Bioceramics, because of its excellent biocompatible and mechanical properties, has always been considered as the most promising materials for hard tissue repair. It is well know that an appropriate cellular response to bioceramics surfaces is essential for tissue regeneration and integration. As the in vivo implants, the implanted bioceramics are immediately coated with proteins from blood and body fluids, and it is through this coated layer that cells sense and respond to foreign implants. Hence, the adsorption of proteins is critical within the sequence of biological activities. However, the biological mechanisms of the interactions of bioceramics and proteins are still not well understood. In this review, we will recapitulate the recent studies on the bioceramic–protein interactions.

A review of protein adsorption on bioceramics

The replantation of a single digit amputated proximal to the insertion of the flexor digitorum superficialis (FDS) is contra-indicated in adults because this replanted digit usually leads to a stiff proximal interphalangeal joint (PIPJ) that interferes with overall hand function.1–4 Replantation of distal amputations is analogous to the commonly performed distal interphalangeal joint (DIPJ) fusion that still maintains PIPJ motion. However, distal replantation is not commonly performed because it is a technically challenging operation and the loss of function due to a missing fingertip is perceived to be negligible. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes has not been performed. A randomized controlled trial is not possible because it would be unethical and unfeasible to randomize patients to replantation, revision amputation, or some form of reconstruction. A systematic review is the only possible research method to use best available evidence from the literature to determine the outcomes of digital replantation.

The specific aim of this study is to apply strict inclusion criteria to select publications with sufficient details in the data presentation in order to provide comparable data to assess outcomes of distal finger replantation. We hypothesize that replantation of distal digital amputations will have good outcomes.

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A systematic review of the outcomes of replantation of distal digital amputation.

Die Versorgung schwerstverletzter Patienten im Schockraum bedeutet fur das multidisziplinare Behandlungsteam einen strukturierten Evaluationsprozess in einen zielgerichteten Behandlungsprozess zu uberfuhren. Neben dem Faktor Zeit und dem Erkennen vital bedrohlicher Verletzungen, die haufig unter dem Begriff „deadly six“ zusammengefasst werden, sollten aber auch sog. „Bagatellverletzungen“ nicht ubersehen werden, da sie die Lebensqualitat nach Trauma mitunter entscheidend beeinflussen konnen. Die S3-Leitlinie Polytrauma erhebt nicht den Anspruch auf Vollstandigkeit. Wichtige Inhalte, wie z. B. die Versorgung von Kindern sind bisher noch nicht in die Leitlinie eingeflossen, werden aber fur die Uberarbeitung fest eingeplant.

S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung

Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in 10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.

Tibial Shaft Fractures in Children and Adolescents

The decision to replant a severed part is based on the numerous factors that influence survival of the part and the functional and aesthetic benefits gained from replanting. Not all amputees will benefit from or are candidates for replantation. The decision to proceed is therefore made by the surgeon who must consider the mechanism and extent of injury, the age of the patient, the presence of other medical or surgical conditions, the likely functional outcomes, and the patient's motivation to undergo a difficult procedure, which is followed by a lengthy recovery. This is a meta-analysis of the available studies that tracks the outcomes, based on 9 criteria, after the amputation of a total of 1803 digits in 1299 patients. By combining the data from numerous sources, a statistically significant picture emerges which may be used to educate patients and help guide the surgeon in the decision to replant.

A meta-analysis of success rates for digit replantation.

To find out the influencing factors of the immediate and late outcome of replantation and revascularization of the digits the study was carried out as a prospective survey research during 1983 to 1995 with at least 2 year follow up. Traumatic total or subtotal amputation with inadequate circulation of the digits distal to the metacarpal head were included in the study. There were 552 patients with 366 males (675 digits) and 186 females (343 digits). Successful operation was found in 508 patients (92%) with 946 digits (92.9%). Type of injury was the most important factor influencing immediate and late outcome. Regular cigarette smoking resulted in poor immediate survival rate. Prolonged ischaemia had a significant influence in final functional outcome. Using composite skin and subcutaneous vein graft gave good survival rate. Injury at the no man's land area resulted in poor range of movement of the digit. Connecting the profundus tendon stump of the proximal part to the superficialis tendon of the amputated part gave a better result than 2 tendon repair and repairing only the profundus tendon. Replantation should be carried out even if only one digit is involved. At the 2 year follow up 195 patients (38%) were classified in grade I of Chen et al., functional outcome, while 153 (31%) were in grade II, 124 (24%) were in grade III and 36 (7%) were in grade IV.

Results of 1018 digital replantations in 552 patients.

We carried out a randomised, controlled trial in 157 patients who had isolated severe Gustilo type-IIIa and type-IIIb fractures of the metaphysis or diaphysis of the leg to determine the prevalence of vascular injuries and the role of vascular repair. All patients had stable vital signs and clinically adequate circulation in their legs before operation. In a control group of 64 patients we performed conventional surgery with systematic debridement and primary stabilisation of the fractures. In the trial group of 93 patients the major vessels and nerves adjoining the compound fracture were routinely explored and repaired when necessary after the initial procedure. Two of the 28 control patients (7.1%) with type-IIIb compound fractures had signs of inadequate circulation after the first operation. Both had major vascular injuries which were demonstrated at a second procedure. In the trial group, major vascular injuries were found in two of 54 patients (3.7%) with type-IIIa and 11 of 39 patients (28.2%) with type-IIIb compound fractures. Compared with the control group the trial group showed improved results at both the immediate and long-term follow-up. Routine exploration and early repair of injured major vessels of the leg in severe compound fractures gave encouraging results.

Somjet Sakkarnkosol

Papers

Results of 1018 digital replantations in 552 patients.

Vascular injuries in compound fractures of the leg with initially adequate circulation