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To adapt and evaluate a method for assessing the need to update guideline topic areas involving multiple recommendations.The 'Ottawa method' uses literature signals to determine changes in evidence that trigger a need to update individual guideline questions. We adapted the Ottawa method to include a process for aggregating updating signals by topic area (e.g., resuscitation) and tested this method using the German guideline on the treatment of patients with severe/multiple injuries. This involved a focused systematic evaluation of current evidence to identify updating signals and classifying the need to update for each topic area. Then, we surveyed the guideline group online about the modified method.We conducted focused literature searches for 37 topic areas and screened a mean of 97 abstracts per topic area in 2021. The need to update was high for eight (21.6%), intermediate for eight (21.6%), and low for 21 topic areas (56.8%) based on updating signals. The survey response rate was 56% (24/43). Most guideline group members (94%, 16/17 responders) would use the Ottawa method again but their comments identified some weaknesses.The modified Ottawa method is a suitable, efficient tool to generate evidence-based updating signals for guideline topic areas involving multiple recommendations. Further fine-tuning is recommended.

As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies. Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU®. After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment. The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU®.

Background: Tools assessing patient-reported outcomes (PROs) after polytrauma have not been systematically reviewed so far. Therefore, we sought to: (1) collect instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL), and social participation during follow-up after polytrauma, (2) describe their use (e.g. frequency of application during follow-up), and (3) investigate other relevant PROs assessed in the included studies (e.g. pain, depression, anxiety).Methods: The search was conducted in MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, the trials registers ClinicalTrials.gov, and WHO ICTRP. All original empirical research published between January 2005 and April 2018 was included. Data extraction, narrative content analysis, and a critical appraisal were performed.Results: The search yielded 3496 hits and 54 publications were included in the review. Predominantly, HRQoL was assessed (in 48 of 54 publications), with Short Form-36 Health Survey (SF-36) applied most frequently. ADL and (social) participation were rarely assessed. The follow-up period lasted between 8 days and 17.5 years; assessments were performed between one and five times. Most used were a single assessment of PROs, a follow-up period of 1 to 1.5 years, and a postal survey. Other relevant PRO areas reported were function, mental disorders, and pain.Conclusions: There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but further harmonisation between central players, such as trauma registers, is required. Definition and continuous collection of core outcome sets would improve comparability of study results, creating the basis for more targeted treatment. Additional knowledge on rarely reported PRO areas like (social) participation and social network may lead to their consideration in health services provision.Registration: PROSPERO (CRD42017060825)

Background: Systemic inflammation induced by sterile or infectious insults is associated with an enhanced susceptibility to life-threatening opportunistic, mostly bacterial, infections due to unknown pathogenesis. Natural killer (NK) cells contribute to the defence against bacterial infections through the release of Interferon (IFN) γ in response to Interleukin (IL) 12. Considering the relevance of NK cells in the immune defence we investigated whether the function of NK cells is disturbed in patients suffering from serious systemic inflammation. Methods: NK cells from severely injured patients were analysed from the first day after the initial inflammatory insult until the day of discharge in terms of IL-12 receptor signalling and IFN-γ synthesis. Findings: During systemic inflammation, the expression of the IL-12 receptor β2 chain, phosphorylation of signal transducer and activation 4, and IFN-γ production on/in NK cells was impaired upon exposure to Staphylococcus aureus. The profound suppression of NK cells developed within 24 h after the initial insult and persisted for several weeks. NK cells displayed signs of exhaustion. Extrinsic changes were mediated by the early and long-lasting presence of growth/differentiation factor (GDF) 15 in the circulation that signalled through the transforming growth factor β receptor I and activated Smad1/5. Moreover, the concentration of GDF-15 in the serum inversely correlated with the IL-12 receptor β2 expression on NK cells and was enhanced in patients who later acquired septic complications. Interpretation: GDF-15 is associated with the development of NK cell dysfunction during systemic inflammation and might represent a novel target to prevent nosocomial infections. Fund: The study was supported by the Department of Orthopaedics and Trauma Surgery, University Hospital Essen. Keywords: Natural killer cells, Opportunistic infections, Interferon gamma, Interleukin 12, Transforming growth factor receptor, Immunosuppression

Severe brain, thoracic and intrapelvic injuries, as well as heavy bleeding, are the main causes of death in patients with major trauma. Unstable pelvic ring fractures can cause this bleeding and the so-called "C problem". This is usually due to haemorrhagic shock caused by the loss of large volumes of blood from the presacral venous plexus, iliac vessels and the fracture surfaces. Many clinical studies have shown that, in the preclinical setting, unstable pelvic ring injuries are often underestimated. The application of a non-invasive external pelvic ring stabilisation (pelvic binder) is therefore recommended if a pelvic fracture is possible. Several circumferential pelvic binders have been developed and their prehospital use is increasing. Clinical and biomechanical studies have demonstrated that there is a favourable haemodynamic effect in unstable fractures, due to rapid closure of the pelvic ring. It is unclear whether the pelvic binder can be safely removed in a presumably haemodynamically stable patient. A correctly placed pelvic binder leads to anatomical closure of the pelvic ring. Therefore unstable pelvic ring fractures may be clinically and radiologically overlooked. This is a particular problem in unconscious patients. Furthermore, the real severity of the injury may then be underestimated in the diagnostic evaluation. Unconsidered opening of the pelvic binder can thus provoke renewed deterioration of the circulatory situation, especially if the injury was adequately treated by the binder and the C problem was controlled. The aim of this article is to describe procedures for handling pelvic binders, particularly as to how to deal with an already applied pelvic binder and how to "clear the pelvic region" while reducing the risk of haemodynamic instability. A detailed analysis of the literature and a Delphi-like discussion among several experts were performed. The following points were raised: 1) Assessment of the clinical situation, including trauma kinematics. 2) Assessment of the haemodynamic status. 3) Check of the need to open the pelvic binder for diagnostic/therapeutic measures before completing all diagnostic tests. 4) Assessment of the radiology diagnostic testing and release of the pelvic region. The result is a so-called "clear the pelvis algorithm" which describes a structured approach according to specific criteria and which specifies the circumstances under which the pelvic binder can be opened. Additional studies are necessary to analyse the applicability and safety of this algorithm in a clinical context. Our advice is not to "clear" the pelvis if no X-rays or CT scans of the pelvis have been carried out without (or with an opened) pelvic binder.

Am 11. September 2015 fand am Berliner Unfallkrankenhaus (ukb) der zweite TNT-Kongress – der gemeinsame Jahreskongress von TraumaNetzwerk DGU ® , Sektion Notfall-, Intensivmedizin und Schwerverletztenversorgung (NIS) und TraumaRegister DGU ® (TR-DGU) – statt. Neben aktuellen Daten zur Schwerverletztenversorgung und neuen wissenschaftlichen Erkenntnissen stand die Ausgabe des TraumaRegister-Jahresberichtes 2015 auf dem Programm.

Septic segmental bone voids of the diaphysis are difficult to manage. The induced membrane technique by Masquelet has been successfully used to reconstruct segmental defects more than 20 cm. Our article describes a series of 13 cases with extensive posttraumatic bone loss of the metatarsal, tibial, femoral and radial bones after septic injuries followed by multiple surgical interventions. Antibiotic-impregnated polymethyl methacrylate (PMMA) cement spacers were implanted after successful eradication of bacterial infections of soft tissue and bones. After a mean of 9.8 weeks, body-induced membranes were established and the cements spacers removed. To fill up the bone void, cancellous bone autografts were implanted into the membranes. The follow-up examination after 24 months revealed bony union in all cases and favorable functional results. The induced membrane technique has shown to be effective in treating bone defects of upper and lower extremity bone defects.

Advanced Trauma Life Support (ATLS®) is one of the world’s best-known training programs for medical providers. Revisions of the ATLS manual have been evidence based for a number of years. In 2011, a level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published in Germany. The scope of this study was the systematic comparison of the educational content of the ATLS concept and the interdisciplinary “S3 polytrauma guideline.” A total of 123 key recommendations of the guideline were compared with the content of the ATLS manual (9th edition). Depending on the level of agreement, the recommendations were classed in the following categories: (1) Agreement. (2) Minor variation. (3) Major variation. An overall 86 % conformity was found between the key recommendations of the guideline and the ATLS® manual. The ATLS® primary survey (ABCDE) showed an 85 % conformity. The degree of conformity for the individual priorities was as follows: A (Airway) 79 %, B (Breathing) 79 %, C (Circulation) 86 %, D (Disability) 93 %, E (Exposure) 100 %. The ATLS® secondary survey showed a 94 % conformity. The main differences were in the areas of anesthetic induction, fluid administration, and coagulation therapy. According to our comparison, the educational content and manual of the ATLS are largely compatible with a high level of evidence S3 guideline. However, subsequent editions of both the ATLS® and the S3 guideline should re-examine and reassess a number of aspects.

Um die erhebliche Folgemorbiditat offener Frakturen zu minimieren, ist eine hochspezifische Initialbehandlung erforderlich. Neben stringenten operativen Masnahmen ist die Antibiotikaprophylaxe fur das Outcome mitentscheidend. In der Diskussion stehen derzeit Beginn und Dauer der Behandlung sowie die Auswahl der besten Substanzen. Ziel der vorliegenden Studie war es, den Istzustand der Initialtherapie offener Frakturen in deutschen Notaufnahmen zu erheben. Wir fuhrten eine anonyme Online-Umfrage mit einem 16-Item-Fragebogen bei allen 3006 DGU-Mitgliedern durch. Der Fragebogen wurde nach 31 Tagen automatisch geschlossen, 585 Antworten gingen ein (19,5 %). Die Auswertung erfolgte deskriptiv und beschreibt den Istzustand der Versorgung. Es antworteten uberwiegend Fach- (35 %) und Oberarzte (30 %) sowie 17 % Chefarzte, 8 % Assistenzarzte und 10 % Niedergelassene. Neunundfunfzig Prozent der Antworten kamen aus regionalen oder uberregionalen Traumazentren. Funfundsechzig Prozent zweifeln an der Klassifikation des Rettungsdienstes. Die sofortige oder dringliche Operationsindikation sehen uber 93 % der Befragten. Vierundachtzig Prozent beginnen eine Antibiotikaprophylaxe in der Notaufnahme, 63 % nutzen hierfur eine Standard Operating Procedure (SOP). Sechzig Prozent nutzen ein Antibiotikum, 25 % 2 und 15 % 3 oder mehr Substanzen. Sechzig Prozent behandeln langer als 3 Tage antibiotisch. Die fruhe und uberwiegend standardisierte Antibiotikaprophylaxe erscheint in deutschen Notaufnahmen etabliert. Ebenso ist die moglichst fruhe operative Versorgung Standard. Entwicklungspotenzial findet sich bei der Kommunikation zwischen Praklinik und Klinik ebenso wie bei der nach Schweregrad des Weichteilschadens abgestuften Breite und Dauer des Antibiotikaregimes.

Introduction Multiple injured patients, polytrauma or severely injured patients are terms used as synonyms in international literature describing injured patients with a high risk of mortality and cost consuming therapeutic demands. In order to advance the definition of these terms, we analysed a large trauma registry. In detail, we compared critically ill trauma patients first specified on a pure anatomical base according to the ISS or NISS, second in the original “polytrauma definition” with two body regions affected and finally all of them combined with a physiological component. Patients and methods Records that were collected in the TraumaRegister DGU® of the German Trauma Society (Deutsche Gesellschaft fur Unfallchirurgie, DGU) between 1993 and 2011 (92,479 patients) were considered for this study. All patients with primary admission from scene with a minimum hospital stay of 48 h and an Injury Severity Score (ISS) ≥ 16 were included. Pre-hospital and early admission data were used to determine physiological risk factors and calculate individual risk of death using the Revised Injury Severity Classification (RISC). Results 45,350 patients met inclusion criteria. The overall hospital mortality rate was 20.4%. The predicted mortality according to the RISC-Score was 21.6%. 36,897 patients (81.4%) had injuries in several body regions. The prevalence of the five physiological risk factors varied between 17% (high age) and 34% (unconsciousness). There were 17,617 patients (38.8%) without any risk factor present on admission, while 30.6% (n = 13,890) of the patients had one and 30.5% (n = 13,843) had two or more factors present. Patients with ISS ≥ 16 but no physiological risk factor present had a very low mortality rate of 3.1% (542 of 17,617). With an increasing number of physiological factors there was an almost linear increase in mortality up to an 86% rate in patients with all five factors present. The ‘polytrauma’ definition of Butcher and colleagues with AIS ≥ 3 in at least two different body regions would apply to only 56.2% of patients in the present group with ISS ≥ 16. The mortality in this subgroup is only marginally higher (21.8%; 5559 of 25,494) than in the group of patients with only one severely affected body region (18.5%; 3675 of 19,875). Conclusions In our opinion the principle of sharpening an anatomically based definition by a defined physiological problem will help to specify the really critically ill trauma patients.

Staphylococcus aureus (SA) is the most common causative agent for implant-associated osteitis. The present study characterizes a novel model of a low grade acute SA osteitis with bone defect in the femur which is stabilized by a titanium locking plate. Wild-type Balb/c mice were osteotomized, fixed by a locking plate and infected with SA. Mice underwent debridement 7 and 14 days later and were sacrificed at Day 28. At Days 7, 14, and 28 after inoculation local and systemic cell populations and IL-6 were analyzed. Fracture healing was quantified by radiography. The control group underwent the same procedure without infection. The bacterial load of implant-associated osteitis with biofilm formation was quantified by counting CFU and real-time PCR. Fracture healing determined by radiography was delayed in infected compared to non-infected mice. Throughout the investigation period CFU and leukocyte counts, as well as IL-6 levels were found to be significantly elevated in infected mice at the infection site but not systemically. Our murine model allows the detailed investigation of implant associated localized osteitis with biofilm producing SA and its influence on fracture healing. The model provides a tool to analyze therapeutic or prophylactic approaches to the problem of biofilm-associated osteitis.

Orthopadie und Unfallchirurgie Mitteilungen und Nachrichten | Dezember 2012 D GU Am 7. September 2012 traf sich die Sek tion Notfall-, Intensivmedizin und Schwerverletztenversorgung (NIS) zu ihrem zweiten Jahreskongress an der Medizinischen Hochschule (MHH) in Hannover. An das wissenschaftliche Symposium bestehend aus vier Sessions rund um die aktuellen Entwicklungen in der Schwerverletztenversorgung folgte die kommentierte Ausgabe des TraumaRegister DGU®-Jahresberichtes 2012. Die Sektions mitglieder trafen sich am folgenden Tag zu einem Arbeitstreffen.

BACKGROUND: Accidental hypothermia, acidosis, and coagulopathy represent the lethal triad in severely injured patients. Therapeutic hypothermia however is commonly used in transplantations, cardiac and neurosurgical surgery, or after cardiac arrest. However, the effects of therapeutic hypothermia on the coagulation system following multiple trauma need to be elucidated.METHODS: In a porcine model of multiple trauma including blunt chest injury, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of therapeutic hypothermia on coagulation was evaluated. A total of 40 pigs were randomly assigned to sham (only anesthesia) or trauma groups receiving either hypothermia or normothermia. Each group consisted of 10 pigs. Analyzed parameters were cell count (red blood cells, platelets), pH, prothrombin time (PT), fibrinogen concentration, and analysis with ROTEM and Multiplate.RESULTS: Trauma and consecutive fluid resuscitation resulted in impaired coagulation parameters (cell count, pH, PT, fibrinogen, ROTEM, and platelet function). During hypothermia, coagulation parameters measured at 37°C, such as PT, fibrinogen, thrombelastometry measurements, and platelet function, showed no significant differences between normothermic and hypothermic animals in both trauma groups. Additional analyses of thrombelastometry at 34°C during hypothermia showed significant differences for clotting time and clot formation time but not for maximum clot firmness. We were not able to detect macroscopic or petechial bleeding in both trauma groups.CONCLUSION: Based on the results of the present study we suggest that mild hypothermia can be safely performed after stabilization following major trauma. Mild hypothermia has effects on the coagulation system but does not aggravate trauma-induced coagulopathy in our model. Before hypothermic treatment can be performed in the clinical setting, additional experiments with prolonged and deeper hypothermia to exclude detrimental effects are required.

Die Versorgung von schwerverletzten Patienten stellt eine komplexe und hochst anspruchsvolle Aufgabe dar. Die Sektion Notfall-, Intensivmedizin und Schwerverletztenversorgung der Deutschen Gesellschaft fur Unfallchirurgie (Sektion NIS) hat sich dieser Herausforderung angenommen. Anlasslich der Ausgabe des Jahresberichts des TraumaRegister DGU® veranstaltete die Sektion NIS ihren ersten Jahreskongress, um ihre Mitglieder und alle Interessierten mit aktuellen Entwicklungen und neusten Forschungsergebnissen aus dem Bereich der nationalen Schwerverletztenversorgung vom Tierstall bis zur S3-Leitlinie zu informieren. Themenschwerpunkte waren dabei neue Erkenntnisse aus den Daten des TraumaRegister DGU® und Qualitatssicherung in der Traumaversorgung. Der hier vorliegende Kongressbericht fasst die wesentlichen Ergebnisse der vorgestellten Studien zusammen und berichtet von aktuellen Entwicklungen in diesem Bereich der Traumaforschung.

Despite the high incidence and prognostic relevance of hemorrhagic shock and abdominal and blunt chest trauma in multiply injured patients, there are no animal models combining these injuries. Therefore, we established a new porcine multiple trauma model consisting of blunt chest trauma, penetrating abdominal trauma (two incisions in the right upper liver lobe using a four-edged scalpel and subsequent liver packing), and pressure-controlled hemorrhagic shock with a mean arterial pressure of 30 ± 5 mmHg (a maximum of 45% of the total blood volume). The combined traumatic insult led to severe signs of hemorrhagic shock and impaired pulmonary function. In conclusion, a consistent, reproducible, and clinically relevant porcine model of multisystem injury with controlled (pressure-controlled blood withdrawal) and uncontrolled components of hemorrhage (liver laceration) with the potential for rebleeding was established.

PLoS one 11(5), e0155870 (2016). doi:10.1371/journal.pone.0155870, Published by PLoS, Lawrence, Kan.

BACKGROUND Recent findings have emphasized the need for early and aggressive coagulation support in bleeding trauma patients. This study aimed to examine whether blood component transfusion and hemostatic drug administration during acute trauma care have changed in daily practice during the recent years. METHODS The multicenter trauma registry of the German Society for Trauma was retrospectively analyzed for primarily admitted patients older than 16 years with an Injury Severity Score ≥ 16 who had received at least five red blood cell (RBC) units between emergency room arrival and intensive care unit admission. Administration of fresh frozen plasma and platelet units has been documented since 2002, and use of hemostatic drugs since 2005. RESULTS From 2002 until 2009 (n = 2,813), the fresh frozen plasma:RBC ratio increased from 0.65 to 0.75 (p = 0.02) and the platelet:RBC ratio from 0.04 to 0.09 (p < 0.0001). A constant increase was also observed regarding the overall use of hemostatic drugs (n = 1,811; 2005-2009) as these were administered to 43.4% of the patients in 2005 and to 60.7% in 2009 (p < 0.0001). Especially, the administration of fibrinogen concentrate (2005: 17.0%, 2009: 45.6%; p < 0.0001) and recombinant factor VIIa (2005: 1.9%, 2009: 6.3%; p = 0.04) showed a marked increase. However, mortality rates remained unchanged during the 8-year study period. CONCLUSIONS The therapy of bleeding trauma patients has changed in Germany during the recent years toward more aggressive coagulation support. This development continues although grades of evidence are still low regarding most of the changes reported in our study. Randomized controlled trials are needed with respect to blood component therapy using predefined ratios and to the administration of hemostatic drugs commonly used for the severely injured.

Several studies have reported a positive relationship of the body fat mass and bone density. However, it is not clear whether adipocyte-derived signaling molecules directly act on osteoblasts or osteoclasts. Therefore, we investigated the effect of fat cell-secreted factors on the proliferation and differentiation of preosteoblasts and the molecular mechanisms involved. This stimulation led to an increased proliferation of MC3T3-E1 and primary preosteoblastic cells (2.8-fold and 1.5-fold, respectively; p

Posttrauma apoptosis resistance of neutrophils (PMN) is related to overshooting immune responses, systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF). Recently, we have shown that the apoptosis resistance in circulating PMN from severely injured patients which is known to be mediated by high serum levels of pro-inflammatory cytokines can be overcome by the activation of Fas death receptor. Here, we aimed to study whether stimulation of surface Fas leads to the inactivation of hyperactivated PMN from critically ill patients with SIRS. PMN from 23 multiple trauma patients (mean injury severity score (ISS) 34±1.9) were isolated at day 1 after admission to the trauma center. PMN from 17 volunteer blood donors served as controls. Neutrophil activity has been determined after ex vivo short (1 h) and long-term (4 h) stimulation of freshly isolated PMN with immobilized agonistic anti-Fas antibodies. We found neutrophil chemotactic migration in response to IL-8, phagocytosis and oxidative burst to be significantly inhibited in control cells already after short-term (1 h) Fas stimulation. In contrast, inactivation of trauma PMN by agonistic anti-Fas antibodies was found to be efficient only after long-term (4 h) incubation of cells with agonistic antibodies. Thus, in trauma PMN down-regulation of neutrophil activity seems to be delayed when compared to cells isolated from healthy controls, suggesting impaired susceptibility for Fas stimulation in these cells. Interestingly, whereas Fas-mediated inhibition of phagocytosis and oxidative burst could be prevented by the broad range caspase inhibitor t-butoxycarbonyl-aspartyl(O-methyl)-fluoromethyl ketone (BocD-fmk), the chemotactic activity in response to IL-8 was unaffected. In conclusion, we demonstrate that stimulation of neutrophil Fas does not only initiate apoptosis but also induces inhibition of neutrophil functions, partially by non-apoptotic signaling.

Drei Jahre nach Grundung des TraumaNetzwerkD DGU sind im Jahre 2009 ein Grosteil der in Deutschland an der Schwerverletztenversorgung beteiligten Kliniken registriert und in regionalen Traumanetzwerken (TNW) organisiert. In diesen Netzwerken sind u. a. Kriterien fur eine Verlegung in Einrichtungen hoherer Versorgungsstufen definiert. In der vorliegenden Arbeit wurde durch eine retrospektive Auswertung des TraumaRegisters DGU die Versorgungsrealitat schwerverletzter Patienten, die nach der Erstversorgung in einem Krankenhaus zur weiteren Versorgung in eine andere Einrichtung verlegt wurden, analysiert. Ziel war es, die Verlegungsrealitat dieses Kollektivs vor der Implementierung flachendeckender Traumanetzwerke in Deutschland darzustellen. Die Daten von 19.035 Patienten des TraumaRegisters der Deutschen Gesellschaft fur Unfallchirurgie (DGU, 2002 bis 2007) wurden ausgewertet. Eingeschlossen wurden alle Patienten mit einem Injury Severity Score (ISS) ≥9 und einem dokumentierten Blutdruck bei der Aufnahme. Unterschieden wurde zwischen Patienten, die im primar aufnehmenden Krankenhaus vollstandig versorgt wurden (Gruppe I, n=16,033, 84,2%), und Patienten, die nach der Erstversorgung in einem Krankenhaus zur definitiven Versorgung in ein anderes Krankenhaus verlegt wurden (Gruppe II, n=3002, 15,8%). Vergleichsparameter waren neben Verletzungsschwere und -muster der physiologische Zustand bei Aufnahme sowie der klinische Verlauf der Patienten. Der durchschnittliche ISS und der Anteil der Patienten mit einem ISS ≥25 waren in beiden Gruppen vergleichbar; 20,7% der Patienten, die in ein anderes Krankenhaus verlegt wurden (Gruppe II), waren bei Aufnahme dort katecholaminpflichtig, 10,1% waren im Schock (RR

The treatment of full-thickness cartilage defects of the knee is a common problem in orthopaedic surgery. Autologous chondrocyte transplantation (ACT) is one of the few reliable treatment options of cartilage defects with good long-term outcomes. The improvement of ACT led to the matrix-based ACT (MACT). The purpose of the study was to compare two different commercially available MACT systems.Eleven patients with a cartilage defect of the knee were treated with the MACI(®) system and another nine patients with the CaRes(®) implant. The patients were prospectively followed and re-examined after one year.One year after surgery all but one patient have significantly improved in their clinical outcome. Both types of MACT revealed similar results in terms of increase in level of activity, pain relief and knee function.The study showed that MACT is a good therapeutic option for full-size defects of the femoral condyle. The MACI(®) implant seems to be easier to handle which is reflected by smaller incisions and a shorter operation time.

Patellafrakturen sind fur ca. 1% aller Skelettverletzungen verantwortlich. Die Diagnose wird anhand des Unfallmechanismus, der korperlichen Untersuchung und des radiologischen Befunds gestellt. Die Art der Behandlung der Patellafraktur hangt dabei vom Frakturtyp, der Grose der Fragmente, der Stabilitat des Extensorenmechanismus und dem Ausmas der Kongruenz der Gelenkflache ab. Unabhangig von der Behandlungsmethode sollte moglichst eine fruhe Ubungsbehandlung angestrebt werden. Die modifizierte Zuggurtungsosteosynthese ist die am weitesten verbreitete Technik und kann nahezu bei allen Frakturformen angewandt werden. Aufgrund ihrer biomechanischen Uberlegenheit ist die kanulierte Schraubenosteosynthese mit Zuggurtung bei der einfachen Patellaquerfraktur inzwischen das Verfahren der Wahl. Bei ausgepragten Trummerfrakturen kann man gezwungen sein, eine partielle oder komplette Patellektomie durchzufuhren, diese wird aber aufgrund der schlechten funktionellen Ergebnisse als Rettungsoperation angesehen.

BACKGROUND: Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers. PATIENT AND METHODS: Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n=713, 5.5%) and patients who received early surgical care after completed diagnostics (group Fruhop, n=5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome. RESULTS: Patients receiving emergency surgery showed an average ISS score of 39+/-15 points, whereas patients receiving early surgery showed an average ISS of 31+/-12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p /=4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery. CONCLUSION: Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany. Language: de

IntroductionSurvivors of polytrauma experience long-term and short-term burden that influences their lives. The patients’ view of relevant short-term and long-term outcomes should be captured in instruments that measure quality of life and other patient-reported outcomes (PROs) after a polytrauma. The aim of this systematic review is to (1) collect instruments that assess PROs (quality of life, social participation and activities of daily living) during follow-up after polytrauma, (2) describe the instruments’ application (eg, duration of period of follow-up) and (3) investigate other relevant PROs that are also assessed in the included studies (pain, depression, anxiety and cognitive function).Methods and analysisThe systematic review protocol is developed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials and the trials registers ClinicalTrials.gov and WHO International Clinical Trials Registry Platform will be searched. Keywords, for example, ‘polytrauma’, ‘multiple trauma’, ‘quality of life’, ‘activities of daily living’ or ‘pain’ will be used. Publications published between January 2005 and the most recent date (currently: August 2016) will be included. In order to present the latest possible results, an update of the search is conducted before publication. The data extraction and a content analysis will be carried out systematically. A critical appraisal will be performed.Ethics and disseminationFormal ethical approval is not required as primary data will not be collected. The results will be published in a peer-reviewed publication.PROSPERO registration numberCRD42017060825.

A common consequence in patients with blunt trauma is a deterioration of the immune system. The specific impacts of a frequently occurring isolated soft tissue trauma on the immune response are described. However, the dimension of trauma needed to cause systemic effects has not been definitely elucidated.Mice were traumatized on the lower leg. The extent of soft tissue trauma was quantified by determination of the wet/dry ratio, magnetic resonance imaging (MRI), and serum content of muscle proteins. Five minutes, 3, 24, 36, 48, and 72 h after trauma (a.t.) the ex vivo cytokine-expression of immune-competent cells were measured.Trauma resulted in an early edema that could be quantified by MRI and wet/dry ration. Release of muscle-specific proteins was detected 5 min a.t. The trauma did not cause significant changes of TNF-alpha response of isolated cells to endotoxin. IL6-response of splenocytes to endotoxin was slightly increased 72 h a.t., while IL6-response of peritoneal macrophages to endotoxin was decreased 36 h a.t.We describe a standardized trauma model for minor soft tissue injury in mice. Systemic effects on the immune system by traumatized lower leg were not found on the level of circulating cytokines or cellular responses to endotoxin.

The femur is the largest, longest and strongest bone in the human skeleton. Fractures of the shaft of the femur can result from high energy as well as low energy trauma and 30% of patients have multiple injuries. In the clinical diagnostic special attention must be paid to the peripheral neurovascular status as well as the possibility of a compartment syndrome. Fractures of the femur shaft are defined according to the AO classification. Treatment is as a rule operative, except for children up the end of 4 years old. Medullary nailing is nowadays the method of choice and the nails can be implanted in an anterograde or retrograde direction. The introduction of nails after boring out the medullar is associated with an increased healing rate in comparison to non-boring techniques. Various techniques are available for the often promising method of repositioning and the intraoperative controls. Plating is reserved only for special situations. External fixation is of great value in adults for temporary fixation of fractures of the femur shaft. Full weight bearing is possible immediately following the operation depending on the type of fracture and method of treatment. Uncomplicated fracture healing does not result in a reduction in the ability to work. Despite the generally good prognosis and improvement in design and technology of implants, fractures of the femur shaft still represent a special challenge for the treating casualty surgeon.

Multiple trauma leads to a deterioration of the immune system. On the one hand, hyperinflammation mediates remote organ damage and may lead to multi-organ failure. On the other hand, immunosuppression develops and promotes an enhanced risk to acquire infectious complications after trauma. The mechanisms that underlie these opposing consequences of trauma are not yet completely understood. There is increasing evidence that endogenous danger signals that derive from destroyed tissues play a role in trauma-induced immune dysfunction. Here, we give an overview on the common animal models that are used to investigate trauma-induced pathology, potential signals and cellular mechanisms that support the imbalance between inflammation and counter-regulation after trauma.

Die Lebenserwartung nach einem generalisierten schweren Trauma wird haufig durch den initialen Verlust groser Blutmengen und der sekundaren Inzidenz einer Sepsis und eines Multiorganversagens (MOV) limitiert. Die mogliche Bedeutung eines Lebertraumas als unabhangiger Letalitatsfaktor bei polytraumatisierten Patienten ist bisher am grosen Patientenkollektiv nicht genau untersucht. Die Daten von 24.711 Patienten des Traumaregisters der Deutschen Gesellschaft fur Unfallchirurgie (DGU) aus 113 Kliniken (1993-2005) wurden retrospektiv ausgewertet. Alle Patienten mit einem „Injury Severity Score“ (ISS)>16 Punkten, ohne isoliertes Schadel-Hirn-Trauma und primarer Aufnahme wurden eingeschlossen. 321 Patienten mit einer Leberverletzung (AISLeber=3–5, AISAbdomen 16) wurden mit 574 am Abdomen verletzten Patienten (AISAbdomen=3–5, AISLeber 16) und 9574 Patienten ohne relevante abdominelle oder Leberverletzung verglichen (AISLeber oder AISAbdomen

The development of immunosuppression during polymicrobial sepsis is associated with the failure of dendritic cells (DC) to promote the polarization of T helper (Th) cells toward a protective Th1 type. The aim of the study was to test potential immunomodulatory approaches to restore the capacity of splenic DC to secrete interleukin (IL) 12 that represents the key cytokine in Th1 cell polarization. Murine polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Splenic DC were isolated at different time points after CLP or sham operation, and stimulated with bacterial components in the presence or absence of neutralizing anti-IL-10 antibodies, murine interferon (IFN) gamma, and/or granulocyte macrophage colony-stimulating factor (GM-CSF). DC from septic mice showed an impaired capacity to release the pro-inflammatory and Th1-promoting cytokines tumor necrosis factor alpha, IFN-gamma, and IL-12 in response to bacterial stimuli, but secreted IL-10. Endogenous IL-10 was not responsible for the impaired IL-12 secretion. Up to 6 h after CLP, the combined treatment of DC from septic mice with IFN-gamma and GM-CSF increased the secretion of IL-12. Later, DC from septic mice responded to IFN-gamma and GM-CSF with increased expression of the co-stimulatory molecule CD86, while IL-12 secretion was no more enhanced. In contrast, splenic macrophages from septic mice during late sepsis responded to GM-CSF with increased cytokine release. Thus, therapy of sepsis with IFN-gamma/GM-CSF might be sufficient to restore the activity of macrophages, but fails to restore DC function adequate for the development of a protective Th1-like immune response.