Initial surgical management of injuries to the lower extremities in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline update

PURPOSE Our aim was to develop new evidence-based and consensus-based recommendations for the initial inhospital management of lower-extremity injuries in patients with multiple and/or severe trauma. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with multiple and/or severe Injuries. METHODS MEDLINE and Embase were systematically searched to May 2021. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for the initial surgical and non-surgical management of fractures, dislocations or vascular injuries of the lower extremities in patients with multiple and/or severe trauma. We considered patient-relevant clinical outcomes such as mortality, complication rates, length of stay, and function. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS Eleven studies were identified. They addressed time to definitive fixation (n = 10 studies) and amputation (n = 1). Two new recommendations were developed, one was modified. All recommendations achieved strong consensus. CONCLUSION This systematic literature review and subsequent expert consensus process resulted in the following new key recommendations. It is recommended that isolated and multiple lower-extremity fractures are managed with primary definitive fixation in patients whose condition is stable. Patients condition is not considered stable should be managed with primary temporary fixation. In addition, it is recommended that dislocations of the lower extremities are reduced and immobilised as early as possible

Lumbar Facet Joint Radiofrequency Denervation Therapy for Chronic Low Back Pain: Enhanced Outcome Compared With Chemical Neurolysis (Ethyl Alcohol 95% or Glycerol 20%)

BACKGROUND It was hypothesized that radiofrequency denervation (RFD) of lumbar facet joints is associated with superior pain abolishment and less complications than chemical neurolysis (with ethyl alcohol or glycerol) in patients with chronic facet joint arthropathy. METHODS For this prospective cohort study, adult patients with chronic lumbar facet joint arthropathy were prospectively enrolled between 2017 and 2019. The following groups were compared before the intervention and 6 weeks, 6 months, and 12 months after the intervention: RFD, chemical neurolysis with ethyl alcohol 95% (EA-95), or glycerol 20% (Gly-20). Outcome parameters included the Core Outcome Measures Index for the back (COMI-back), World Health Organization (WHO) pain ladder level, and visual analog scale (VAS). P values <0.05 were considered statistically significant. RESULTS A total of 95 patients with a mean age of 63.7 years were included. Among them, 30 patients underwent RFD, 30 patients were treated with EA-95, and 35 individuals were treated with Gly-20. After 6 weeks, RFD patients had significantly lower VAS scores compared with the EA-95 group. After 6 months, both VAS and COMI were significantly lower in RFD patients than in the Gly-20 group. Twelve months after intervention, VAS scores were significantly lower in the RFD group compared with the Gly-20 group. CONCLUSIONS This study reveals that RFD is associated with improved pain relief and quality of life compared with chemical neurolysis for facet joint-related chronic lower back pain and should be considered as the treatment of choice in patients with chronic low back pain due to facet joint arthropathy. CLINICAL RELEVANCE The current study provides information that may improve clinical decision making in the treatment of chronic lumbar facet joint arthropathy and to appropriately counsel such patients about expected outcomes

Epidemiology and Mortality of Surgical Amputations in Severely Injured Patients with Extremity Injuries-A Retrospective Analysis of 32,572 Patients from the TraumaRegister DGU®^{®}

Background: Extremity fractures are common injuries in polytraumatized patients. Concomitant injuries to the soft tissue, vessels and nerves in these fractures are defined as mangled extremities. The decision for or against limb salvage is dependent on the patient's physiology and the limb status. In severely injured patients with critical physiological status, limb salvage may be contraindicated. International data on the epidemiology and management of mangled limbs in severely injured patients are lacking. Thus, the aim of this study was to assess the incidence of polytraumatized patients with severe injuries to either upper (UL) or lower limb (LL) as well as their management. Methods: A retrospective cohort analysis was conducted of patients aged 16 years and above with an Injury Severity Score (ISS) ≥ 16 who sustained fractures to the limbs and were admitted to a certified trauma center of the TraumaRegister DGU$^{®}$ (TR-DGU) between 2009 and 2019. Results: In total, we assessed 32,572 patients (UL: 14,567, mean age 48.3 years, 70% male and LL: 18,005, mean age 47.0 years, 70.5% male) The mean ISS in UL was 28.8 (LL 29.3). Fractures to the humerus (n = 4969) and radius (n = 7008) were predominantly assessed in UL, and fractures to the femur (n = 9502) and tibia (n = 8076) were most common in LL. In both groups, the most frequent injury mechanism was motor vehicle accidents, and more than half (UL: 9416 and LL: 11,689) of the patients had additional severe Abbreviated Injury Scale (AIS) ≥ 3 chest trauma. 915 patients in UL and 1481 in LL died within 24 h of the index admission. Surgical amputation occurred in 242 (UL) and 422 (LL) cases with a peak ratio in patients with an ISS above 50 in both groups. In both groups, patients with severe concomitant chest trauma were more often surgically amputated. In both groups, fewer patients with surgical amputations died within 24 h of admission (3.3% vs. 6.3% UL; 6.4% vs. 8.3% LL) compared to patients without amputation, but more patients with surgical amputations died within the overall hospital admissions (15.7% vs. 11.9% UL; 19.2% vs. 14.2%). In both groups, hemodynamical shock as well as the administration of Packed Red Blood Cells (PRBCs) were associated with a higher amputation rate. Conclusions: Surgical amputations after major trauma seem to be rare. Hemodynamical instability seems to play a key role in the management of mangled limbs. Patients with life-saving surgical amputation still have an increased overall in-hospital mortality

Clinical and functional outcomes of locked plating vs. cerclage compression wiring for AO type C patellar fractures- a retrospective single-center cohort study

PURPOSE: Although "tension-band wiring" is still commonly used to stabilize patellar fractures, the technique has recently been scrutinized due to biomechanical insufficiency. Consequently, the AO Foundation renamed the principle to compression cerclage wiring (CCW). Several studies propose favorable outcomes when utilizing locked plating (LP). This study aims to compare outcome of CCW and LP for complex patellar fractures. METHODS: A retrospective, single-center cohort study was performed on patients who underwent operative treatment for (AO 34 C-Type) patellar fractures between April 2013 and March 2023. Patients with a 12 month follow up were included. We grouped and compared patients based on the applied treatment strategy: group LP vs. group CCW. Primary outcome parameters included implant-related complications and revision surgeries. Secondary outcomes were length of stay, return to work and 12 months functional outcome (Lysholm score). Odd ratios for complications and revisions were calculated using the conditional Maximum Likelihood Estimate. The threshold for statistical significance was set at p < 0.05. RESULTS: Of 145 patients, 63 could be included (group LP: n = 23 and group CCW: n = 40). Fractures in group LP were significantly more complex in regard to AO Classification (p < 0.001), number of fragments (p < 0.001) and degree of comminution (p < 0.001), yet odds of complications were significantly lower in group LP (OR: 0.147; 95%CI: 0.015-0.742; p = 0.009). K-wire migration was the most common complication in group CCW (20%). Odds of revision surgery were significantly lower in group LP (OR: 0.000; 95%CI: 0.000-1.120; p = 0.041). The average Lysholm score at one year was favorable in both groups (89.8; SD: 11.9 in group LP and 90.6; SD: 9.3 in group CCW; n.s.). CONCLUSION: In our study cohort, LP was routinely chosen for more complex fracture morphologies; nevertheless the data implies that LP may be considered as the superior fixation technique in regard to complications and revision operations. Especially, K-wire migration occurs frequently after CCW. The one year functional outcome was comparable between the groups, with both demonstrating good results. Prospective randomized studies are indicated to validate our findings

Cellular activation status in femoral shaft fracture hematoma following different reaming techniques - A large animal model

The local inflammatory impact of different reaming protocols in intramedullary nailing has been sparsely investigated. We examined the effect of different reaming protocols on fracture hematoma (FH) immunological characteristics in pigs. To do so, a standardized midshaft femur fracture was induced in adult male pigs. Fractures were treated with conventional reamed femoral nailing (group RFN, n = 6); unreamed femoral nailing (group UFN, n = 6); reaming with a Reamer Irrigator Aspirator device (group RIA, n = 12). Animals were observed for 6 h and FH was collected. FH-cell apoptosis and neutrophil receptor expression (Mac-1/CD11b and FcγRIII/CD16) were studied by flow cytometry and local temperature changes were analyzed. The study demonstrates that apoptosis-rates of FH-immune cells were significantly lower in group RIA (3.50 ± 0.53%) when compared with non-RIA groups: (group UFN 12.50 ± 5.22%, p = 0.028 UFN vs. RIA), (group RFN 13.30 ± 3.18%, p < 0.001, RFN vs. RIA). Further, RIA-FH showed lower neutrophil CD11b/CD16 expression when compared with RFN (mean difference of 43.0% median fluorescence intensity (MFI), p = 0.02; and mean difference of 35.3% MFI, p = 0.04, respectively). Finally, RIA induced a transient local hypothermia and hypothermia negatively correlated with both FH-immune cell apoptosis and neutrophil activation. In conclusion, immunologic changes observed in FH appear to be modified by certain reaming techniques. Irrigation during reaming was associated with transient local hypothermia, decreased apoptosis, and reduced neutrophil activation. Further study is warranted to examine whether the rinsing effect of RIA, specific tissue removal by reaming, or thermal effects predominantly determine local inflammatory changes during reaming

Criteria to clear polytrauma patients with traumatic brain injury for safe definitive surgery (<24 h)

INTRODUCTION: Optimizing treatment strategies in polytrauma patients is a key focus in trauma research and timing of major fracture care remains one of the most actively discussed topics. Besides physiologic factors, associated injuries, and injury patterns also require consideration. For instance, the exact impact and relevance of traumatic brain injury on the timing of fracture care have not yet been fully investigated. METHODS: In this retrospectively cohort study at a level one trauma center, patients requiring trauma team activations from 2015 to 2020 were screened. Patients with an injury severity score >16 and at least one body region requiring operative fixation were included. Patients who underwent their first definitive surgery 24 h as group DFC (Delayed Fracture Care). Outcomes were early mortality (<72 h), SIRS and sepsis, timing to first definitive surgery and completed reconstruction, total number of surgeries, and factors influencing the surgical strategy (e.g., unstable physiology). Odds ratios for treatment strategies and influencing factors were calculated using the Fisher`s exact test with conditional maximum likelihood estimate. Results: From a total of 901 patients screened, 239 were included in the analyzes (Group DFC: 151, Groups SDS: 88). Groups did not significantly differ regarding early mortality, SIRS and sepsis. Group SDS had a significantly lower mean number of operations (4.3 vs. 5.3; p = 0.037) and a significantly shorter mean time until completion of reconstructive operations (10 days vs. 15 days; p = 0.013). Unstable physiology and intracranial trauma sequelae with the necessity for neurosurgical interventions (NSI) were identified as most significant factors for delaying definitive fracture care (OR: 2.85; 95 % CIs: 1.56 to 5.33 and OR: 5.59; 95 % CIs: 1.63 to 29.85), while the presence of intracranial bleeding (IB) without NSI did not have a significant influence (OR: 1.21; 95 % CIs: 0.63 to 2.34). Conclusion: The necessity of NSI and unstable physiology are highly relevant factors for delaying definitive fracture care in polytrauma patients, while the presence of IB without NSI had less impact. In this cohort, early definitive fracture care in physiologically stable patients without NSI, was not associated with increased patient morbidity

Systemic acylcarnitine levels are affected in response to multiple injuries and hemorrhagic shock - an analysis of lipidomic changes in a standardized porcine model

INTRODUCTION Along with recent advances in analytical technologies, TCA-cycle intermediates are increasingly identified as promising makers for cellular ischemia and mitochondrial dysfunction during hemorrhagic shock (HS). For traumatized patients, the knowledge of the role of lipid oxidation substrates is sparse. In this study, we aimed to analyze the dynamics of systemic acylcarnitine (AcCa) release in a standardized polytrauma model with HS. METHODS 52 male pigs (50 ± 5 kg) were randomized into two groups: Group IF (isolated fracture) was subject to a standardized femur shaft fracture. Group PT (polytrauma) was subject to a femur fracture, followed by blunt chest trauma, liver laceration and a pressure controlled hemorrhagic shock for 60 min. Resuscitation was performed with crystalloids. Fractures were stabilized by intramedullary nailing. Venous samples were collected at 6 timepoints (baseline, trauma, resuscitation, 2 h, 4 h and 6 h). Lipidomic analysis was performed via liquid chromatography coupled mass spectrometry. Measurements were collated with clinical markers and near-infrared spectrometry measurements (NIRS) of tissue perfusion. Longitudinal analyses were performed with linear mixed models and spearman's correlations were calculated. A p-value of 0.05 was defined as threshold for statistical significance. RESULTS From a total of 303 distinct lipids, we identified two species of long-chain AcCas. Both showed a highly significant (p < 0.001) two-fold increase after HS in Group PT that promptly normalized after resuscitation. This increase was associated with a significant decrease of the base excess (p = 0.005) but recovery after resuscitation was faster. For both AcCas, there were significant correlations with decreased muscle tissue oxygen delivery (p = 0.008, p = 0.003) and significant time-lagged correlations with the increase of creatine kinase (p < 0.001, p < 0.001). CONCLUSION Our results point to plasma AcCas as a possible indicator for mitochondrial dysfunction and cellular ischemia in HS. The more rapid normalization after resuscitation in comparison to acid base changes may warrant further investigation. STUDY TYPE Experimental Animal Model. LEVEL OF EVIDENCE N/A

Pediatric trauma and emergency surgery: an international cross-sectional survey among WSES members

Background: In contrast to adults, the situation for pediatric trauma care from an international point of view and the global management of severely injured children remain rather unclear. The current study investigates structural management of pediatric trauma in centers of different trauma levels as well as experiences with pediatric trauma management around the world. Methods: A web-survey had been distributed to the global mailing list of the World Society of Emergency Surgery from 10/2021-03/2022, investigating characteristics of respondents and affiliated hospitals, case-load of pediatric trauma patients, capacities and infrastructure for critical care in children, trauma team composition, clinical work-up and individual experiences with pediatric trauma management in response to patients´ age. The collaboration group was subdivided regarding sizes of affiliated hospitals to allow comparisons concerning hospital volumes. Comparable results were conducted to statistical analysis. Results: A total of 133 participants from 34 countries, i.e. 5 continents responded to the survey. They were most commonly affiliated with larger hospitals (&gt; 500 beds in 72.9%) and with level I or II trauma centers (82.0%), respectively. 74.4% of hospitals offer unrestricted pediatric medical care, but only 63.2% and 42.9% of the participants had sufficient experiences with trauma care in children ≤ 10 and ≤ 5&nbsp;years of age (p = 0.0014). This situation is aggravated in participants from smaller hospitals (p &lt; 0.01). With regard to hospital size (≤ 500 versus &gt; 500 in-hospital beds), larger hospitals were more likely affiliated with advanced trauma centers, more elaborated pediatric intensive care infrastructure (p &lt; 0.0001), treated children at all ages more frequently (p = 0.0938) and have higher case-loads of severely injured children &lt; 12&nbsp;years of age (p = 0.0009). Therefore, the majority of larger hospitals reserve either pediatric surgery departments or board-certified pediatric surgeons (p &lt; 0.0001) and in-hospital trauma management is conducted more multi-disciplinarily. However, the majority of respondents does not feel prepared for treatment of severe pediatric trauma and call for special educational and practical training courses (overall: 80.2% and 64.3%, respectively). Conclusions: Multi-professional management of pediatric trauma and individual experiences with severely injured children depend on volumes, level of trauma centers and infrastructure of the hospital. However, respondents from hospitals at all levels of trauma care complain about an alarming lack of knowledge on pediatric trauma management

Systemic and tissue neutrophil responses to experimental trauma

Neutrophils are the most abundant type of circulatory white blood cells. Neutrophil activation can be triggered by stimuli such as bacterial invasion, obstruction of vessels, fractures or organ injuries. Upon severe trauma, or following myocardial infarction, a pathological neutrophil response can occur. This may form the basis for life threatening complications like organ failure. Furthermore, this may also lead to impaired wound or fracture healing in trauma cases. The current thesis demonstrates that prolonged surgery (> 60 minutes) for trauma is associated with aberrant neutrophil presence in blood. To be more precise, the total number of circulatory neutrophil drops significantly after 60 minutes of surgery. Moreover, the number of a specific subtype of neutrophils, which are normally virtually absent, rises during ongoing surgery. These findings could form a first pathophysiological background for the ‘Damage Control Surgery´-concept. In additional experiments it was shown that during these post-traumatic neutrophil alterations, the pulmonary as well as the bone marrows neutrophil populations also change markedly. Furthermore, in the case of isolated fractures, both blood and pulmonary neutrophil populations differ from healthy conditions for as long as two weeks. It was further shown that the applied treatment strategy for fracture fixation affects the viability of neutrophils in fracture hematoma. These novel insights may form the basis for novel treatment modalities and guidelines, resulting in improved outcome of trauma patients

Systemic and tissue neutrophil responses to experimental trauma

Neutrophils are the most abundant type of circulatory white blood cells. Neutrophil activation can be triggered by stimuli such as bacterial invasion, obstruction of vessels, fractures or organ injuries. Upon severe trauma, or following myocardial infarction, a pathological neutrophil response can occur. This may form the basis for life threatening complications like organ failure. Furthermore, this may also lead to impaired wound or fracture healing in trauma cases. The current thesis demonstrates that prolonged surgery (&gt; 60 minutes) for trauma is associated with aberrant neutrophil presence in blood. To be more precise, the total number of circulatory neutrophil drops significantly after 60 minutes of surgery. Moreover, the number of a specific subtype of neutrophils, which are normally virtually absent, rises during ongoing surgery. These findings could form a first pathophysiological background for the ‘Damage Control Surgery´-concept. In additional experiments it was shown that during these post-traumatic neutrophil alterations, the pulmonary as well as the bone marrows neutrophil populations also change markedly. Furthermore, in the case of isolated fractures, both blood and pulmonary neutrophil populations differ from healthy conditions for as long as two weeks. It was further shown that the applied treatment strategy for fracture fixation affects the viability of neutrophils in fracture hematoma. These novel insights may form the basis for novel treatment modalities and guidelines, resulting in improved outcome of trauma patients.</jats:p