Showing papers in "Injury-international Journal of The Care of The Injured in 2007"

Fracture healing: the diamond concept.

Abstract: Fracture healing is a complex physiological process. With the latest advances made in molecular biology and genetics it is now known that it involves the spatial and temporal coordinated action of several different cell types, proteins and the expression of hundreds of genes working towards restoring its structural integrity without scar formation. The standard tissue engineering approach to provide solutions for impaired fracture healing, bone restoration and regeneration includes the utilisation of growth factors, scaffolds and mesenchymal stem cells (triangular concept). However, although the mechanical environment is discussed and is considered as an important element in bone regeneration, its importance is often underestimated and it is not always given the necessary attention. The available scientific evidence supports the view that all the 4 known factors contributing to bone restoration should be given an equal acknowledgment and recognition. The traditional discussed triangular concept therefore should be reconsidered and be accepted as the 'diamond concept'.

Early coagulopathy in multiple injury: An analysis from the German Trauma Registry on 8724 patients

Abstract: Summary Background There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking. Patients and methods A retrospective analysis using the German Trauma Registry database including 17,200 multiple injured patients was conducted to determine (a) to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated (b) with the amount of intravenous fluids (i.v.) administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality. Eight thousand seven hundred and twenty-four patients with complete data sets were screened. Results Coagulopathy upon ER admission as defined by prothrombin time test (Quick's value) −1 , was present in 34.2% of all patients. There was an increasing incidence for coagulopathy with increasing amounts of i.v. fluids administered pre-clinically. Coagulopathy was observed in >40% of patients with >2000ml, in >50% with >3000ml, and in >70% with >4000ml administered. Ten percentage of patients presented with clotting disorders although pre-clinical resuscitation was limited to 500ml of i.v. fluids maximum. The mean ISS score in the coagulopathy group was 30 (S.D. 15) versus 21 (S.D. 12) ( p p p p Conclusion There is a high frequency of established coagulopathy in multiple injury upon ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome.

Systemic inflammation after trauma.

Abstract: Trauma is still one of the main reasons for death among the population worldwide. Mortality occurring early after injury is due to "first hits", including severe organ injury, hypoxia, hypovolaemia or head trauma. Massive injury leads to activation of the immune system and the early inflammatory immune response after trauma has been defined as systemic inflammatory response syndrome (SIRS). "Second hits" such as infections, ischaemia/reperfusion or operations can further augment the pro-inflammatory immune response and have been correlated with the high morbidity and mortality in the latter times after trauma. SIRS can lead to tissue destruction in organs not originally affected by the initial trauma with subsequent development of multi-organ dysfunction (MOD). The initial pro-inflammatory response is followed by an anti-inflammatory response and can result in immune suppression with high risk of infection and sepsis. Trauma causes activation of nearly all components of the immune system. It activates the neuroendocrine system and local tissue destruction and accumulation of toxic byproducts of metabolic respiration leads to release of mediators. Extensive tissue injury may result in spillover of these mediators into the peripheral bloodstream to further maintain and augment the pro-inflammatory response. Hormones like ACTH, corticosteroids and catecholamines as well as cytokines, chemokines and alarmins play important roles in the initiation and persistence of the pro-inflammatory response after severe injury. The purpose of this review is therefore to describe the immunological events after trauma and to introduce important mediators and pathways of the inflammatory immune response.

Autologous iliac crest bone graft: Should it still be the gold standard for treating nonunions?

Abstract: Nonunion is a common complication following long-bone fracture, with a prevalence that ranges from 2.5-46%, depending on the location and severity of the injury to the bone, soft tissue, and vascular structures. The treatment of nonunions involves addressing the biology of fracture repair and the mechanical stability of fracture fixation, which are interrelated. Nonunion treatment has traditionally included the addition of autograft from the iliac crest to enhance healing. However, there an associated morbidity with the harvesting of the graft, and alternatives such as bone marrow aspirate, platelet-rich plasma, allograft, and ceramics have also been studied. In addition, new advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors, such as bone morphogenetic proteins, to accelerate bone healing. This article reviews the benefits of iliac crest bone graft relative to those of other modalities in the treatment of nonunions.

The epidemiology of fractures in children

Abstract: A retrospective study of all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of fractures was 20.2/1000/year and that 61% of children's fractures occurred in males. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. The incidence of fractures in cyclists and pedestrians remains relatively high whereas the incidence in vehicle occupants is low suggesting that road safety programs have been successful. Similar programs should be instituted for young cyclists. The importance of accident prevention programmes in the home is also highlighted.

Modulation of immune response by head injury.

Abstract: Despite the fact that traumatic brain injury (TBI) is a silently growing epidemic, we are yet to understand its multifaceted pathogenesis, where various cellular pathways are initiated in response to both the primary mechanical insult and secondary physiologically mediated injury Although the brain has traditionally been considered an immunologically privileged site, evidence to the contrary exists in studies of central nervous system (CNS) pathology, in particular TBI Transmigration of leukocytes following blood brain barrier (BBB) disruption results in activation of resident cells of the CNS, such as microglia and astrocytes, to possess immunological function Both infiltrating peripheral immune cells and activated resident cells subsequently engage in the intrathecal production of cytokines, important indicators of the presence of neuroinflammation Cytokines can either promote this neurotoxicity, by encouraging excitotoxicity and propagating the inflammatory response, or attenuate the damage through neuroprotective and neurotrophic mechanisms, including the induction of cell growth factors Certain cytokines perform both functions, for example, interleukin-6 (IL-6) This review article discusses the notion that the inflammatory response to TBI is no longer a peripherally mediated phenomenon, and that the CNS significantly influences the immunological sequence of events in the aftermath of injury

Epidemiology of periprosthetic femur fracture around a total hip arthroplasty

Abstract: Periprosthetic femoral fractures can be classified as intraoperative and postoperative fractures. The intraoperative fractures mostly occur during the insertion of the femoral stem. Depending on the fixation method used, differences in the incidence of intraoperative fractures have been reported. An increase of intraoperative fractures is reported with the introduction of uncemented stems and this is often a consequence of the effort to obtain a sufficient press-fit to gain initial stem stability. In revision surgery an even higher incidence has been reported, ranging between 3.6% and 20.9% when cemented or uncemented prostheses are used, respectively. This review article reports on the prevalence of periprosthetic femoral fractures around a total hip replacement.

Molecular aspects of fracture healing:Which are the important molecules?

Abstract: Fracture healing is a complex physiological process involving a coordinated interaction of hematopoietic and immune cells within the bone marrow, in conjunction with vascular and skeletal cell precursors. Multiple factors regulate this cascade of molecular events, which affects different stages in the osteoblast and chondroblast lineage during processes such as migration, proliferation, chemotaxis, differentiation, inhibition, and extracellular protein synthesis. A clear understanding of the cellular and molecular pathways in fracture healing is not only critical for advancing fracture treatment, but it may also enhance further our knowledge of the mechanisms involved within skeletal growth and repair, as well as the mechanisms of aging. An overview of the important molecules involved in fracture healing, including osteogenic autocoids and inhibitory molecules, and their interactions and possible mechanisms of synergy during the healing process is presented in this article.

Prevalence of long-bone non-unions.

Abstract: Despite the enormous progress made during recent decades in the treatment of long-bone fractures, fracture healing is still haunted by complications and above all non-unions. Non-unions represent a particular challenge, and the difficulties surrounding their management are frequently underestimated. Knowledge of the epidemiology of long-bone non-union can assist the treating surgeon in the application of the optimum fracture treatment.

Fracture healing in osteoporotic fractures: is it really different? A basic science perspective.

Abstract: Osteoporosis is a major health problem characterized by compromised bone strength that predisposes patients to an increased risk of fracture. Osteoporotic patients differ from normal subjects in bone mineral composition, bone mineral content, and crystallinity. Poor bone quality in patients with osteoporosis presents the surgeon with difficult treatment decisions. Much effort has been expended on improving therapies that are expected to preserve bone mass and thus decrease fracture risk. Manipulation of both the local fracture environment in terms of application of growth factors, scaffolds and mesenchymal cells, and systemic administration of agents promoting bone formation and bone strength has been considered as a treatment option from which promising results have recently been reported. Surprisingly, less importance has been given to investigating fracture healing in osteoporosis. Fracture healing is a complex process of bone regeneration, involving a well-orchestrated series of biological events that follow a definable temporal and spatial sequence that may be affected by both biological factors, such as age and osteoporosis, and mechanical factors such as stability of the osteosynthesis. Current studies mainly focus on preventing osteoporotic fractures. In recent years, the literature has provided evidence of altered fracture healing in osteoporotic bone, which may have important implications in evaluating the effects of new osteoporosis treatments on fracture healing. However, the mechanics of this influence of osteoporosis on fracture healing have not yet been clarified and clinical evidence is still lacking.

Biomechanical testing of the locking compression plate: When does the distance between bone and implant significantly reduce construct stability?

Abstract: Summary Aim To investigate in vitro the mechanical stability of a locking compression plate (LCP) construct in a simulated diaphyseal fracture of the humerus at increasing distances between the plate and bone. Materials and method A series of biomechanical in vitro experiments were performed using composite humerus sawbone as the bone model. Osteotomy created in the mid-diaphyseal region. A 10 mm osteotomy gap was bridged with a seven-hole 4.5 stainless steel plate with one of four methods: a control group consisted of a dynamic compression plate applied flush to the bone and three study groups which comprised of a LCP applied flush to the bone, at 2 mm and at 5 mm from the bone. Standard AO technique used with locking head screws used for LCP fixation. Static and dynamic loading tests performed in a custom made jig in which the bone model was fixed both proximally and distally. Samples were subjected to cyclical compression, compression load to failure, cyclical torque and torque to failure. Plastic deformation and failure was assessed using three-dimensional measurements. Scanning electron microscopy of the plate and screw surface allowed detailed inspection of micro-fracture in areas of fatigue. Results Comparable results were achieved in both the DCP and LCP constructs in which the plate was applied at or less than 2 mm from the bone. When applied 5 mm from the bone the LCP demonstrated significantly increased plastic deformation during cyclical compression and required lower loads to induce construct failure. Conclusion • At a distance 5 mm we observe an inferior performance in the mechanical properties of the LCP construct with decrease in axial stiffness and torsional rigidity. • If it is desirable for an LCP to be used the distance between plate and bone should be ≤2 mm.

Risk factors contributing to fracture non-unions

Abstract: Many studies have been carried out on the matter of pseudoarthrosis since the 1920s, where pseudoarthrosis is defined to occur when consolidation cannot be completed wi thout new biological or mechanical st imulation. Since then, several authors have contr ibuted their knowledge of osteogenetic mechanisms, placing the emphasis on the risk factors of a non-union. In genera[ terms the risk factors contr ibut ing to non-union can be separated into genera[ and local factors (Table 1 ). The purpose of this study is to ident i fy and report on the di f ferent factors which have been implicated in the pathogenesis of non-union of fractures.

Mesenchymal stem cell tissue engineering: techniques for isolation, expansion and application.

Abstract: Mesenchymal stem cells (MSCs) are undifferentiated multipotent cells which reside in various human tissues and have the potential to differentiate into osteoblasts, chondrocytes, adipocytes, fibroblasts and other tissues of mesenchymal origin. In the human body they could be regarded as readily available reservoirs of reparative cells capable to mobilize, proliferate and differentiate to the appropriate cell type in response to certain signals. These properties have triggered a variety of MSC-based therapies for pathologies including nonunions, osteogenesis imperfecta, cartilage damage and myocardial infarction. The outcome of these approaches is influenced by the methodologies and materials used during the cycle from the isolation of MSCs to their re-implantation. This review article focuses on the pathways that are followed from the isolation of MSCs, expansion and implantation.

Locking Compression Plate with Minimally Invasive Plate Osteosynthesis in diaphyseal and distal tibial fracture: A retrospective study of 32 patients

Abstract: Summary With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5 mm LCP and 3.5 mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior–anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.

The role of mesenchymal stem cells in maintenance and repair of bone.

Abstract: The maintenance of stable bone mass during adult life, following rapid skeletal growth during childhood, is the result of a carefully controlled balance between the activities of bone forming (osteoblast) and bone resorbing (osteoclast) cells. Although skeletal turnover continues throughout adult life, the net effect of formation and resorption on bone mass is zero in healthy individuals. Later in life, bone mass begins to fall as resorption outpaces formation, particularly in post-menopausal women, which leads to increased fracture risk. The opposing actions of these two cell types are coupled by molecular interactions between them that are thought to be influenced by the actions of the precursor cells of the osteoblast lineage, mesenchymal stem cells (MSCs). In addition to regulating normal skeletal homeostasis, MSCs also play an important role in fracture repair. Bone fracture or injury initiates a series of cellular and molecular pathways that commence with hematoma formation and an inflammatory cascade that regulates MSCs activity leading to fracture healing and the reestablishment of skeletal integrity. Although tremendous strides have been made in increasing our understanding of bone biology, there is surprisingly little data about the role of MSCs in vivo in the maintenance of skeletal integrity or fracture repair. In recent years, the pivotal importance of anabolic therapies in the setting of osteoporosis in which bone mass is substantially increased above and beyond what is attainable with the bisphosphonate class of drugs has put MSC biology firmly on the scientific agenda. Although the biology of cultured MSCs is reasonably well understood, the biology of MSCs in vivo in both bone turnover and fracture repair remains poorly understood. The recent phenotypic characterization of in vivo MSCs and the ability to prospectively purify such cells will open up new avenues of research into a better understanding of the role of MSCs in bone turnover. The purpose of this article is to review bone and fracture biology from the perspective of recent advances in our understanding of MSCs and to highlight the major deficiencies in our current knowledge.

The health economics of the treatment of long-bone non-unions.

Abstract: A review of the existing evidence on economic costs of treatment of long-bone fracture non-unions has retrieved 9 papers. Mostly the tibial shaft non-unions have been utilised as models for these economic analyses. Novel treatment strategies like BMP-7 grafting, Ilizarov ring external fixation or supplementary use of therapeutic ultrasound devices have been compared with standard methods of treatment focusing on direct and indirect costs and expenses. A cost-identification query was conducted and revealed costs of pound 15,566, pound 17,200 and pound 16,330 for humeral, femoral, and tibial non-unions respectively on a "best-case scenario". The existing scientific evidence can only imply the extent of the economic burden of long-bone non-unions. Further systematic studies are needed to assess the direct medical, direct non-medical, indirect, and monetised quality of life and psychosocial costs of non-unions.

Risk factors for periprosthetic femoral fracture

Abstract: Periprosthetic femur fractures are associated with high patient morbidity and are difficult reconstructive challenges. Early identification and appropriate intervention are critical to prevent this complication. Studies varying from case reports to national arthroplasty registry databases have demonstrated that certain factors are associated with an increased risk of fracture. These include trauma, patient-specific problems, and technical issues related to the hip replacement itself. Recent evidence from large registries has shown that the key to prevention of periprosthetic femur fractures is routine follow-up with radiographic studies.

Effect of mechanical stability on fracture healing--an update.

Abstract: The effects of mechanical stability and mechanical stimulation have been studied extensively in vivo using a variety of animal models and stimulators. Early results indicated that stimulation does not significantly contribute to fracture healing. Lately, however, more rigid external stimulators that withstand increased callus formation have identified a contribution of mechanical stimulation in the initial period of fracture healing. However, these studies also show that the same amount of movement inhibits union during the last phase of fracture healing. On the cellular level, most investigations have used 2-dimensional cell culture systems to study the response of different cell phenotypes to mechanical stimulation, shear stress, and hydrostatic pressure. Cell proliferation and differentiation are clearly altered by these stimuli, however, the response depends on the cell type, the magnitude of the strain, and the cofactors applied. Lately, 3-dimensional cell cultures in mechano-bioreactors have been used to investigate the response of bone marrow stromal cells. These results indicate that the predominant stimulus for proliferation is perfusion. Mechanical stimulation affects cell differentiation and depends on the strain magnitude and the cell phenotype. As a consequence, today's implants should be applied in a fashion that supports maximum perfusion at the fracture site. In the early period, the osteosynthesis should facilitate micromotion of the fragments if secondary fracture healing is desired. At the same time, joint congruency, and axial and rotational positions have to be maintained. In the final period of healing, motion within the calcifying callus should be limited, which is naturally achieved by the increasing stiffness of the callus ossification.

Displaced intra-articular calcaneal fractures: 15-Year follow-up of a randomised controlled trial of conservative versus operative treatment

Abstract: Summary Aim To report the 15-year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment published in 1993. Patients and methods Of the initial study, 46 patients (82%) were still alive at a mean of 15 years post injury and 26 patients (57%) agreed to review. The patients had been randomly allocated to either conservative or operative treatment in the original study. Clinical [American orthopaedic foot and ankle society hindfoot scale (AOFAS), foot function index (FFI) and calcaneal fracture score] and radiological (Bohler's angle and calcaneum height) outcome measures were used. The grade of osteoarthritis was also assessed at long-term follow-up. Results At long-term follow-up, the clinical outcomes were not different between conservative versus operative treatment. AOFAS hindfoot scale: conservative=78.5 and operative=70, p =0.11; FFI: conservative=24.4 and operative=26.9, p =0.66; calcaneal fracture score: conservative=70.1 and operative=63.5, p =0.41. The radiological outcomes were also not different between both groups. Bohler's angle: conservative=10.4° and operative 16.9°, p =0.07; height of calcaneum: conservative=37.2mm and operative=38.2mm, p =0.57; grade of osteoarthritis of the sub-talar joint: p =0.54. There was no correlation between Bohler's angle and the outcome measures in either group. Conclusion The results of this 15-year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment and demonstrate similar findings to those at one year follow-up.

Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures.

Abstract: Summary Aim To evaluate the use of rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures. Introduction The complex three-dimensional anatomy of the pelvis and acetabulum make assessment, classification and treatment of fractures of these structures notoriously difficult. Conventional imaging only provides two-dimensional images of these fractures. While interpretation of traditional imaging techniques becomes better with experience, novel techniques may assist in the understanding of these complex injuries. Methods Twenty patients with acetabular fractures were studied. Life size three-dimensional models were manufactured from standardised CT scans, using the rapid prototyping process, selective laser sintering. Each model was presented to the operating surgeon prior to surgery. The surgeons found that the models greatly assisted in their understanding of the personality of the fracture. Three consultant orthopaedic surgeons and three senior trainees were asked to classify each fracture using conventional radiographs (AP pelvis, Judet views and CT scans) and then using the model. The kappa statistic was used to evaluate inter- and intraobserver agreement. Results Interobserver agreement was not absolute using either conventional radiographs or the models. For the consultants the kappa statistic using conventional radiographs was 0.61 while the kappa value using the model was 0.76 ( p p Conclusion Full sized models of acetabular fractures greatly assisted surgeons understand the personality of complex fractures prior to surgery and have been shown in this study to significantly reduced the degree of interobserver variability in fracture classification. This effect is particularly evident for less experienced surgeons. This technique is available and relatively inexpensive. The use of these models should prove invaluable as a tool to aid clinical practice.

The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

Abstract: Summary Introduction Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. Methods A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. Results The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p p =0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p =0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. Conclusion In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.

Definition and classification of fracture non-unions.

Abstract: Classifications in general provide relevant information for clinical purposes to compose a suitable treatment strategy and for research purposes to be able to define comparable study groups. Two distinct types of non-unions are described in the established literature. In the first type the ends of the fragments are hypervascutar or hypertrophic and are capable of biologic reaction. In the second type the ends of the fragments are avascular or atrophic and are inert and incapable of biologic reaction. Hypervascular as well as avascular non-unions may be complicated by the presence of infection, poor soft-tissue quality, short peri-articular fragments or significant deformity, demanding mu[ti-stage treatment strategies with concomitant worsened prognosis and subsequent increased frequency of amputation.

Synthetic bone scaffolds and fracture repair

Abstract: Synthetic scaffolding has been used in the treatment of bone defects and fractures for over 100 years. They remain a critical tool in the treatment of large-volume bone defects, and their role as potential substitues for human bone graft continues to expand. Various materials are used commercially to produce osteoconductive scaffolds including ceramics (both bioactive and bioinert) and select polymers, all of which offer distinct advantages and dissadvantages. While currently used principally as osteoconductive conduits for growth, the role of bone-graft substitues in fracture treatment is likely to change, as biomaterial research moves towards utilizing current and future scaffold materials as delivery systems for biologic fracture treatments.

Necrotising fasciitis of upper and lower limb: A systematic review

Abstract: Necrotising fasciitis is a rapidly progressive, life threatening soft tissue infection. In a significant proportion of patients, the extremities are involved as a result of trauma, needle puncture or extravasation of drugs, often leading to limb loss and devastating disability. In this systematic review of necrotising fasciitis of the upper and lower extremities, we report on the clinical characteristics, the predisposing factors, the associated diseases, the pathogenic bacteria, the surgical treatment and the final outcome in terms of limb loss and mortality. Data for a total of 451 patients were analysed for each parameter of interest. A percentage of 22.3% of the reviewed patients underwent amputation or disarticulation of a limb following failure of multiple debridements to control infection and the mortality rate was estimated as high as 21.9%.

Emergency Medical Service (EMS) systems in developed and developing countries.

Abstract: Summary Objectives To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. Method We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries. Results A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1 min) and Montreal, Canada (median 16.1 min) reported the shortest and Germany (median: 30 min) and Austria (median: 26 min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). Conclusion This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.

Preoperative planning in pelvic and acetabular surgery: The value of advanced computerised planning modules

Abstract: An experimental computer program for virtual operation of fractured pelvis and acetabulum based on real data of the fracture is presented. The program consists of two closely integrated tools, the 3D viewing tools and the surgeon simulation tools. Using 3D viewing tools the virtual model of a fractured pelvis is built. This procedure is performed by computer engineers. Data from CT of a real injury in DICOM format are used. With segmentation process each fracture segment becomes a separate object and is assigned a different colour. The virtual object is then transferred to the personal computer of the surgeon. Bone fragments can be moved and rotated in all three planes and reduction is performed. After reduction, fixation can be undertaken. The appropriate ostheosynthetic material can be chosen. Contouring of the plate is performed automatically to the reduced pelvis. The screws can be inserted into the plate or across the fracture. The direction and length of the screws is controlled by turning the pelvis or by making bones more transparent. The modeling of the plate in all three axes can be recorded as the exact length of the screws. There is also a simulation tool for intraoperative C-arm imaging in all directions. All the steps of the procedure are recorded and printed out. Postoperative matching of real operation and virtual procedure is also possible. We operated on 10 cases using virtual preoperative planning and found it very useful. The international study is still in progress. One case is presented demonstrating all the possibilities of the virtual planning and surgery. The presented computer program is an easily usable application which brings significant value and new opportunities in clinical practice (preoperative planning), teaching and research.

Trauma and immune response – effect of gender differences

Abstract: A major consequence of traumatic injury is immunosuppression Findings from previous studies suggest that the depression of immune functions is severe in young males, ovariectomised and aged females In contrast, the immune functions in proestrus females following trauma-haemorrhage are maintained Studies have also shown that the survival rate in proestrus females following trauma-haemorrhage and the induction of subsequent sepsis is significantly higher than in age-matched males and ovariectomised females Furthermore, administration of female sex hormone 17beta-oestradiol in males and ovariectomised females after trauma-haemorrhage prevents the suppression of immune response Thus, these findings suggest that sex hormones play a significant role in shaping the host response following trauma This article reviews studies delineating the mechanism by which sex hormones regulate immune cell functions in the experimental model of trauma-haemorrhage The findings from the studies reviewed in this article suggest that sex steroids can be synthesised by the immune cell The findings further indicate that T cell and macrophages express receptors for androgen and oestrogen Since these cells are also the cells that produce cytokines, local synthesis of active steroids in these cells may become the significant factor in modulating their cytokine production

Locking plate osteosynthesis for Vancouver Type B1 and Type C periprosthetic fractures of femur: a report on 12 patients.

Abstract: Many methods have been described to stabilise periprosthetic fractures around a total hip arthroplasty. Locking plate fixation offers increased angular stability and, theoretically, better fixation in osteoporotic bone. This study presents our results with the use of locking plate fixation for Vancouver Type B1 and Type C periprosthetic fractures following total hip arthroplasty (THA). Twelve patients underwent fixation of periprosthetic fractures with either a locking compression plate (LCP) or a distal femur less invasive stabilisation system (LISS). There were six Type B1 and six Type C fractures. One patient died soon after surgery. The mean follow-up was 13.9 months (range 12-18 months). The fracture healed in 10 of the remaining 11 patients with a median time to union of 4.8 months. There was one implant failure prior to fracture healing and one implant failure after fracture healing. Both were attributed to technical errors. Seven patients returned to their previous level of mobility. Two patients required the use of one walking stick after fracture healing, but had been able to walk unaided before their fall. One patient required two sticks, after previously requiring only a single stick. There were no infections. Our experience encourages us that locking plates have a role to play in managing periprosthetic fractures around a stable femoral stem, especially in patients with poor soft tissue and osteoporosis.

Debridement and wound closure of open fractures: the impact of the time factor on infection rates.

Abstract: Open fracture management represents an orthopaedic emergency. Early aggressive management of these debilitating injuries within the first 6h has been encouraged in order to minimise the risk of infection and long term sequelae. Debridement and wash-out of the wound, followed by stabilisation of the bony elements and closure of the soft-tissue envelope are all considered essential. However, the available scientific evidence supporting the timing of this multistage approach of open fracture management, and the "Six-hour rule" itself, are unclear. This review article analyses the available evidence regarding the impact of the timing of wound debridement and closure of open fractures of the lower extremity.

Role of biological modifiers regulating the immune response after trauma.

Abstract: Trauma induces a profound immunological dysfunction. This is characterised by an early state of hyperinflammation, followed by a phase of immunosuppression with increased susceptibility to infection and multiple organ failure. Therapeutic strategies directed at restoring immune homeostasis after traumatic injuries have largely failed in translation from "bench to bedside". The present review illustrates the role of biological modifiers of the posttraumatic immune response by portraying different modalities of therapeutic immune modulation. The emphasis is placed on anti-inflammatory (steroids) and immune-stimulatory (interferon) pharmacological strategies and modified resuscitative strategies, as well as more unconventional immunomodulatory approaches, such as immunonutrition.