Showing papers by "Georg Osterhoff published in 2017"

Current concepts in locking plate fixation of proximal humerus fractures

Abstract: Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

Is Early Definitive Fixation of Bicondylar Tibial Plateau Fractures Safe? An Observational Cohort Study.

Abstract: Objectives:The optimal treatment protocol for bicondylar plateau fractures remains controversial. Contrary to popular practice which favors a staged protocol in many high-energy fracture patterns, we have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries whe

Anterior subcutaneous internal fixation of the pelvis - what rod-to-bone distance is anatomically optimal?

Abstract: Introduction Anterior fixation of the pelvis using subcutaneous supra-acetabular pedicle screw internal fixation (INFIX) has proven to be a useful tool by avoiding the downsides of external fixation in patients where open fixation is not suited. The purpose of this study was to find a rod-to-bone distance for the INFIX that allows for minimal hazard to the inguinal neuro-vascular structures and, at the same time, as little as possible interference with the soft tissues of the proximal thigh when the patient is sitting. Methods An INFIX was applied to 10 soft-embalmed cadaver pelvises with three different rod-to-bone distances. With each configuration, the relations of the rod to the neuro-vascular and the muscular surroundings were measured in supine and sitting position. Results Except for the femoral artery, vein and nerve, all investigated anatomical structures of the groin were under compression with a rod-to-bone distance of 1 cm. With a rod-to-bone distance of 2 cm most of the anatomical structures were safe in supine position, although less than with 3 cm. With hip flexion some structures got under compression, especially the lateral femoral cutaneous nerve (LFCN, 80%) and the anterior cutaneous branches of the femoral nerve (ACBFN, 35%). With a rod-to-bone distance of 3 cm almost all anatomical structures were safe in supine position, while with hip flexion most superficial structures of the proximal thigh got under compression, especially the LFCN (75%) and the ACBFN (60%). Conclusions Aiming for a rod-to-bone distance of 2 cm is the safest way with regard to compression of the femoral neuro-vascular bundle and at the same time leads to the least compression of more superficial structures like the LFCN, the ACBFN, or the sartorius and the rectus femoris muscles in sitting position.

Bacterial reduction and shift with NPWT after surgical debridements: a retrospective cohort study

Abstract: Surgical debridement, negative-pressure wound therapy (NPWT) and antibiotics are used for the treatment of open wounds. However, it remains unclear whether this treatment regimen is successful in the reduction and shift of the bacterial load. After debridement in the operating room, NPWT, and antibiotic treatment, primary and secondary consecutive microbiological samples of 115 patients with 120 open wounds with bacterial or yeast growth in ≥1 swab or tissue microbiological sample(s) were compared for bacterial growth, Gram staining and oxygen use at a level one trauma center in 2011. Secondary samples had significantly less bacterial growth (32 vs. 89%, p < .001, OR 17), Gram-positive bacteria (56 vs. 78%, p = .013), facultative anaerobic bacteria (64 vs. 85%, p = .011) and Staphylococcus aureus (10 vs. 46%, p = .002). They also tended to include relatively more Coagulase-negative Staphylococci (CoNS) (44 vs. 18%) and Pseudomonas species (spp.) (31 vs. 7%). Most (98%) wounds were successfully closed within 11 days, while wound revision was needed in 4%. The treatment regimen of combined use of repetitive debridement, irrigation and NPWT in an operating room with antibiotics significantly reduced the bacterial load and led to a shift away from Gram-positive bacteria, facultative anaerobic bacteria, and S. aureus, as well as questionably toward CoNS and Pseudomonas spp. in this patient cohort. High rates of wound closure were achieved in a relatively short time with low revision rates. Whether each modality played a role for these findings remains unknown.

Guide wire insertion for percutaneous LC2 screws in acetabular and pelvic ring fixation using a transpedicular working cannula.

Abstract: Closed reduction and percutaneous screw fixation (CRIF) of iliac crescent fractures and fractures of the anterior column of the acetabulum has become an established method in the treatment of these injuries. After reduction, safe insertion of a guide wire is a key step during this procedure. We present a technique that can facilitate introducing the guide wire under fluoroscopic guidance and allow for decreased radiation exposure.

Normative values for CT-based texture analysis of vertebral bodies in dual X-ray absorptiometry-confirmed, normally mineralized subjects

Abstract: To develop age-, gender-, and regional-specific normative values for texture analysis (TA) of spinal computed tomography (CT) in subjects with normal bone mineral density (BMD), as defined by dual X-ray absorptiometry (DXA), and to determine age-, gender-, and regional-specific differences. In this retrospective, IRB-approved study, TA was performed on sagittal CT bone images of the thoracic and lumbar spine using dedicated software (MaZda) in 141 individuals with normal DXA BMD findings. Numbers of female and male subjects were balanced in each of six age decades. Three hundred and five TA features were analyzed in thoracic and lumbar vertebrae using free-hand regions-of-interest. Intraclass correlation (ICC) coefficients were calculated for determining intra- and inter-observer agreement of each feature. Further dimension reduction was performed with correlation analyses. The TA features with an ICC 0.8 with other features were excluded from further analysis for dimension reduction. From the remaining 31 texture features, a significant correlation with age was found for the features mean (r = −0.489, p < 0.001), variance (r = −0.681, p < 0.001), kurtosis (r = 0.273, p < 0.001), and WavEnLL_s4 (r = 0.273, p < 0.001). Significant differences were found between genders for various higher-level texture features (p < 0.001). Regional differences among the thoracic spine, thoracic–lumbar junction, and lumbar spine were found for most TA features (p < 0.021). This study established normative values of TA features on CT images of the spine and showed age-, gender-, and regional-specific differences in individuals with normal BMD as defined by DXA.

Nurse gender and its influence on emergency department triage-upsides and downsides of registry data.

Abstract: The goal of any clinical research is to find answers or solutions to problems that might have an impact on our health care systems and in consequence the patients within these systems. The past has shown that many of these studies frequently fight with a lack of reliability and validity because of inadequate sample sizes. Small sample sizes can lead to biased or skewed conclusions, and are frequently unable to detect existing differences between examined groups or treatments. A good way to avoid the problems inherent with small sample sizes is the use of the so-called “big data”. Pooled data from multiple studies of good and comparable quality or robust prospective registries have the ability to provide true population estimates and detect small differences with remarkable statistical power. However, the success of a registry depends on the quality of data collection by the participants and the collaborating centers. An important clinical problem that has not been answered so far and that was addressed by Vigil et al. in their study published in this issue of PAIN is the potential lack of efficiency in a health care system that may result from social factors such as health care providers’ sex, race, or perceived authority role. These are known, for instance, to influence pain behaviors and clinical pain reporting. Diagnostic and treatment algorithms as well as triage scoring systems based on objective health parameters try to account for these confounders to use health care resources more efficiently. Evenwhen using triage systems, though, the acquisition of some parameters still requires an interaction between patient and health care provider and, thus, can be prone to unconscious confounding factors. A very good example for such a parameter is pain and sex being a knownconfounder. In this context, it has been shown that females exhibit greater overall empathic reactions to behavioral suffering as compared with males. In their study “How Nurse Gender Influences Patient Priority Assignments in U.S. Emergency Departments”, Vigil et al. investigated whether emergency department patients’ pain intensity (PI) ismeasured differently bymale and female nurses by the use of data from the Veterans’ Health Administration Corporate Data Warehouse (VHA’s CDW). The VHA’s CDW is a registry that contains data from one of the largest integrated health care information systems in the United States. Most studies using the CDW report on pharmacy or medications, systems issues, and weightmanagement or obesity, but it also contains vast amount of other data that are produced by a health care system—such as vital signs and the Emergency Severity Index (ESI) scores of every patient who underwent a triage in one of the emergency departments of the VHA. The ESI is an established triage scoring system frequently used to estimate urgency and the expected need of resources for patients entering emergency departments. For their study, Vigil et al. analyzed ESI scores among a large national sample from that database. Two of the parameters assessed for the ESI are PI and respiratory rate. Vigil et al. found that patients’ PI did not differ by nurse gender. However, the authors found that, when male patients were assessed, nurse gender influenced how PI and respiratory rate measurements were associated with ESI scores of different urgency. Higher PI levels were associated with more urgent (higher priority) ESI scoring by female nurses, yet less urgent ESI scoring by male nurses. In contrast, male patients with high respiratory rates received more urgent ESI scores by male nurses, whereas nurse gender did not influence ESI scoring for female patients. The findings of the study put light on the fact that in a health care context, the communication between patient and care provider goesbeyond exchanging simplemedical facts and vital parameters. To receive care, the patient has a motivation to send signals communicating their distress and their need for care. As stated by Vigil et al, “care beginswith thepatient believing that their expression has been acknowledged and appropriately acted upon.” Hence, the fact that sex has an influence on the ESI scoring would have implications on the reliability of the ESI and thus decrease its value in terms of steering resources and capacities in an emergency department. The use of a large-scale database is certainly a strength of the study as large samples can allow for statistical precision and improve external validity. Vigil et al. are to be congratulated for the high analytic standards applied on their data and the meticulous description of their methodical procedures. One has to consider that “big data” studies frequently have 2 main limitations: First, the potential presence of confounding factors that had not been acquired by the original registry. Triage decisions—even when usinganalgorithmas theESI—arealways influencedby farmore than the simple parameters of PI, respiratory rate, and heart rate. As mentioned by the authors, “during face-to-face communication, voluntary and involuntary and information is exchanged explicitly via languageand implicitly bynonverbal cues”. Especially in thecontext of an emergency department triage situation, nonverbal messages like the color of the skin (paleness, beginning cyanosis, and a rash), drops Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.