory tissue response often required aspiration with a needle or small incision but did not influence the ultimate functional or radiologic result of treatment. Owing to the biodegradability of these internal fixation devices, over 1,000 implant removal procedures were avoided during the 9-year period under review, allowing medical personnel at these facilities to focus on other procedures. Avoidance of removal procedures results in financial benefits and psychological advantages. The benefits of absorbable implants for war surgery are the same as for civilian life. Absorbable implants can also be used in open fractures and infection operations.

Reinsertion of the ruptured ulnar collateral ligament of the metacarpophalangeal joint of the thumb with an absorbable self-reinforced polylactide mini tack.

Total rupture of the ulnar collateral ligament of the first metacarpophalangeal joint is a common injury and it needs to be operated on, otherwise the injured joint will be unstable and it will cause disability due to loss of pinch grip. A special absorbable device--self-reinforced poly-L-lactide mini tack--was used to stabilise this ruptured ligament. 140 patients were operated on because of this ligament injury. The preliminary results after six months' follow-up were good. Normal movement was regained in 118 out of 140 patients (84.3%) and stability in 138 patients (98.6%). Five reoperations (3.6%) were needed--one because of scar pain, one because of local infection nine months postoperatively, one because of instability and two because of late loosening of the tack six and nine months postoperatively. Overall the preliminary results were good. On the basis of these findings we consider this new absorbable fixation method suitable for clinical use for reinserting the ruptured ulnar collateral ligament of the first metacarpophalangeal joint of thumb.

Effect of self-reinforced polyglycolide membranes on cortical bone: an experimental study on rats.

A self-reinforced polyglycolide (SR-PGA) membrane has been developed recently by our research group and testing of it begun. To study the behavior of this membrane and its effect on cortical bone, 93 Wistar rats were operated on. SR-PGA membrane was applied around the rats' femoral diaphyses, either over the periosteum or directly over the bone, after periosteal stripping. In a control group no membrane was applied, but the femoral periosteum was stripped away. The rats were sacrificed 1, 3, 6, 12, 24, and 30 weeks postoperatively. Radiology, histology, oxytetracycline fluorescence labeling, microradiography, and planimetry were used to determine the outcome. A fibrous tissue capsule had formed around and replaced the membrane. SR-PGA membrane had a positive effect on new bone formation. Callus was frequently seen proximally and distally to the implant. Periosteal thickening occurred whether or not SR-PGA membrane was used. PGA fibers decreased in number and diameter continuously until they vanished by 30 weeks. No infections or adverse reactions were encountered. Accordingly, SR-PGA membrane is considered to be biocompatible and applicable in the treatment of cortical bone lesions such as comminuted fractures and defects.

Strength retention of self-reinforced polyglycolide membrane: an experimental study.

Self-reinforced polyglycolide (SR-PGA) devices are stronger than non-reinforced ones. To study the strength retention of SR-PGA membrane, in vitro and in vivo, membranes were either immersed in distilled water at 37 degrees C, or implanted in the subcutis or around the femoral bone of rats. The SR-PGA membranes lost their strength in vitro by 6 wk, while they retained it for 15 wk in vivo due to the fibrous tissue that formed around and inside the implant (biomembrane). This is an advantage when clinical application of the membrane is being considered.

Repair of bone defects with absorbable membranes. A study on rabbits.

Self-reinforced polyglycolic acid (SR-PGA) devices were developed in the mid-eighties, applied for fixation purposes and proved to be biocompatible. In this study SR-PGA membranes (10 x 10 mm) were used to augment defects on the medial aspect of distal femoral metaphysis in 31 New Zealand rabbits. Defects of 3.5 mm were either filled with autografts or left non-grafted. In a control group, no membranes were used. The rabbits were followed up for six, 12 and 24 weeks. Radiography, histology, oxytetracycline (OTC) fluorescence labelling and microradiography were used. Defects where membranes were used, healed by new bone formation. In some cases where polyglycolic acid (PGA) membranes were not used, defects were invaded by fibrous tissue. Membranes sometimes slipped away from their positions opposite to grafted defects. This study proved that the advantage of the use of PGA membranes could be taken in augmentation of cancellous bone defects in rabbits.

The effect of absorbable self-reinforced polyglycolide membrane on metaphyseal bone. An experimental study on rats.

The effect of self-reinforced polyglycolide (SR-PGA) absorbable membranes on metaphyseal bone was studied in eighty-seven rats. SR-PGA membranes, 0.15 mm thick, were implanted on the femoral metaphyseal bone: on the periosteum, and directly on bone after periosteal stripping. In a control group, only periosteal stripping was performed. The rats were killed after 1, 3, 6, 12 and 24 weeks. Fibrous tissue formation around the implant, periosteal thickening and new bone formation occurred more extensively when SR-PGA membranes were implanted directly on bone after periosteal stripping. Fibrous tissue invaded the membranes. At twenty-four weeks, few fibre remnants were found embedded in a rim of fibrous tissue. No locally adverse reactions were recorded. Polyglycolide (PGA) appeared to have a positive inductive effect on new bone formation.

Absorbable membranes for bone repair: an experimental study on rabbits.

To study the use of absorbable self-reinforced polyglycolide (SR-PGA) membranes for bone repair, distal femoral metaphyseal osteotomies were created in 10 rabbits and diaphyseal osteotomies in five. Osteotomies were fixed with intramedullary PLLA rods and PGA membranes were applied over the osteotomy. They were followed up for 6, 12 and 24 weeks. Radiography, histology, microradiography and oxytetracycline fluorescence labelling studies were used to evaluate the outcome. Healing occurred without complications in the metaphyseal series while failure was recorded in the diaphyseal series. In metaphyseal osteotomies, new bone formation was seen medially (on the side of PGA membrane), more proximal and medial to the membrane than at the inlet of osteotomy.

Reinsertion of the ruptured ulnar collateral ligament of the metacarpophalangeal joint with an absorbable self-reinforced polylactide tack.

70 patients with total avulsion or rupture of the ulnar collateral ligament of the first metacarpophalangeal joint were treated surgically, using an absorbable self-reinforced poly-L-lactide mini-tack placed through the ligament and a channel in the base of the proximal phalanx. The device stabilized the joint immediately, and 69 ligaments remained stable at 6 months. The subjective result was good or satisfactory in 66 of the cases. One case needed further surgery for pain in the scar and another developed local infection 9 months post-operatively. On the basis of these findings, the new absorbable fixation method seems to be a suitable method for clinical use.

Intramedullary fixation of cortical bone osteotomies with self-reinforced polylactic rods in rabbits.

Osteotomies of the femoral shaft in rabbits were fixed with intramedullary rods made of poly-L-lactic acid (SR-PLLA) and poly-DL/L-lactic acid (SR-PDLLA/PLLA). Follow up was from one week to 2 years. In the PLLA group, in 37 out of 40 osteotomies the fixation was firm and the bone was united. In the PDLLA/PLLA group, the fixation was firm in 30 out of 45, but in 13 of these angular deformity of more than 10 degrees had occurred. The fixation had failed in 15. No inflammatory or foreign body reaction was seen in either group. This study demonstrates that SR-PLLA rods are suitable fixation for cortical osteotomies in rabbits.

Self-reinforced absorbable screws in the fixation of displaced ankle fractures: a prospective clinical study of 152 patients.

The series consisted of 152 patients with ankle fractures treated between May 1987 and August 1989 using absorbable screws of self-reinforced polyglycolide 3.4 mm in inner diameter and 25-70 mm in length. The mean follow-up time was 2 years, 5 months (range, 1 year, 7 months-3 years, 10 months). After open reduction, a channel was drilled through the fracture surfaces and the fragments were fixed with one absorbable screw or screws. A plaster cast was used postoperatively. At 1-year follow-up observation, the radiographical result was anatomical in 93.3% of 104 patients with unimalleolar and bimalleolar ankle fractures (Weber A or B) and in 80.5% of 41 severe ankle fractures. Seven patients were unavailable for follow-up observation. Two reoperations were performed because of primary or secondary failure of fixation. In all unimalleolar and bimalleolar fractures and in 95.1% of severe ankle fractures the functional recovery score was at least satisfactory. Sinus formation as a sign of tissue reaction was observed in 10 patients 2-6 months postoperatively, but this did not influence the healing of the fracture or the functional recovery. This report is the first extensive publication on the clinical use of absorbable screws.

Preliminary study of porous hydroxylapatite particle containment with a curved biodegradable implant in the sheep mandible.

A conventional augmentation method without a splint was compared with the use of a biodegradable polyglycolide (PGA) splint as a container of hydroxylapatite (HA) particles. With the PGA splint there was a 35% rate of dehiscence of the incision, leading to loss of HA particles. Based on microradiographic measurements, the HA was retained better on the side augmented by the conventional technique. Toward the end of 24 weeks, however, a decrease of augmentation and in the quantity of HA was seen with both methods. According to the histologic studies, there was evidence of HA phagocytosis by osteoclast-type cells. In the histomorphometric studies after 24 weeks of follow-up, new bone ingrowth was 12% without and 10% with the PGA splint. Although the planimetric studies showed the PGA splint to be a good container, the material still requires further development.

Absorption, biocompatibility, and fixation properties of polylactic acid in bone tissue: an experimental study in rats.

The absorption, biocompatibility, and fixation properties of self-reinforced (SR) poly-L-lactic acid (PLLA) and poly-DL-lactic acid (PDLLA) were investigated in cancellous bone in 56 rats. Osteotomies of the distal femur were operatively fixed with cylindrical implants made of SR-PLLA and SR-PDLLA/PLLA (40 PDLLA:60 PLLA). The follow-up times were one, three, six, 12, 24, 36, and 48 weeks. Roentgenographic, microradiographic, histologic, histomorphometric, and oxytetracycline-labeling studies were done. Histologically, there was no evidence of inflammation or foreign-body reaction in the bony tissues. Histomorphometric analysis showed that absorption in the SR-PDLLA/PLLA implant was faster than in the SR-PLLA implant. Absorption started peripherally in the implants and continued with subsequent replacement by new bone. At 48 weeks the implant was completely surrounded by a layer of new bone. The SR-PLLA and SR-PDLLA/PLLA implants were visible in all specimens during the 48-week follow-up period. Ninety-five percent of the osteotomies were consolidated. Implants made of SR polylactic acid in rats proved to be biocompatible and slowly absorbable, and they possessed sufficient mechanical properties for fixation of osteotomies.

Left atrial rupture following blunt thoracic injury. Case report.

A 22-year-old man presented with intermittent tachycardia and left-sided flail chest after an automobile accident. Initially his condition was stable, but 7 hours after the injury cardiac asystole appeared. Cardiopulmonary resuscitation was immediately begun and operation was performed. A rupture of the left atrium was successfully repaired without cardiopulmonary bypass.

A histomorphological study on self-reinforced polyglycolide (SR-PGA) osteosynthesis implants coated with slowly absorbable polymers.

A total of 150 osteotomies of rabbits' distal femur were fixed with absorbable self-reinforced polyglycolide (SR-PGA) rods coated with slowly absorbable polymers. In order to reduce the degradation rate of the SR-PGA construction rods were coated with n-butyl-2-cyanoacrylate, polydioxanone (PDS), poly-beta-hydroxybutyrate (PHBA), or poly-l-lactide (PLLA). Biocompatibility and the rate of biodegradation were evaluated in histological, histomorphometric, microradiographic, and oxytetracycline labeling studies. PDS, PHBA, and PLLA coatings showed good biocompatibility although there were scattered fluid accumulations around the rod in each group. Cyanoacrylate coating seemed to inhibit cartilage regeneration and cause the formation of considerable amount of connective tissue around the implant. The PGA core of the rod had totally degraded in 24 to 36 weeks in each coating group. Cyanoacrylate and PDS coatings were not detectable after 6 weeks while PHBA and PLLA coatings were still observed after 48 weeks. There were five (14%) non-unions in the cyanoacrylate coating group, one (3%) in the PHBA coating group caused by a purulent infection and none in the PDS and PLLA coating groups.

Comparison of in vitro hydrolysis, subcutaneous and intramedullary implantation to evaluate the strength retention of absorbable osteosynthesis implants.

To evaluate the behaviour of mechanical properties of absorbable osteosynthesis implants in vivo, the strength retention of self-reinforced polyglycolide rods in distilled water at 37 degrees C in the subcutis and femoral medullary cavity of the rabbit was investigated. The self-reinforced polyglycolide rods lost their strength significantly faster in vivo than in vitro. The strength loss of the self-reinforced polyglycolide rods was only slightly faster in the medullary cavity than in the subcutis. As the removal of the implants from the medullary cavity became difficult 5-6 wk after implantation, it is suggested that subcutaneous implantation would be a suitable method to evaluate the strength retention of absorbable osteosynthesis implants.

Degradable polyglycolide rods for the internal fixation of displaced bimalleolar fractures.

Cylindrical biodegradable rods of self-reinforced polyglycolide were constructed for internal fixation of fractures in cancellous bone. The self-reinforced texture was achieved by embedding polyglycolide fibres in a polyglycolide matrix. In a prospective clinical study, 62 patients with displaced bimalleolar fractures were managed by open reduction and internal fixation using these rods. The results were assessed between 1.1 and 3.4 years from implantation. One wound infection occurred (1.6%). Five patients (8.1%) developed a sterile accumulation of fluid at the site of operation which required drainage: the final outcome was not affected. Minor displacement of the fracture (1-2 mm) occurred in nine patients (14.5%) but did not need further operation. The functional result was excellent in 39 patients (63%). This was considered acceptable given the severity of the fractures. Consequently, at our hospital, when a displaced malleolar fracture needs internal fixation biodegradable rods are now the treatment of choice. The psychological and financial advantages of avoiding implant removal are considerable.