Showing papers in "Injury-international Journal of The Care of The Injured in 2011"
TL;DR: The basic biology of fracture healing is summarized, which includes an acute inflammatory response including the production and release of several important molecules, and the recruitment of mesenchymal stem cells in order to generate a primary cartilaginous callus.
Abstract: The biology of fracture healing is a complex biological process that follows specific regenerative patterns and involves changes in the expression of several thousand genes. Although there is still much to be learned to fully comprehend the pathways of bone regeneration, the over-all pathways of both the anatomical and biochemical events have been thoroughly investigated. These efforts have provided a general understanding of how fracture healing occurs. Following the initial trauma, bone heals by either direct intramembranous or indirect fracture healing, which consists of both intramembranous and endochondral bone formation. The most common pathway is indirect healing, since direct bone healing requires an anatomical reduction and rigidly stable conditions, commonly only obtained by open reduction and internal fixation. However, when such conditions are achieved, the direct healing cascade allows the bone structure to immediately regenerate anatomical lamellar bone and the Haversian systems without any remodelling steps necessary. In all other non-stable conditions, bone healing follows a specific biological pathway. It involves an acute inflammatory response including the production and release of several important molecules, and the recruitment of mesenchymal stem cells in order to generate a primary cartilaginous callus. This primary callus later undergoes revascularisation and calcification, and is finally remodelled to fully restore a normal bone structure. In this article we summarise the basic biology of fracture healing.
1,379 citations
TL;DR: The use of RIA device as harvesting method seems a promising alternative with a low complication rate and the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used.
Abstract: Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.
671 citations
TL;DR: In animal models enhancing angiogenesis promotes bone regeneration, suggesting that modifying fracture vascularization could be a viable therapeutic approach for accelerated/improved bone regeneration clinically.
Abstract: Angiogenesis is a key component of bone repair. New blood vessels bring oxygen and nutrients to the highly metabolically active regenerating callus and serve as a route for inflammatory cells and cartilage and bone precursor cells to reach the injury site. Angiogenesis is regulated by a variety of growth factors, notably vascular endothelial growth factor (VEGF), which are produced by inflammatory cells and stromal cells to induce blood vessel in-growth. A variety of studies with transgenic and gene-targeted mice have demonstrated the importance of angiogenesis in fracture healing, and have provided insights into regulatory processes governing fracture angiogenesis. Indeed, in animal models enhancing angiogenesis promotes bone regeneration, suggesting that modifying fracture vascularization could be a viable therapeutic approach for accelerated/improved bone regeneration clinically.
386 citations
TL;DR: Evaluated the type of materials used and their efficacy for the treatment of large bone defects in traumatology and orthopaedic surgery and advocate the use of the diamond concept as a guideline to help judge the extent of therapy the injury warrants.
Abstract: Introduction The gold standard for restoring bone defects is still considered to be autologous bone grafting. However, clinical benefits are not guaranteed and donor-site complications and morbidity is not infrequent. Research is on-going for the development of alternative bone substitutes of both biological and synthetic origin. The purpose of this study was to evaluate the type of materials used and their efficacy for the treatment of large bone defects in traumatology and orthopaedic surgery. Materials and method A literature review was carried out of Embase and PubMed databases. Inclusion criteria were articles in English language focusing on the use of bone substitutes in trauma and orthopaedic surgery for the treatment of bone defects and included details on the structural, biological or biomechanical properties of the pure product. Furthermore, based on two clinical challenges, fracture non-union and impaction grafting we elaborated on the use of polytherapy for large bone defects as guided by the diamond concept. Results All the products indicated in this manuscript possess osteoconductive activities but have different resorption times and biomechanical properties. Bone graft substitute materials are used for a wide range of clinical applications even when the level of clinical evidence is low. The size and location of the defect and the local biological and mechanical environment as well as the biomechanical characteristics of the material determine the type of device that can be implanted in a bone defect. Conclusion Proper assessment of the biological and mechanical environment and accurate patient selection are necessary to judge the extent of therapy the injury warrants. A sound understanding of various aspects of biomaterial properties and their relation and influence towards bone healing is of utmost importance. We suggest the application of polytherapy for the treatment of large bone defects and advocate the use of the diamond concept as a guideline.
367 citations
TL;DR: fixation of proximal humerus fractures with proximal Humerus locking plates is associated with a high rate of complications and reoperation, and further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.
Abstract: Purpose: Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates. Methods: The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias. Results: Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%. Discussion: Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.
356 citations
TL;DR: The effect of intrinsic material properties on biological performance, mechanical strength and biodegradability of CaP bone substitutes is described.
Abstract: Bone repair is a multi-dimensional process that requires osteogenic cells, an osteoconductive matrix, osteoinductive signalling, mechanical stability and vascularization. In clinical practice, bone substitute materials are being used for reconstructive purposes, bone stock augmentation, and bone repair. Over the last decade, the use of calcium phosphate (CaP) based bone substitute materials has increased exponentially. These bone substitute materials vary in composition, mechanical strength and biological mechanism of function, each having their own advantages and disadvantages. It is known that intrinsic material properties of CaP bone substitutes have a profound effect on their mechanical and biological behaviour and associated biodegradation. These material properties of bone substitutes, such as porosity, composition and geometry change the trade-off between mechanical and biological performance. The choice of the optimal bone substitutes is therefore not always an easy one, and largely depends on the clinical application and its associated biological and mechanical needs. Not all bone graft substitutes will perform the same way, and their performance in one clinical site may not necessarily predict their performance in another site. CaP bone substitutes unfortunately have yet to achieve optimal mechanical and biological performance and to date each material has its own trade-off between mechanical and biological performance. This review describes the effect of intrinsic material properties on biological performance, mechanical strength and biodegradability of CaP bone substitutes.
339 citations
TL;DR: The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome.
Abstract: Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.
321 citations
TL;DR: Osteoconductive, osteogenic and osteoinductive products will also be classified and their advantages and disadvantages described.
Abstract: Autologous bone is used very often in the treatment of fresh fractures, delayed unions and non-unions. Alternatives have included allografts and in recent years also demineralized bone matrix. The growing availability of good synthetic bone grafts and their advantages in safety and avoiding donor-site morbidity are the reasons that these products are being used more and more. There are on the market a wide variety of substitutes with different capabilities. Nevertheless autologous bone graft is still considered as the gold standard and will be discussed here in that context. Osteoconductive, osteogenic and osteoinductive products will also be classified and their advantages and disadvantages described.
299 citations
TL;DR: Preoperative assessment of the local BMD and the patients' biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures.
Abstract: Background Several studies reported high failures rates after internal fixation of proximal humerus fractures Loss of reduction and screw cut-out are the most common reasons for revision surgery Several risk factors for failure have been described in the literature The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup Methods Two different surgical techniques (PHILOS locking plate and Humerusblock) were used In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support Results The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support The failure rate significantly increased with the number of risk factors Conclusion Preoperative assessment of the local BMD and the patients’ biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered
297 citations
TL;DR: An overview about the current materials and their evidence of clinical use is given, especially ceramics and polymers, which show similar properties to bone and are degradable.
Abstract: Critical sized bone defects have to be filled with material to allow bone healing. The golden standard for this treatment is autogenous bone grafting. Because of donor size morbidity, equivalent synthetic bone scaffolds should be developed. Different materials, especially ceramics and polymers are in the focus of research. Calcium phosphate ceramics show similar properties to bone and are degradable. Different modifications can improve the bioactive features. This article gives an overview about the current materials and their evidence of clinical use.
272 citations
TL;DR: A review of the clinical application of the most commonly used growth factors for bone repair, the bone morphogenetic proteins (BMPs), and the potential use of human mesenchymal stromal/stem cells (MSC) for clinical application is discussed in this article.
Abstract: Reconstruction of large bone defects or non-unions resulting from biochemical disorders, tumour resections or complicated fractures is still a challenge for orthopaedic and trauma surgery. On the one hand, autografts harbour most features of ideal bone graft substitutes but on the other hand, they have a lot insurmountable disadvantages. An ideal bone graft substitute should be biomechanically stable, able to degrade within an appropriate time frame, exhibit osteoconductive, osteogenic and osteoinductive properties and provide a favourable environment for invading blood vessels and bone forming cells. Whilst osteoconductivity of biomaterials for bone tissue engineering strategies can be directed by their composition, surface character and internal structure, osteoinductive and osteogenic features can be provided by growth factors originally participating in fracture healing and/or multipotent mesenchymal stromal/stem cells (MSC) capable of rebuilding bone and marrow structures. In this review, aspects of the clinical application of the most commonly used growth factors for bone repair, the bone morphogenetic proteins (BMPs), and the potential use of human MSC for clinical application will be discussed.
TL;DR: The authors' cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of effect size for the most important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon for optimal decision making when operative treatment of such fractures is contemplated.
Abstract: The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I2 tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4–61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of effect size for the most important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon for optimal decision making when operative treatment of such fractures is contemplated.
TL;DR: This paper presents a helpful tool for readers who want to evaluate or assess the quality of a measurement instrument on reliability and validity using standardised criteria that were recently published by the COSMIN group.
Abstract: High quality instruments are useful tools for clinical and research purposes. To determine whether an instrument has high quality, measurement properties such as reliability and validity need to be assessed, using standardised criteria. This paper discusses these quality domains and measurement properties using the standardised criteria that were recently published by the COSMIN group. Examples are given of studies evaluating the measurement properties of instruments frequently used in trauma. This paper presents a helpful tool for readers who want to evaluate or assess the quality of a measurement instrument on reliability and validity.
TL;DR: The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.
Abstract: Introduction Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject. Methods An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500m and proportion of time that prosthesis is worn. Results As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500m than those with an AKA or bilateral amputation ( p =0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA. Conclusion This study describes the impact of LLA of different levels on patients' lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.
TL;DR: This review summarizes recent findings pertaining to the definition and characterisation of MSCs in skeletal tissues and discusses the mechanisms of their actions in regenerating of bone in vivo, bringing together literature showing that the ways M SCs are extracted, expanded and implanted can considerably affect bone formation outcomes.
Abstract: The enhancement of bone regeneration with biological agents including osteogenic growth factors and mesenchymal stem cells (MSCs) is becoming a clinical reality. Many exciting findings have been obtained following MSC implantation in animal models, and the data demonstrating their clinical efficacy in humans are promising. The overwhelming majority of experimental work has been performed with MSCs ‘‘amplified’’ in vitro. The nature of native MSCs in skeletal tissues however, remains poorly understood. This review summarizes recent findings pertaining to the definition and characterisation of MSCs in skeletal tissues and discusses the mechanisms of their actions in regenerating of bone in vivo. In respect to traditional tissue engineering paradigm, we bring together literature showing that the ways MSCs are extracted, expanded and implanted can considerably affect bone formation outcomes. Additionally, we discuss current animal models used in MSC research and highlight recent experiments showing important contribution of the host, and not only donor MSCs, in bone tissue formation. This knowledge provides a platform for novel therapy development for bone regeneration based on pharmacologically manipulated endogenous MSCs.
TL;DR: The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns; the development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.
Abstract: Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.
TL;DR: The properties of an ideal measure of outcome in the TBI population are reviewed and the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI are described.
Abstract: Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their care-givers and society as a whole. Clinicians and researchers require reliable and valid measures of long term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors, but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we describe the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI. These measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe); Disability Rating Scale (DRS); Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Functional Status Examination (FSE) and the TBI-specific and generic quality of life measures used in TBI patients (SF-36 and SF-12, WHOQOL-BREF, SIP, EQ-5D, EBIQ, and QOLIBRI).
TL;DR: The evaluation and implementation of cost-effective preventive and therapeutic strategies in the short term may help to ameliorate the future financial burden of PFF, and, more importantly, improve the outcome and quality of life for the elderly after fracture.
Abstract: Aims This study was designed to estimate trends in the number of proximal femoral fractures (PFFs), and consequent bed day requirements and financial implications for England until 2033. Methods Trends in the number of coded PFFs from 1998 to 2008 (collected from Hospital Episode Statistics Online) were projected forward to 2033, and modified according to published data concerning population demographics and declining PFF prevalence. Estimates of 30 day postoperative mortality were calculated according to projected demographic data. Financial estimates were calculated according to current cost and adjusted according to projected inflation. Results Despite a decline in the prevalence of PFF among the aging population (2.98% since 2002), we estimate that approximately 100,000 patients annually will require surgery for fractured neck of femur by 2033 in England, with a 30d mortality of 8.9–9.3%, costing £3.6–5.6 billion (inflation adjusted) in total care. Conclusions The evaluation and implementation of cost-effective preventive and therapeutic strategies in the short term may help to ameliorate the future financial burden of PFF, and, more importantly, improve the outcome and quality of life for the elderly after fracture.
TL;DR: Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions.
Abstract: A B S T R A C T Introduction: Clinical observations together with recent research highlighted the role of coagulopathy in acute trauma care and early aggressive treatment has been shown to reduce mortality. Methods: Datasets from severely injured and bleeding patients with established coagulopathy upon emergency room (ER) arrival from two retrospective trauma databases, (i) TR-DGU (Germany) and (ii) Innsbruck Trauma Databank/ITB (Austria), that had received two different strategies of coagulopathy management during initial resuscitation, (i) fresh frozen plasma (FFP) without coagulation factor concentrates, and (ii) coagulation factor concentrates (fibrinogen and/or prothrombin complex concentrates) without FFP, were compared for morbidity, mortality and transfusion requirements using a matched-pair analysis approach. Results: There were no major differences in basic characteristics and physiological variables upon ER admission between the two cohorts that were matched. ITB patients had received substantially less packed red blood cell (pRBC) concentrates within the first 6 h after admission (median 1.0 (IQR25-75 0-3) vs 7.5 (IQR25-75 4-12) units; p < 0.005) and the first 24 h as compared to TR-DGU patients (median 3 (IQR25-75 0-5) vs 12.5 (8-20) units; p < 0.005). Overall mortality was comparable between both groups whilst the frequency for multi organ failure was significantly lower within the group that had received coagulation factor concentrates exclusively and no FFP during initial resuscitation (n = 3 vs n = 15; p = 0.015). This translated into trends towards reduced days on ventilator whilst on ICU and shorter overall in-hospital length of stays (LOS). Conclusion: Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions. Prospective and randomised clinical trials with sufficient patient numbers based upon this strategy are advocated. 2011 Published by Elsevier Ltd.
TL;DR: Although the detection of a statistically significant reduction in mortality is promising, overall trial quality was low and trial size was small, and the results of this meta-analysis should be confirmed by the conduct of a large multi-center trial.
Abstract: Introduction To determine whether the provision of early standard enteral nutrition (EN) confers treatment benefits to adult trauma patients who require intensive care. Materials and methods MEDLINE and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted. Methodologically sound randomised controlled trials (RCTs) conducted in adult trauma patients requiring intensive care that compared the delivery of standard EN, provided within 24 h of injury, to standard care were included. The primary analysis was conducted on clinically meaningful patient-oriented outcomes, which included mortality, functional status and quality of life. Secondary analyses considered vomiting/regurgitation, pneumonia, bacteraemia, sepsis and multiple organ dysfunction syndrome. Meta-analysis was conducted using an analytical method known to minimise bias in the presence of sparse events. The impact of heterogeneity was assessed using the I 2 metric. Results Three RCTs with 126 participants were found to be free from major flaws and were included in the primary analysis. The provision of early EN was associated with a significant reduction in mortality (OR = 0.20, 95% confidence interval 0.04–0.91, I 2 = 0). No other outcomes could be pooled. A sensitivity analysis and a confirmatory analysis conducted using a different analytical method confirmed the presence of a mortality reduction. Conclusion Although the detection of a statistically significant reduction in mortality is promising, overall trial quality was low and trial size was small. The results of this meta-analysis should be confirmed by the conduct of a large multi-center trial.
TL;DR: The data suggest that light therapy can play an important role in normotrophic wound healing by affecting keratin expression, and Illumination would provide an easily applicable, safe and cost-effective treatment of surface wounds.
Abstract: Background: Low level light therapy (LLLT) is an attractive alternative to enhance wound healing. So far most studies are performed with red or infrared irradiation. However, we recently showed that blue light (470 nm) can significantly influence biological systems, improving perfusion by release of nitric oxide from nitrosyl complexes with haemoglobin in a skin flap model in rats. Here, we compared the effects of blue and red low level light by light-emitting diodes (LEDs) on in vivo wound healing in an excision wound model in rats. Methods: Circular excision wounds were surgically created on the dorsum of each rat. Excisions on either the left or right side were illuminated post-OP and on five consecutive days for 10 min by LED at 470 nm or 630 nm with an intensity of 50 mW/cm 2 , while protecting the contralateral side from exposure. In the control group, neither side was illuminated. On day 7 post-OP, we analysed planimetric and histological parameters, as well as expression of keratin-1, keratin-10 and keratin-17 on mRNA level. Results: Illumination substantially influenced wound healing. Blue light significantly decreased wound size on day 7, which correlated with enhanced epithelialisation. Light also affected mRNA expression. Both wavelengths decreased keratin-1 mRNA on day 7 post-OP, while keratin-10 mRNA level was elevated in both light treated group compared to control. Keratin-17 mRNA was also elevated in the red light group, but was unchanged in the blue light group. Conclusion: In contrast to previous studies, we showed that also blue light significantly influences wound healing. Furthermore, our data suggest that light therapy can play an important role in normotrophic wound healing by affecting keratin expression. Illumination would provide an easily applicable, safe and cost-effective treatment of surface wounds.
TL;DR: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures in the elderly.
Abstract: Background Older patients tend to have acetabular fractures with medial displacement patterns and associated comminution, particularly of the quadrilateral surface. Our goal was to investigate the appropriateness of open reduction and internal fixation using an infra-pectineal buttress plate for osteopenic acetabular fractures. Materials and method We conducted a retrospective review involving twenty one consecutive patients over the course of 4 years with an acetabular fracture in an academic level 1 trauma centre. We performed the modified Stoppa approach with buttress plating of the quadrilateral surface. Clinical examination radiographs was done using criteria described by Matta. Functional outcome was evaluated using surveys including SF-12, WOMAC, Harris Hip score and modified Postel Merle D’Aubigne. Results Average follow-up was 4.2 years with a minimum of 2 years. Mean age for patients was 64.3 years. We obtained anatomic reduction in 52.4% (11/21) of cases, imperfect reduction in 38.1% (8/21) of cases and poor reduction in 9.5% (2/21) of cases. Significant loss of reduction was seen in 2 patients. A superior dome impaction (a Gull sign) was correlated to arthroplasty ( p = 0.02) and reduced quality of initial reduction ( p = 0.02). Two patients required re-intervention with a total hip arthroplasty. There was one traumatic injury to the obturator nerve and 2 patients were noted to have temporary weakness of the hip adductors postoperatively. Conclusion Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures in the elderly.
TL;DR: Vigilant monitoring for neurovascular complications, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament surgeries is the key to successful management of these difficult injuries.
Abstract: Traumatic knee dislocations are uncommon yet serious injuries that historically have had variable prognosis. The evaluation and management of traumatic knee dislocations remains controversial. Appropriate early management has been shown to have a significant impact on long term functional outcome. A comprehensive review of the recent literature is presented alongside our current approach to management. The dislocated knee is an under diagnosed injury which relies on a high index of clinical suspicion on presentation of any knee injury. There is now a degree of consensus regarding need for surgery, timing of surgery, vascular investigations, surgical techniques and rehabilitation protocols. Vigilant monitoring for neurovascular complications, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament surgeries is the key to successful management of these difficult injuries.
TL;DR: In this overview several facts and myths regarding bone-graft substitutes are summarized.
Abstract: The use of artificial bone grafts has been developed over recent years and is expected to increase further, for some indications even replacing the gold standard, autograft, in trauma and reconstructive surgery. However, the effectiveness of these materials is still a subject of debate, mostly because of unclear definitions or limited market surveillance. In this overview several facts and myths regarding bone-graft substitutes are summarized.
TL;DR: Hip fracture patients have a large drop in haemoglobin that is associated with the initial trauma rather than the operation, highlighting the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients even when the initial haemochemistry is apparently normal.
Abstract: Introduction Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death. We speculate that a significant proportion of the blood loss related to hip fractures has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury. Methods In a retrospective study all patients with both a diagnosis of hip fracture and an operative delay of >48 h were assessed. The information collected included: fracture classification, serial haemoglobins and patient co-morbidities. The exclusion criteria included a pre-injury diagnosis of anaemia, anti-coagulation and gastrointestinal bleeds. Results Between 2007/2008 sixty-eight intracapsular and fifty extracapsular hip fracture patients had serial haemoglobins and operative delays of >48 h (mean 75 h, range 48–270 h). The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (±SEM 2.2) and 108.5 g/L (±SEM 2.2) respectively. This difference was statistically significant (Student's t-test p The mean haemoglobin drop in the extracapsular and intracapsular fracture groups was 20.2 g/L (range 0–49 g/L) and 14.9 g/L (range 0–59 g/L) respectively. Conclusions Hip fracture patients have a large drop in haemoglobin that is associated with the initial trauma rather than the operation. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients even when the initial haemoglobin is apparently normal.
TL;DR: Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.
Abstract: Over the last decades, the medical world has advanced dramatically in the understanding of fracture repair. The three components needed for fracture healing are osteoconduction, osteoinduction and osteogenesis. With newly designed scaffolds, ex vivo produced growth factors and isolated stem cells, most of the challenges of critical size bone defects have been resolved in vitro, and in some cases in animal models as well. However, there are still challenges needed to be overcome before these technologies can be fully converted from the bench to the bedside. These technological and biological advancements need to be converted to mass production of affordable products that can be used in every part of the world. Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.
TL;DR: The surgeon must develop the ideal biological environment (non-union bed) where molecular and physiological processes will evolve facilitating an early and successful osteogenesis leading to bone continuity and functional restoration of the affected limb.
Abstract: Bone regeneration presents a unique challenge to both clinicians and scientists. Recently, a vast amount of knowledge has been attained with regard to the molecular mediators, cell populations and the overall cascade of events participating in the bone repair processes. For the treatment of bone non-unions or bone defects, the 'diamond concept' for biological enhancement supports the implantation of mesenchymal stem cells, a scaffold and a growth factor. Prior to the implantation of any or all of these materials however, the surgeon must develop the ideal biological environment (non-union bed) where molecular and physiological processes will evolve facilitating an early and successful osteogenesis leading to bone continuity and functional restoration of the affected limb. At the end of the surgical procedure the non-union bed should have been transformed to a 'biological chamber' active enough to support efficiently all the necessary physiological processes for a successful outcome. The notion of creating the optimum 'biological chamber' represents the centre of the highest biological activity and in a sense the heart of the diamond concept.
TL;DR: Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%,respectively, following penetrating abdominal injury following traumatic insult during pregnancy.
Abstract: Introduction Trauma in pregnancy is the leading cause of non-obstetrical maternal death and remains a major cause of fetal demise. The objective of this study was to examine the outcomes of pregnant patients sustaining abdominal injury. Patients and methods This is a retrospective analysis of all pregnant trauma patients admitted to two level 1 trauma centers from February 1, 1996 to December 31, 2008. Patient data abstracted included mechanism of injury, physiologic parameters on admission, Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS), gestational age, diagnostic and surgical procedures performed, complications, and maternal and fetal mortality. Univariate analysis and logistic regression analysis were used. Results During the 155-month study period, 321 pregnant patients were included, of which 291 (91%) sustained a blunt injury, while 30 (9%) were victims of penetrating trauma. Of the penetrating injuries, 22 (73%) were gunshot wounds, 7 (23%) stab wounds, and 1 (4%) shotgun injury. The overall maternal and fetal mortality was 3% ( n = 9) and 16% ( n = 45), respectively. Mean age was 22 ± 6 year-old, and the mean ISS was 12 ± 16. The overall mean abdominal AIS was 2 ± 1.2. When adjusted for age, abdominal AIS, ISS, and diastolic blood pressure, the penetrating trauma group experienced higher maternal mortality [7% vs. 2% (adjusted OR: 7; 95% CI: 0.65–79), p = 0.090], significantly higher fetal mortality [73% vs. 10% (adjusted OR: 34; 95% CI: 11–124), p p Conclusions Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%, respectively, following penetrating abdominal injury. Penetrating injury mechanism, severity of abdominal injury and maternal hypotension on admission were independently associated with an increased risk for fetal demise following traumatic insult during pregnancy.
TL;DR: A literature review of ankle fractures in the English, German and Dutch literature to identify studies relating to functional outcome, subjective outcome and radiographic evaluation at least 4 years after an operatively treated ankle fracture found that the Weber A type fractures do not show a better long-term outcome than Weber B type fractures.
Abstract: The aim of this literature review is to systematically gather the highest level of available evidence on the long-term outcome after operatively treated ankle fractures in the English, German and Dutch literature. A search term with Boolean operators was constructed. The search was limited to humans and adults and the major databases were searched from 1966 to 2008 to identify studies relating to functional outcome, subjective outcome and radiographic evaluation at least 4 years after an operatively treated ankle fracture. Of the 42 initially relevant papers, 18 met our inclusion criteria. A total of 1822 fractures were identified. The mean sample-size weighted follow-up was 5.1 years. The initial number of patients that were included in the studies was 2724, which results in a long-term follow-up success rate of 66.9%. Regarding the fracture reduction we found 4 papers reporting on 106 fractures. Of the fractures that were classified according to Danis–Weber, 736 were eligible for correlation with the long-term outcome. In 442 fractures a comparison was possible between supination–external rotation stage 2 and 4 of the Lauge-Hansen classification. Only one study reported on the influence of initial cartilage lesions on the outcome. Regarding the involvement of the posterior malleolus, two studies reported on the long-term outcome. None of the studies addressed the influence of hindfoot varus or valgus on the long-term outcome after ankle fracture. Only 79.3% of the optimally reduced fractures show good to excellent long-term outcome. The Weber A type fractures do not show a better long-term outcome than Weber B type fractures. Recommendations for future research were formulated.
TL;DR: Continuing design changes to this method of fixation has reduced the risk of secondary fracture around a proximal femoral nail, which is one of the most significant of fracture healing complications.
Abstract: Introduction A sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail. Methods We analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures. Results The overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value Conclusion Secondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.