Limb Lengthening Using the PRECICE^TM Nail System: Complications and Results

Background: Three types of telescopic nails are mainly used for intramedullary limb lengthening nowadays. Despite some important advantages of this new technology (e.g. controlled distraction rate, not restricted availability, possibility to perform accordion maneuvers), few articles exist on clinical results and complications after lengthening with the PRECICETM nail (Ellipse, USA). Objectives: The aim of the current study was to describe and analyze the complications associated with lengthening with the PRECICETM nail. Are the problems preventable when using the PRECICE, related to the distraction rate control, the lengthening goals and technique and handling? Methods: We retrospectively reviewed the charts of 9 patients operated between 2012 and 2013 with a PRECICETM nail for a leg length discrepancy (LLD). The mean age of the patients was 32 years (range, 17 - 48 years). There were 5 femoral and 4 tibial procedures. The causes of LLD were posttraumatic (n = 5) and congenital (n = 4). The mean LLD was 36.4 ± 11.4 mm. The minimum follow-ups were 2 months (average, 5 months; range, 2 - 9 months). Results: The mean distraction rate was 0.5 ± 0.1 mm/day. We observed in 7 patients differences in achieving the lengthening goals (average, 1.6 mm; range, -20.0 - 5.0 mm). Average lengthening was 34.7 ± 10.7 mm. All patients reached normal alignment and normal joint orientation. An unintentional loss of the achieved length during the consolidation phase was noticed in patients with delayed bone healing in two cases. In the first case (loss of 20mm distraction) the nail could be redistracted and the goal length was achieved. In the second case (loss of 10mm distraction) the nail broke shortly after the diagnosis and the nail was exchanged. Conclusions: We report of loss of achieved length after lengthening with a telescopic nail. Weight bearing before complete consolidation of the regenerate might be a risk factor for that. Thorough examination of the limb length and careful evaluation of the radiographs are required in the follow-up period. The PRECICE nail system requires the same vigilance like the other intramedullary systems too

Effects of Trauma-Hemorrhage and IL-6 Deficiency on Splenic Immune Function in a Murine Trauma Model

Splenic immune function is known to be depressed following hemorrhage. The present study investigates the effects of femoral shaft fracture, isolated or in combination with hemorrhage, on early stage cytokine production capacity of splenocytes and observes the role of IL-6 under these conditions. Male IL-6 knockout (IL-6−/−) and wild-type mice (WT) were randomly divided into three groups: sham (S), isolated femoral fracture (Fx), and femoral fracture + volume controlled hemorrhage (TH-Fx) (n = 6 per group). Animals were sacrificed four hours after induction of hemorrhage and fracture. Cytokine release (TNF-α, IL-6, and IL-10) of isolated and LPS-stimulated splenocytes was determined by cytometric bead array. Femoral fracture with or without hemorrhage caused a suppression of in vitro cytokine production capacity of splenocytes at an early posttraumatic stage in WT and IL-6−/−. In the absence of IL-6, the profile of splenic cytokine secretion is significantly altered, identifying this cytokine as a potential therapeutic target to modulate the posttraumatic immune response

Open Repair Versus Thoracic Endovascular Aortic Repair in Multiple-Injured Patients: Observations From a Level-1 Trauma Center

Background: Blunt trauma of the thoracic aorta is a rare but potentially life-threatening entity. Intimal tears are a domain of non-operative management, whereas all other types of lesions should be repaired urgently. There is now a clear trend favoring minimally invasive stent grafting over open surgical repair. Objectives: The aim of the present study was to retrospectively evaluate the mortality and morbidity with either treatment option. Therefore, a retrospective observational study was performed to compare two different treatment methods at two different time periods at one trauma center. Patients and Methods: Between 1977 and 2012, all severely injured patients referred to our level 1 trauma center were screened for blunt aortic injuries. We compared baseline characteristics, 30-day and overall mortality, morbidity, duration of intensive care treatment, procedure time, and transfusion of packed red blood between patients who underwent open surgical or stent repair. Results: During the observation period, 45 blunt aortic injuries were recorded. The average Injury Severity Score (ISS) was 41.8 (range 29 - 68). Twenty-five patients underwent Open Repair (OR), and another 20 patients were scheduled to emergency stent grafting. The 30-day mortality in the surgical and stent groups were 5/25 (20%) and 2/20 (10%), respectively. The average time for open surgery was 151 minutes; the mean time for stent grafting was 67 minutes (P = 0.001). Postoperative stay on the intensive care unit was between one and 59 days (median 10) in group one and between four and 50 days in group two (median 26)(P = 0.03). Patients undergoing OR required transfusion of 6.0 units of packed red cells in median; patients undergoing stent grafting required a median of 2.0 units of packed red cells (P < 0.001). In the stent grafting group, 30-day mortality was 10% (2/20). Conclusions: Due to more sophisticated diagnostic tools and surgical approaches, mortality and morbidity of blunt aortic injuries were significantly reduced over the years compared to thoracic endovascular aortic repair and OR over two different time periods

Road Traffic Related Injury Severity in Truck Drivers: A Prospective Medical and Technical Analysis of 582 Truck Crashes

Background: While cyclists and pedestrians are known to be at significant risk for severe injuries when exposed to road traffic accidents (RTA) involving trucks, little is known about RTA injury risk for truck drivers. Objectives: The aim of this study was to analyze the injury severity in truck drivers following RTAs. Patients and Methods: Our local accident research unit prospectively documented 43000 RTAs involving 582 trucks between 2000 and 2011. Injury severity, including the abbreviated injury scale (AIS) and the maximum abbreviated injury scale (MAIS) were analyzed. Technical parameters (e.g. delta-v, direction of impact), the location of accident, and its dependency on the road type were also taken into consideration. Results: Thirteen percent (77/582) of truck drivers were injured. Extremities were found to be at highest risk of injury with the lower extremities (36x) being injured most severely (10x: AIS 2 and 3). Death occurred only after collisions with other trucks, and severity of injuries increased with an increased speed limit. The maximum abbreviated injury scale was higher in the crash opponents (56x MAIS ≥ 3) compared to the truck drivers (8x MAIS ≥ 3). Overall, 82% of the crash opponents were injured. Conclusions: The safety of truck drivers is assured by their vehicles, the consequence being that the risk of becoming injured is likely to be low. However, the legs especially are at high risk for severe injuries during RTAs. This probability increases in the instance of a collision with another truck. Nevertheless, in RTAs involving trucks and regular passenger vehicles, the other party is in higher risk of injury

Effectiveness of Bicycle Safety Helmets in Preventing Facial Injuries in Road Accidents

Background: The effectiveness of bicycle safety helmets in preventing head injuries is well- documented. Recent studies differ regarding the effectiveness of bicycle helmets in preventing facial injuries, especially those of the mid-face and the mandible. Objectives: The present study was conducted to determine the protective effect of a bicycle helmet in preventing mid-face and mandibular fractures. Patients and Methods: Data from an accident research unit were analyzed to collect technical collision details (relative collision speed, type of collision, collision partner, and use of a helmet) and clinical data (type of fracture). Results: Between 1999 and 2011, 5,350 bicycle crashes were included in the study. Of these, 175 (3.3%) had fractures of the mid-face or mandible. In total, 228 mid-face or mandibular fractures were identified. A significant correlation was found between age and relative collision speed, and the incidence of a fracture. While no significant correlation was found between the use of a helmet and the incidence of mid-facial fractures, the use of a helmet was correlated with a significantly increased incidence of mandibular fractures. Conclusions: Higher age of cyclists and increasing speed of the accident opponent significantly increase the likelihood of sustaining facial fractures. The use of bicycle helmets does not significantly reduce the incidence of mid-facial fractures, while being correlated with an even increased incidence of mandibular fractures

Human macrophages limit oxidation products in low density lipoprotein

This study tested the hypothesis that human macrophages have the ability to modify oxidation products in LDL and oxidized LDL (oxLDL) via a cellular antioxidant defence system. While many studies have focused on macrophage LDL oxidation in atherosclerosis development, less attention has been given to the cellular antioxidant capacity of these cells. Compared to cell-free controls (6.2 ± 0.7 nmol/mg LDL), macrophages reduced TBARS to 4.42 ± 0.4 nmol/mg LDL after 24 h incubation with LDL (P = 0.022). After 2 h incubation with oxLDL, TBARS were 3.69 ± 0.5 nmol/mg LDL in cell-free media, and 2.48 ± 0.9 nmol/mg LDL in the presence of macrophages (P = 0.034). A reduction of lipid peroxides in LDL (33.7 ± 6.6 nmol/mg LDL) was found in the presence of cells after 24 h compared to cell-free incubation (105.0 ± 14.1 nmol/mg LDL) (P = 0.005). The levels of lipid peroxides in oxLDL were 137.9 ± 59.9 nmol/mg LDL and in cell-free media 242 ± 60.0 nmol/mg LDL (P = 0.012). Similar results were obtained for hydrogen peroxide. Reactive oxygen species were detected in LDL, acetylated LDL, and oxLDL by isoluminol-enhanced chemiluminescence (CL). Interestingly, oxLDL alone gives a high CL signal. Macrophages reduced the CL response in oxLDL by 45% (P = 0.0016). The increased levels of glutathione in oxLDL-treated macrophages were accompanied by enhanced catalase and glutathione peroxidase activities. Our results suggest that macrophages respond to oxidative stress by endogenous antioxidant activity, which is sufficient to decrease reactive oxygen species both in LDL and oxLDL. This may suggest that the antioxidant activity is insufficient during atherosclerosis development. Thus, macrophages may play a dual role in atherogenesis, i.e. both by promoting and limiting LDL-oxidation. © 2005 Hultén et al; licensee BioMed Central Ltd

Current Concepts for Patellar Dislocation

Context: Patellar dislocation usually occurs to the lateral side, leading to ruptures of the Medial Patellofemoral Ligament (MPFL) in about 90% of the cases. Even though several prognostic factors are identified for patellofemoral instability after patellar dislocation so far, the appropriate therapy remains a controversial issue. Evidence Acquisition: Authors searched the Medline library for studies on both surgical and conservative treatment for patellar dislocation and patellofemoral instability. Additionally, the reference list of each article was searched for additional studies. Results: A thorough analysis of the anatomical risk factors with a particular focus on patella alta, increased Tibial Tuberosity-Trochlear Groove (TT-TG) distance, trochlear dysplasia as well as torsional abnormalities should be performed early after the first dislocation to allow adequate patient counseling. Summarizing the results of all published randomized clinical trials and comparing surgical and conservative treatment after the first-time patellar dislocation until today indicated no significant evident difference for children, adolescents, and adults. Therefore, nonoperative treatment was indicated after a first-time patellar dislocation in the vast majority of patients. Conclusions: Surgical treatment for patellar dislocation is indicated primarily in case of relevant concomitant injuries such as osteochondral fractures, and secondarily for recurrent dislocations

Graft remodeling during growth following anterior cruciate ligament reconstruction in skeletally immature sheep

INTRODUCTION: Ruptures of the anterior cruciate ligament are being diagnosed with increasing frequency in skeletally immature individuals. It was our aim to investigate the graft remodelling process following an autologous, transphyseal reconstruction of the anterior cruciate ligament (ACL) in skeletally immature sheep. We hypothesized that the ligamentisation process in immature sheep is quicker and more complete when compared to adult sheep. MATERIALS AND METHODS: Skeletally immature sheep with an age of 4 months underwent a fully transphyseal ACL reconstruction using an autologous tendon. The animals were subsequently sacrificed at 3, 6, 12 and 24 weeks following surgery. Each group was characterised histomorphometrically, by immunostaining (VEGF, SMA), by transmission electron microscopy (TEM) and biomechanically (UFS Roboter). RESULTS: The histomorphometric analysis and presence of VEGF and SMA positive cells demonstrated a rapid return to a ligament like structure. The biomechanical analysis revealed an anteroposterior translation that was still increased even 6 months following surgery. CONCLUSION: As in adult sheep models, the remodeling of a soft tissue graft used for ACL reconstruction results in a biomechanically inferior substitute. However, the immature tissue seems to remodel faster and more complete when compared to adults

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

<p>Abstract</p> <p>Background</p> <p>With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.</p> <p>Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.</p> <p>Discussion</p> <p>The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.</p> <p>In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.</p> <p>Summary</p> <p>It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.</p