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Purpose The aim of this retrospective analysis was to investigate and evaluate differences in functional outcome and satisfaction of patients treated with a TOPS and patients using socket prosthesis after transfemoral amputation. Methods This retrospective comprehensive analysis included patients from a single hospital, and was conducted between February 2017 and December 2018. Overall n = 139 patients with prosthesis were included and divided into two comparable groups (socket- and TOPS group). Incomplete data sets were excluded. This led to n = 36 participants for the socket- and n = 33 for the TOPS group. Functional outcome and satisfaction were evaluated by Patient Reported Outcome Measures (PROMs). The used PROMs were: Questionnaire for Persons with a Transfemoral Amputation (Q-TFA), EQ5D-5L, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Prosthesis Mobility Questionnaire (PMQ 2.0) and Functional Independence Measure (FIM). Results Significant results in favor of TOPS patients were identified for the EQ-5D 5L (p = 0.004), Q-TFA (p = 0.000), SAT-PRO (p = 0.000) and PMQ 2.0 (p = 0.000). For FIM, no statistical significance was found (p = 0.318). Conclusion In this study, transfemoral amputees treated with an osseointegrated prosthetic attachment (TOPS) showed significantly higher scores for mobility and satisfaction. This demonstrates the high potential of TOPS in the prosthetic treatment of patients with transfemoral amputation with regard to their functional abilities in daily life.

Background The role of factor XIII (FXIII) in trauma-induced coagulopathy (TIC) is not fully understood. Methods We evaluated FXIII supplementation in severely injured patients with persistent bleeding. This was a retrospective case series analysis. Results Twenty-four patients received FXIII concentrate within 24 h of admission for bleeding that continued after transfusion of > 6 U red blood cells (RBCs); control patients (n = 27) did not receive FXIII concentrate. Both study groups were similar regarding injury severity score and global coagulation tests, but FXIII activity levels were significantly higher and lactate levels significantly lower in the control group, respectively. The differences in FXIII activity between the groups could be attributed to a more severe trauma-induced coagulopathy in FXIII-deficient patients, as demonstrated by lower fibrinogen and higher lactate levels. The median dose of FXIII concentrate within 24 h of admission was 2500 IU (IQR: 1250–4375). Median 24-h transfusion of RBCs (primary study endpoint) was significantly higher in the FXIII group versus controls (10.0 U, IQR 5–14 U vs. 2, IQR 0–6 U; p Conclusions The substitution of FXIII in patients who were more seriously compromised due to higher lactate levels and who presented with initially more severe bleedings than patients in the control group, resulted in a comparable transfusion necessity after 24 h. Thus, we guess that the substitution of FXIII in severely injured patients with ongoing bleeding might have an impact on their clinical outcome.

Objective Geriatric patients account for a significant proportion of the collective treated by psychiatric consultation service in hospitals. In the Emergency Department (ED), psychotropic drugs are frequently recommended, notwithstanding their extensive side-effect profiles. This study sought to investigate medication safety of geriatric patients referred to psychiatric consultation service in the ED. Methods Medication lists of 60 patients from the general internal medicine and trauma surgery EDs referred to psychiatric consultation service were analyzed. Utilizing PRISCUS list and Fit fOR The Aged (FORTA) classification, prescriptions of potentially inappropriate medications (PIMs) were assessed. Results 84 drugs were newly prescribed following psychiatric consultations. The total number of drugs per patient was 5.4 ± 4.2 before psychiatric consultation and 6.5 ± 4.2 thereafter ( p < .001). 22.6 % of the newly recommended drugs were PIMs according to the PRISCUS list, while 54.8 % were designated as therapeutic alternatives to PIMs. 54.8 % and 20.2 % of the newly recommended drugs were FORTA category C and D drugs, respectively. An average of 1.2 ± 1.7 drug–drug interactions (DDIs) existed before psychiatric consultation and 1.3 ± 1.9 DDIs thereafter ( p = .08). Conclusion The majority of newly recommended drugs by psychiatric consultation service in the ED were designated as suitable therapeutic alternatives to PIMs according to the PRISCUS list, but had comparatively unfavorable ratings according to the FORTA classification, demonstrating discrepancies between these two PIM classification systems. Physicians delivering psychiatric consultation services in the ED should not solely rely on one PIM classification system.

We present a rare case of neglected hip dislocation in a 3-year-old boy. Hip dislocations in childhood represent less than 6% of all injuries. The boy presented to the ED with ongoing hip pain after his leg got stuck in a carousel. The physical and radiologic examination revealed a posterior right hip dislocation. The closed reduction failed, so open reduction during surgery was performed. The postoperative protocol included 3 days of immobilization with early mobilization and pain-adapted weight bearing. No signs of femoral head malperfusion occurred 2 months after the injury. The patient did not complain of any limitations such as weight bearing problems or loss of range of motion. In comparison to adults, there are several specialties such as the fact that minor trauma can lead to hip dislocations due to the laxity of the ligaments, and due to the limited direct anamnestic options, neglected hip dislocations can occur. The treatment should focus on immediate proper reduction. The main complications after traumatic hip dislocation are avascular necrosis of the femoral head, redislocation, and early osteoarthritis.

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.Frakturassoziierte Infektion („fracture-related infections“, FRI) stellen eine Herausforderung für die unfallchirurgische Versorgung dar. Die Probleme in der Behandlung solcher Infektionen sind vielfältig. Insbesondere bei noch nicht abgeschlossener Frakturheilung sind neben der Infektsanierung zusätzlich die Widerherstellung der knöchernen Kontinuität zu adressieren. Das Ausmaß der begleitenden Weichteilschädigung ist von besonderer Relevanz, da eine reduzierte Vaskularisation zu Einschränkungen in der Frakturheilung führt. Während akute Infektionen häufig einfach zu erkennen sind, können die Symptome bei chronischen Infektionen unspezifisch sein und sich der Diagnostik entziehen. Diese Tatsache macht die Behandlung solcher Infektionen kompliziert und erfordert z. T. ein interdisziplinäres Vorgehen. Aus diesem Grund hat die „Fracture-related Infection Consensus Group“ einen Algorithmus entwickelt, der erstmals 2017 publiziert sowie 2018 und 2020 erneuert wurde. Bei den FRI handelt es sich um biofilmassoziierte Infektionen, sodass die aktuellen Richtlinien sich an die bereits etablierten Therapiealgorithmen für periprothetische Infektionen anlehnen. Trotz der Analogien zu periprothetischen Infektionen bestehen auch Unterschiede bei der Behandlung, da die Aspekte der Frakturheilung und Knochendefektsanierung einen determinierenden Faktor in der Therapie der FRI darstellen. Im Folgenden werden die Besonderheiten von FRI herausgestellt sowie die Klassifikationen und ein Leitfaden zur Behandlung erörtert.

While improvements in pre-hospital and in-hospital care allow more multiple trauma patients to advance to intensive care, the incidence of posttraumatic multiple organ dysfunction syndrome (MODS) is on the rise. Herein, the influence of a selective IL-6 trans-signaling inhibition on posttraumatic cytokine levels was investigated as an approach to prevent MODS caused by a dysbalanced posttraumatic immune reaction. Therefore, the artificial IL-6 trans-signaling inhibitor sgp130Fc was deployed in a murine multiple trauma model (femoral fracture plus bilateral chest trauma). The traumatized mice were treated with sgp130Fc (FP) and compared to untreated mice (WT) and IL-6 receptor knockout mice (RKO), which received the same traumas. The overall trauma mortality was 4.4%. Microscopic pulmonary changes were apparent after multiple trauma and after isolated bilateral chest trauma. Elevated IL-6, MCP-3 and RANTES plasma levels were measured after trauma, indicating a successful induction of a systemic inflammatory reaction. Significantly reduced IL-6 and RANTES plasma levels were visible in RKO compared to WT. Only a little effect was visible in FP compared to WT. Comparable cytokine levels in WT and FP indicate neither a protective nor an adverse effect of sgp130Fc on the cytokine release after femoral fracture and bilateral chest trauma.

Background: Most patients with blunt aortic injuries, who arrive alive in a clinic, suffer from traumatic pseudoaneurysms. Due to modern treatments, the perioperative mortality has significantly decreased. Therefore, it is unclear how exact the prediction of commonly used scoring systems of the outcome is. Methods: We analyzed data on 65 polytraumatized patients with blunt aortic injuries. The following scores were calculated: injury severity score (ISS), new injury severity score (NISS), trauma and injury severity score (TRISS), revised trauma score coded (RTSc) and acute physiology and chronic health evaluation II (APACHE II). Subsequently, their predictive value was evaluated using Spearman´s and Kendall´s correlation analysis, logistic regression and receiver operating characteristics (ROC) curves. Results: A proportion of 83% of the patients suffered from a thoracic aortic rupture or rupture with concomitant aortic wall dissection (54/65). The overall mortality was 24.6% (16/65). The sensitivity and specificity were calculated as the area under the receiver operating curves (AUC): NISS 0.812, ISS 0.791, APACHE II 0.884, RTSc 0.679 and TRISS 0.761. Logistic regression showed a slightly higher specificity to anatomical scoring systems (ISS 0.959, NISS 0.980, TRISS 0.957, APACHE II 0.938). The sensitivity was highest in the APACHE II with 0.545. Sensitivity and specificity for the RTSc were not significant. Conclusion: The predictive abilities of all scoring systems were very limited. All scoring systems, except the RTSc, had a high specificity but a low sensitivity. In our study population, the RTSc was not applicable. The APACHE II was the most sensitive score for mortality. Anatomical scoring systems showed a positive correlation with the amount of transfused blood products.

Background: Early detection of acute kidney injury (AKI) is crucial in the management of multiple-organ dysfunction syndrome in severely injured patients. Standard laboratory parameters usually increase with temporal delay. Therefore, we evaluated neutrophil gelatinase-associated lipocalin (NGAL) as an early marker for acute kidney injury. Patients and Methods: We retrospectively evaluated patients admitted to a level 1 trauma center. We collected clinicodemographic data and measured kidney-related factors and plasma cytokines. Results: A total of 39 patients were included. Patients with AKI had significantly higher levels not only of serum creatinine and urea, but also of NGAL (all p

Die Arthroskopie am oberen Sprunggelenk ist heute ein Standardverfahren der operativen Orthopadie. Die Operation ist risikoarm und mit hohem Patientenkomfort moglich. Einige Operationen konnen auch ambulant durchgefuhrt werden. Die Bandbreite potenzieller Indikationen wachst dabei stetig. So ist die Arthroskopie mittlerweile das Standardverfahren zur Behandlung weichteiliger und knocherner Impingement-Syndrome. Auch osteochondrale Lasionen konnen haufig arthroskopisch bzw. arthroskopisch assistiert behandelt werden. Fruh- oder Spatsynovialektomien bei entzundlich rheumatischen Arthritiden werden ebenso arthroskopisch durchgefuhrt wie die Akutbehandlung septischer Arthritiden. Daneben konnen arthroskopische Verfahren heute in bestimmten Grenzen bei gewissenhafter Indikationsstellung selbst bei manifester Arthrose erfolgreich angewandt werden. Nowadays, arthroscopy of the upper ankle joint is a standard procedure of orthopedic surgery. The procedure can be performed with little risk and high patient comfort. Furthermore, ambulant surgery is possible for some of the procedures. The bandwidth of potential indications is increasing steadily. Arthroscopic treatment of soft tissue and bony upper ankle impingement is now the standard procedure. Osteochondral lesions can be managed arthroscopic or arthroscopy-assisted as well. Early or late synovectomy in systemic rheumatoid diseases is performed arthroscopically just as acute therapy of septic arthritis. In addition, arthroscopic procedures can nowadays be used in the treatment of manifest osteoarthritis in certain cases.

Background/aim Multiple organ dysfunction syndrome (MODS) is the leading cause of late posttraumatic mortality. This study analyzed the prognostic values of osteoprotegerin (OPG) and neutrophil gelatinase-associated lipocalin (NGAL/lipocalin 2) compared to interleukin-6 (IL-6) in multiply injured patients. Patients and methods A retrospective observational cohort study on multiply injured patients with an injury severity score (ISS) of ≥16 was performed. OPG, NGAL and IL-6 blood concentrations were measured. Statistical analysis comprised receiver-operating-characteristic (ROC) analysis with the corresponding area under the curve (AUC). Results Thirty-nine patients with a mean ISS of 34±11 were included. Fourteen patients (36%) developed MODS and 8 patients (21%) died. Plasma levels of NGAL, OPG, and IL-6 were significantly elevated in the MODS+ group. Each biomarker positively correlated with MODS score and diagnosis of MODS. Conclusion NGAL and OPG might be indicative of MODS and could have the potential to be biomarkers in the early detection of patients at risk of posttraumatic MODS.

Background Flail chest is considered as one of the most severe forms of blunt thoracic trauma. However, its actual influence on post-traumatic morbidity and mortality is debatable. Materials and methods A retrospective cohort analysis was performed of multiply injured patients (injury severity score ≥16) at a level I trauma center. Flail chest was defined as segment fracture of at least three consecutive ribs on at least one side. Propensity score matching was performed. Results A total of 600 patients were included, with a mean age of 44.1±19.1 years and a mean injury severity score of 31.6±10.4. Overall, 367 patients (61.2%) had a serial rib fracture. Forty-five patients (7.5%) presented with flail chest. Patients with flail chest more often had lung contusions (70 vs. 50%, p=0.04) and pneumo-/hematothorax (93 vs. 71%, p=0.005). There were no differences in post-traumatic morbidity and mortality. Conclusion Flail chest had no independent influence in addition to injury severity on post-traumatic morbidity and mortality in multiply injured patients with blunt thoracic trauma.

Introduction Transcutaneous osseointegrated prosthetic systems (TOPS) are anchored prosthetic systems for major limb loss. Sometimes TOPS patients suffer from periprosthetic fractures. The aim of this study was to analyze the management and outcomes of periprosthetic fractures in patients with TOPS and to introduce a novel classification system for this entity. Material/methods Since 2010, 140 patients were treated with TOPS after transfemoral amputation in two centers in Germany. Fifteen patients sustained periprosthetic fractures, with five intra- and ten postoperative fractures. The outcome was analyzed by Prosthesis Mobility Questionnaire (PMQ), K-level and prosthesis wear time per day. A subgroup analysis for the body mass index (BMI) was performed. Results All postoperative fractures were treated with implant-retaining osteosynthesis. Fourteen fractures healed without complications after a mean of 3 months. One postoperative fracture developed a clinically asymptomatic firm non-union. No Endo-Fixstem had to be removed. For the fracture and control group, a significant increase of the PMQ (p p p = 0.002) and overweight patients (p Conclusion Periprosthetic fractures do not necessarily worsen outcomes of TOPS treatment. Proper classification and standardized appropriate treatment strategies according to fracture morphology are paramount for reliably good outcomes. We recommend to not remove or exchange the implant (Endo-Fixstem) even if it is assembly. Higher BMI did not have an impact onto rehabilitation success after TOPS to major limb loss of the lower extremity.

Introduction. Pelvic and lumbar spine injuries are very common especially in multiple trauma patients. The usual mechanism in young patients leading to pelvic fractures is a high-energy trauma such as traffic accidents. In elderly patients, low energy traumas are causal for such injuries. Compared to the high number of patients with pelvic or lumbar spine injuries, cerebral fat embolism is a quite rare finding but it needs to be considered to not misinterpret the radiological findings. Case. We present the case of a 41-year-old patient, who got hit and trapped in the lumbar region by a hydraulic arm in a car repair shop. The patient was primarily admitted to a level II trauma center. The radiological and clinical examinations revealed an open pelvic type C injury in terms of a spinopelvic dissociation, dislocation of the left hip joint, rupture of the mesentery of the rectum and colon sigmoideum, and a complex injury to the left ureter. Additionally, CT scan showed fluid with higher density than cerebro spinal fluid (CSF) in the lateral ventricles indicating an intracranial bleeding. After an immediate surgery to stabilize the patient, he was admitted to a level I trauma center. The reanalysis of the existing CT datasets combined with a new head CT leads to the conclusion that the high density fluid in the lateral ventricles is not a intracranial bleeding but rather fat deriving from the complex pelvic and lumbar spine fracture into the CSF system. Therefore, an immediate operation was performed to stabilize the spinopelvic dissociation and to close the injured dural sheath. Additionally, a ventricle drainage has been placed, which confirmed the diagnosis of intrathecal fat embolism. Afterwards, complex plastic surgery was necessary to restore the soft tissue damage. Conclusions. Intrathecal fat embolism in muliple trauma patients is a rare condition, which should be considered in patients with complex spine or pelvic injuries. It is important to distinguish this rare condition from intracranial bleedings, which are much more common because the consequent therapeutic strategy is quite different. In case of intrathecal fat embolism, a ventricle drainage system should be placed immediately, and the underlying spine or pelvic injuries need to be stabilized combined with closure of the dural sheath to prevent continuous fat embolism and meningeal infection.

Endotracheal intubation (ETI) with direct view laryngoscopy (DL) is the gold standard for airway management. Videolaryngoscopy (VL) can improve glottis visualization, thus facilitating ETI. The aim of this monocentric, randomized, prospective study on a physician staffed German air ambulance is to compare DL and VL for ETI in terms of number of attempts and time as well as visualization of the glottis in a prehospital setting in a physician-based rescue system in adult patients. A power analysis was performed &agrave, priori. We used consecutive on-scene randomization with a sealed envelope system for the DL and VL-group. Successful ETI with first pass success was significantly more frequent with VL than DL and three seconds faster. The percentage of glottis opening and the Cormack &amp, Lehane classification were significantly better with VL than DL. Regarding improved first pass success in ETI with the VL, we would recommend the use of VL for prehospital airway management in physician-based rescue systems.

STUDY DESIGN Retrospective cohort analysis. PURPOSE Comparison of balloon kyphoplasty (BKP) and radiofrequency kyphoplasty (RFK) with respect to height restoration of the fractured vertebral bodies and the pain relief experienced after the surgical procedure. OVERVIEW OF LITERATURE BKP and RFK both offer safe, time-saving, and potent treatment options for vertebral compression fractures, but neither of these methods demonstrated any key advantage over the other yet. METHODS We performed a retrospective analysis of a cohort of 156 patients (mean age, 73±11 years) with 252 fractured vertebral bodies treated with kyphoplasty. Pain intensity was measured using a Visual Analogue Scale. Preoperative and postoperative computed tomography images were analyzed and gauged using modified bisegmental Cobb angle, vertebral angle, as well as anterior (Ha), middle (Hm), and posterior (Hp) vertebral body heights. RESULTS The mean postoperative pain relief was 5.1±1.8, which was maintained over the entire follow-up period. There were no significant differences in the pain relief between BKP and RFK. Postoperative changes in the vertebral angle (-1.3°±3.3°, p

Forearm fractures are frequent in children. It is important to identify predisposing factors for increased fracture risk. This retrospective analysis aimed to investigate the correlation between forearm fractures in children and co-factors such as age, TV consumption, consumption of soft drinks, the kind of soft drinks consumed as well as physical activity in daily life and BMI.This retrospective cohort analysis compared 355 participants at the age of 4 to 12 between 2017 and 2018 with and without forearm fractures in children. It was based on a questionnaire to assess the above-mentioned cofactors regarding behavior and lifestyles choices and aimed to identify whether or not these lead to an increased risk of forearm fractures. For statistical analysis logistic regression was used.Logistic regression showed a significant effect on forearm fractures in children for the variables age (Odds ratio 3.3 [95% confidence interval 1.5-7.3], P = .003), TV consumption (Odds ratio 5.4 [95% confidence interval 2.5-22.6], P .001), consumption of soft drinks (Odds ratio 2.6 [95% confidence interval 1.2-5.6], P = .013), and the kind of soft drinks consumed (Odds ratio 3.1 [95% confidence interval 1.5-6.3], P = .003), [Nagelkerkes-RThe study showed a significant correlation between TV and soft drink consumption and increased risk for forearm fractures in children. TV consumption and consumption of soft drinks should be reduced in children to prevent forearm fractures.

Aims To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. Patients and Methods A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients’ injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. Results In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Conclusion Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255–60.

Pediatric proximal femoral fractures are not common (about 1% of all pediatric fractures) with potentially devastating complications. Post-traumatic avascular necrosis following pediatric femoral neck fractures remains unsolved problem. The factors that were found to be predictors for avascular necrosis include age, fracture type, and displacement. To decrease the incidence of this complication, many authors recommend treating displaced proximal femoral fractures with urgent open anatomic reduction and stable internal fixation to help improve long-term outcomes.

Christoph Life is a simulator-based air medical training program and a new and innovative educational concept. Participants pass different scenarios with a fully equipped and movable helicopter simulator. Main focuses of the program are crew resource management (CRM) elements and team training. Information about expectations end effectiveness of the training is sparse.During a 2-day training, participants learn CRM basics and complete various emergency medical scenarios. For evaluation, we used an anonymous questionnaire either with polar questions or a 6-coded psychometric Likert scale. The Wilcoxon test was used for statistical analysis. The significance level was set at P.05.Thirteen teams of emergency physicians and specially trained paramedics underwent Christoph Life. It was evaluated largely positively and considered very helpful for daily work (5.7 ± 0.5) and avoiding mistakes (5.7 ± 0.5). The quality of participants' knowledge about CRM basics (3.5 ± 1.2 vs. 5.4 ± 0.7, P.001), self-assessment of communication skills (4.2 ± 0.7 vs. 4.8 ± 0.8, P = .02), and active reflection of communication aspects (3.9 ± 0.9 vs. 5.5 ± 0.5, P.001) could be strikingly increased.There is a considerable demand for intensified training on the part of the users. We were able to show that a simulator-based air medical training program is a helpful training tool with an obvious subjective benefit for the participants' nontechnical skills.

Introduction Occupational infection of clinical health care workers with blood-borne viruses (BBVs) like human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) is a current and often emotionally discussed issue. HCV and especially HIV are still stigmatized. The consequence is a broad and maybe irrational fear of professional health care workers being infected occupationally. Therefore, we assessed preoperative screening to: (1) answer whether this can detect not previously diagnosed blood-borne virus infections to a great extent, (2) calculate a cost-benefit ratio to find out, if the screening's potential ability to prevent occupational transmission of BBVs to health care workers faces unjustifiable high costs. Hypothesis Preoperative routine screening is limited suitable for enhancement of detecting fomites compared to interview the patient. Materials and methods Retrospective cohort study of preoperative screening for HIV, HBV and HCV (HBsAg, anti-HCV and HIV-Ab/Ag-Combination) for every patient who was admitted to the traumatologic department for elective arthroplasty between 01/01/1997 and 31/12/2008. Results Among the 1534 patients who underwent elective prosthetic surgery [total hip (879) and knee arthroplasty (508), followed by shoulder, elbow and upper ankle joint], 693 (45.2%) patients were male and 841 (54.8) female. Mean age was 64.2 ± 13.8 years. Screening tests were available for 1373 patients (89.5%). Among all screened patients, we found 21 HCV, 10 HBV and 1 HIV infections. 5 HBV (0.5%) and 7 HCV infections (0.7%) were unknown before. Every newly detected infectious patient occasions screening costs about 7250 €. Considering this data, the risk of HCV transmission from an index patient with unknown status of infectiousness to health care worker after percutaneous contact to blood is 0.08 ‰ and of HIV transmission is 0.00054 ‰ in our study population. Discussion Routine preoperative screening for BBVs of patients undergoing elective arthroplasty, who were asked for HBV, HCV and HIV, should be reconsidered and is, in times of sparse funds, overpriced. Level of evidence IV.

Aims This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent. Patients and Methods The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014. Results A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p Conclusion This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214–19.

To examine outcomes and mortality in multiple-injury patients initially admitted or transferred to a level-I trauma center in Germany and to analyze the reasons for transfers from other level hospitals.. Retrospective analysis of data recorded from January 2005 through December 2014. We compared 2 main groups: patients admitted directly to the level-I center and patients transferred from another center. We also analyzed transferred patients according to whether they came from local, regional or supraregional trauma centers. Demographic information and trauma characteristics were collected. We also recorded variables related to management in the intensive care unit (eg, duration of ventilation, transfusion requirement), complications [eg, presence of Acute Respiratory Distress Syndrome or Multiple Organ Dysfunction Syndrome], Glasgow Outcome Scale, and mortality. The reasons for transfer were extracted from the case histories and transfer protocols.. A total of 999 cases were identified: 863 patients were admitted directly and 136 were transferred (from local centers, 43.3%; regional centers, 39.7%; supraregional centers, 16.9%). We identified no negative effects on short-term outcomes that could be attributed to interhospital transfers. Transferred patients had higher Acute Physiology and Chronic Health Evaluation II scores on admission, but their injuries were not more severe than transferred patients'. Interhospital transfer was not independently associated with mortality, and the mean hospital stay and outcomes were similar in the 2 groups. Reasons for transfer differed according to the timing of transfer and to type of trauma center (regional or local vs supraregional center).Patients transferred to a level-I trauma center are generally more severely ill at the time of admission, but mortality and mean hospital stay are similar in directly admitted and transferred patients.Examinar los resultados y la mortalidad de pacientes politraumáticos admitidos de forma primaria y secundaria en un hospital de traumatología de nivel 1 en Alemania, así como analizar el motivo de traslado desde los otros hospitales.Análisis retrospectivo de una base de datos que abarca de enero de 2005 a diciembre de 2014. Se construyeron dos grupos principales [de admisión primaria (AP) y de admisión secundaria (AS)] y se investigó el carácter de los hospitales de transferencia (locales vs regionales vs suprarregionales). Se incluyeron datos demográficos, características del traumatismo, aspectos relacionados con la unidad de cuidados intensivos (UCI) [como por ejemplo tiempo de ventilación, requisitos de transfusión, complicaciones postraumáticas como el síndrome de distrés respiratorio del adulto (SDRA) y el síndrome de disfunción orgánica múltiple (SDOM)] y la escala de Glasgow y mortalidad. Los motivos de transferencia analizados fueron obtenidos a través de la historia clínica y los protocolos de transferencia.Se identificaron 999 pacientes: 863 AP y 136 AS procedentes de centros traumatológicos locales (43,3%), regionales (39,7%) y suprarregionales (16,9%). No hay efectos negativos en los resultados a corto plazo debido al transporte interhospitalario de pacientes politraumatizados. Los pacientes con AS mostraron un puntaje APACHE II aumentado en el momento de admisión, pero no presentaron heridas de mayor gravedad que los pacientes con AP. La transferencia secundaria no es un factor de riesgo independiente de mortalidad: la estancia media hospitalaria para ambos grupos es semejante y el resultado es equivalente. Los motivos y el momento de transferencia difieren según el nivel del centro traumatológico (suprarregional vs regional/local).Los pacientes transferidos a un hospital de traumatología nivel 1 por lo general se encuentran más enfermos (en el momento de admisión), pero presentan resultados semejantes de mortalidad y estancia en comparación con los pacientes admitidos de forma primaria.

BACKGROUND AND OBJECTIVES: Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. METHODS: A retrospective analysis (2000–2009) of polytrauma patients (age > 16 years, ISS ≥ 16) with severe chest trauma (AIS_{Chest} ≥ 3) was performed. Patients with AIS_{Head} ≥ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS_{Chest}, Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. RESULTS: Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS_{Chest}, age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT-(p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. CONCLUSIONS: Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS_{Chest}, but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.

Background Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. Objectives Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. Methods We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16–65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. Results There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AISextremities, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. Conclusion In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities.

Traumatic lesions of great vessels such as the aorta are life-threatening injuries. There is limited evidence about the influence of traumatic aortic injuries in multiple trauma patients in particular with regard to posttraumatic complications. The aim of this study was to evaluate the influence of blunt thoracic aortic injuries in multiple trauma patients compared to a multiple trauma cohort without this specific injury. In addition, the safety of Thoracic Endovascular Aortic Repair (TEVAR) in multiple trauma patients was analyzed. A retrospective study was performed. We included all multiple trauma patients (ISS ≥ 16, age > 14 years) between 2005 and 2014 with (group BTAI) and without (group nBTAI) blunt traumatic aortic injuries who were treated at our level-1 trauma center. Demographic as well as clinical parameters were analyzed including injury pattern, mechanism of injury, posttraumatic complications such as ARDS, multiple organ dysfunction syndrome (MODS) and others. A matched pair analysis was performed by propensity score matching. In total, 721 patients were enrolled (group BTAI: n = 45; nBTAI: n = 676). In the initial study population, surgical intervention was done in n = 32 (71.1%) patients (TEVAR: n = 25; 78.1%), there was an increased AISChest and overall injury severity in group BTAI with associated significantly more posttraumatic complications in group BTAI. The matched pair analysis consisted of 42 patients per group. Beside an increased ventilation time, no significant differences were evident after the matching process. There was a trend to increased risk for SIRS using binary logistic regression analysis. Multiple trauma patients with blunt thoracic aortic injuries who are treated at a level-1 trauma center show a comparable outcome matched to their counterparts without aortic injuries. Our study confirms that using TEVAR in polytraumatized patients is a safe procedure. In all patients treated with TEVAR, there were no procedure-related complications, especially no neurological deficit.

Patients with multiple injuries are particularly susceptible to accidental hypothermia which is correlated with an increased risk of post-traumatic complications and mortality; however, its impact on neurological outcome in cases where there is concomitant traumatic brain injury is underexplored. We analyzed severely injured patients (ISS ≥ 16) including a moderate-to-severe traumatic brain injury (AISHead ≥ 3). The primary endpoint was objective neurological recovery, expressed as Glasgow Outcome Scale (GOS) score at time of discharge. Secondary endpoints were mortality, systemic inflammatory response syndrome (SIRS), sepsis, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Statistical analysis included logistic regression (odds ratio). The significance level in all analyses was p = 0.05. We analyzed 278 patients (M age = 43 years, SD 19; M ISS = 32.8, SD 10.7). Mortality was 17% (n = 14). 102 patients (37%) were hypothermic on admission. Hypothermic patients were more severely injured (ISS 35.6 ± 11.1 vs. 31.2 ± 10.1, p = 0.001; APACHE II 18.1 ± 7.4 vs. 16.2 ± 7.3, p = 0.045) and had a higher transfusion requirement. Mortality rate in hypothermic patients was increased (23.5 vs. 13.1%, p = 0.03); however, hypothermia was not an independent predictor of mortality. Median GOS at discharge was 3 (IQR 3); in 47% of patients the outcome was favorable (GOS 4 or 5) and 36% it was poor (GOS 2 or 3). There were no differences in post-traumatic complications. Analysis of 73 matched pairs of hypothermic and normothermic patients could not prove hypothermia as an independent predictor of poor neurological outcome (OR 1.7, 95% CI 0.8–3.6, p = 0.1) in the total population. However, older patients (> 41 years) had a 4.2-times higher risk (95% CI 1.4–12.7; p = 0.01) of poor neurological outcome, if they were hypothermic on admission. Accidental hypothermia seems to have a negative impact on neurological recovery in older patients with multiple injuries including traumatic brain injury which outweighs potential benefits.

Prehospital estimation of injury severity is essential for prehospital therapy, deciding on the destination hospital and the associated emergency room care. The aim of this study was to compare prehospital estimates of the abbreviated injury scale (AIS) and the Injury Severity Score (ISS) by emergency physicians with the values of AIS and ISS of injury severity determined at the conclusion of diagnostics.In this prospective study, the ISS was determined prehospital by emergency physicians. The validated AIS and ISS were analyzed based on final diagnoses. A Bland-Altman plot was used in analyzing the agreement between two different assays as well as sensitivity and specificity were determined. Confidence intervals were calculated for a Wilson score. Significance level was set at p ≤ 0.05.The prehospital ISS was estimated at 26.0 ± 13.0 and was 34.7 ± 16.3 (p 0.001) after in-hospital validation. In addition, most of the AIS subgroups were significantly higher in the final calculation than preclinically estimated (p 0.05). When analyzing subgroups of trauma patients (ISS 16 vs. ISS ≥ 16), we were able to demonstrate a sensitivity of 90% to identify a multiple-trauma patient. Diagnosing a higher injury severity group (ISS ≥ 25), sensitivity dropped to 61.1%. The Bland-Altman plot demonstrates that injury severity is underestimated in higher injury levels.Multiple-trauma patients can be identified using the ISS. Anatomic scores might be used for transport decisions; however, an accurate estimation of the injury severity should also be based on other criteria such as patient status, mechanism of injury, and other triage criteria.

Introduction: Reliable diagnosis of shock in multiply injured patients is still challenging in emergency care. Point-of-care tests could have the potential to improve shock diagnosis. Therefore, this study aimed to analyze the impact of admission blood glucose on predicting shock in multiply injured patients.Methods: A retrospective cohort analysis of patients with an injury severity score (ISS) ≥ 16 who were treated in a level I trauma center from 01/2005 to 12/2014 was performed. Shock was defined by systolic blood pressure ≤ 90 mmHg and/or shock index ≥ 0.9 at admission. Laboratory shock parameters including glucose were measured simultaneously. Receiver-operating-characteristic (ROC) analysis and multivariate logistic regression analysis was performed.Results: Seven hundred and seventy-two patients were analyzed of whom 93 patients (12.0%) died. Two hundred and fifty-nine patients (33.5%) were in shock at admission. Mortality was increased if shock was present at admission (18.1% vs. 9.0%,p p p p 11.5 mmol/L had a 2.2-fold risk of shock (95% CI [1.4–3.4],p = 0.001). Admission blood glucose of > 11.5 mmol/L positively correlated with mortality too (Spearman rho = 0.65,p p = 0.004).Discussion: Admission blood glucose was proven as an independent indicator of shock and mortality and, therefore, might help to identify multiply injured patients at particular risk.

With an incidence of 3–8 % of all fractures, pelvic fractures are relatively rare [1–4]. They range from low-energy stable fractures to high-energy unstable fractures with accompanying soft tissue injuries (complex pelvic trauma). Within polytrauma patients the percentage ascends to 25 %, which is similar to the incidence of pelvic fracture in fatal motor vehicle accidents with 23–25 % [5–7] .

Purpose Computer-assisted surgery is used for decision making, treatment, and quality control throughout the reconstruction process of unilateral midface defects. The current approaches exploit the symmetry of the face by mirroring the intact side on the defect side using various segmentation methods. All commercially available implementations, however, are somewhat time consuming and dependent on the level of expertise of the user. We present a method for automatic reconstruction of unilateral midface defects using registration. Material and methods To reconstruct a skull by registration, the defect volume has to be virtually deleted from the skull. This modified data set is then mirrored and registered onto the original, defect-free skull. The fusion of these two skulls is the virtual reconstructed skull bridging the defect. Reconstruction by registration was performed for 24 different skulls without motion or dental restoration artifacts. Subsequently, simulation was performed with four accurately defined, various-sized, defects of the orbito-zygomatic complex. The results of the automated virtual reconstructions were compared with those obtained for the same defects as determined using conventional atlas-based planning software (iPlan). To simulate various clinical situations, four groups each containing six skulls were evaluated: the complete skull, midface and neurocranium, midface and lower jaw, and midface alone. The differences were compared using the similarity coefficients of Sorensen-Dice and Jaccard. Statistical analyses were performed using the t-test and Mann–Whitney U test. Results The reconstruction results were similar for all the groups. The Sorensen-Dice coefficients of similarity for all reconstructed skulls were 0.869 and 0.874 for the registration and atlas-based reconstructions, respectively. The corresponding Jaccard coefficients were 0.774 and 0.781, respectively. Atlas-based reconstruction showed significantly better results in group 3 (midface and lower jaw) alone. Conclusion Virtual automated reconstruction by registration had equivalent accuracy to conventional atlas-based reconstruction across a spectrum of defects, from simple orbital to complex orbito-zygomatic defects. However, for those involving the midface and lower jaw, atlas-based reconstruction showed significantly better results. Although the new approach is somewhat hardware demanding, it is user independent, dispensing with the need for time-consuming adjustments to the results of planning. The first clinical application of registration reconstruction revealed performance equivalent to that of the conventional approach.

Introduction Occupational infection of clinical health care workers with blood-borne viruses (BBVs), like human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) is a current and often emotionally discussed issue. HCV and especially HIV are still stigmatized. The consequence is a broad and maybe irrational fear of professional health care workers being infected occupationally. Therefore, we assessed preoperative screening to: (1) answer whether this can detect not previously diagnosed blood-borne virus infections to a great extent; (2) calculate a cost/benefit ratio to find out, if the screening's potential ability to prevent occupational transmission of BBVs to health care workers faces unjustifiable high costs. Hypothesis Preoperative routine screening is limited suitable for enhancement of detecting fomites compared to interview the patient. Materials and methods Retrospective cohort study of preoperative screening for HIV, HBV and HCV (HBsAg, anti-HCV and HIV-Ab/Ag-combination) for every patient who was admitted to the traumatologic department for elective arthroplasty between 01/01/1997 and 31/12/2008. Results A total of 1534 patients underwent elective prosthetic surgery [total hip (879) and knee arthroplasty (508), followed by shoulder, elbow and upper ankle joint]. Six hundred and ninety-three (45.2%) patients were male, 841 (54.8) female. Mean age was 64.2 ± 13.8 years. Screening tests were available for 1373 patients (89.5%). Among all screened patients, we found 21 HCV, 10 HBV and 1 HIV infections. Five HBV (0.5%) and 7 HCV infections (0.7%) were unknown before. Every newly detected infectious patient occasions screening costs about 7250 €. Considering this data, the risk of HCV transmission from an index patient with unknown status of infectiousness to health care worker after percutaneous contact to blood is 0.08‰ and of HIV transmission is 0.00054‰ in our study population. Discussion Routine preoperative screening for BBVs of patients undergoing elective arthroplasty, who were asked for HBV, HCV and HIV, should be reconsidered and is in times of sparse funds overpriced. Level of evidence IV.