European Journal of Trauma and Emergency Surgery最新文献

Purpose: This systematic review seeks to investigate whether tranexamic acid (TXA) should be administered to patients over 65 years of age undergoing hip fracture surgery. This select patient population is at increased risk of requiring red blood cell transfusions, why there might be a case for TXA intervention.

Methods: Following PRISMA guidelines, a systematic search was conducted on EMBASE and PubMed databases on the 27th of November 2023. Only randomized controlled trials (RCT) with a mean age of above 65 years where eligible for inclusion. Only studies with intravenous intervention and control with saline were included. A Cochrane Risk of Bias tool was used to investigate potential biases. The certainty of each outcome was interpreted using the GRADE approach. The primary outcome was red blood cell transfusion rate and the secondary outcome was thromboembolic event rate.

Results: This review comprised of 12 RCTs with a combined 1397 patients, of whom 699 received TXA and 698 received saline. Pooled results show a significant reduction in blood transfusion rate for patients who received TXA (RR 0.612, 95%CI 0.480-0.779, p-value < 0.001). Thromboembolic event rate was reported in 9 studies, tallying 1147 patients. Results showed no significant change in thromboembolic event rate for patients receiving TXA intervention (RR 0.922, 95%CI 0.603-1.411, p-value = 0.710).

Conclusion: Tranexamic acid significantly reduced the need for blood transfusion in patients undergoing hip fracture surgery. Furthermore, no significant change in thromboembolic events is present, but due to low thromboembolic event rate in the patient population, no definite conclusion can be made regarding the safety of tranexamic acid. Furthermore, a higher grade of homogeneity between studies with regards to TXA intervention timing and dose would be helpful. In conclusion, intervention with TXA appears promising with regards to transfusion requirement in the targeted population.

Purpose: This study aimed to compare the incidence rates of concomitant injuries, including meniscal and cartilage injuries, between multiligamentous knee injuries (MLKI) with and without dislocation based on our 15-year experience of knee dislocation and MLKI at a level 1 trauma center.

Methods: We retrospectively identified 100 patients (115 knees) with MLKIs and/or dislocations at our trauma center between 2007 and 2021. Magnetic resonance imaging was routinely performed to evaluate the injured structures and extent of injury. The anatomic structures of the knee were categorized into anterior and posterior cruciate ligaments (ACL, PCL) and medial and posterolateral structures, and further classified according to the modified Schenck classification. The study participants were divided into two groups: 40 and 75 knees classified as MLKI with and without dislocation, respectively.

Results: MLKIs with dislocations showed 13% (5/40 knees) and 18% (7/40 knees) incidence, whereas MLKIs without dislocation showed 15% (11/75 knees) and 13% (10/75 knees) incidence of medial and lateral meniscal tears respectively. The two groups also had a significant discrepancy in the patterns of meniscal tears. For medial meniscal tears, radial tears were more prevalent in MLKIs with dislocation, and longitudinal tears in MLKIs without dislocation (p = 0.197). For lateral meniscal tears, anterior horn or totally detached tears were more prevalent in MLKIs with dislocation, and radial tears in MLKIs without dislocation (p = 0.026). Additionally, complete rupture of all four major ligaments was found in 38% (15/40 knees) of the cases with dislocation, with the majority showing complete ruptures of both the ACL and PCL. Concomitant serious injuries, such as popliteal artery injury and fractures, were observed only in cases involving high-energy trauma and dislocation.

Conclusions: MLKIs with dislocation show distinct ligament and meniscal injury patterns compared to those without, highlighting the importance of severity and anatomical classification in diagnosing associated knee injuries.

Clinical relevance: The initial distinction in the severity of MLKIs, along with the anatomical classification, have practical implications in identifying associated meniscal tears and injuries to structures surrounding the knee joint.

Level of evidence: IV Retrospective comparative study.

Trauma care requires a multidisciplinary approach, with surgeons ensuring timely and effective treatment for severely injured patients while collaborating closely with intensivists, emergency physicians, and rehabilitation teams. In addition to advanced surgical skills, trauma surgeons develop non-technical competencies such as leadership, communication, and decision-making to coordinate care effectively. This chapter addresses the challenges of maintaining trauma surgical competence in Europe, focusing on essential training programmes, quality improvement initiatives, and interdisciplinary collaboration. It also examines the impact of an ageing population, the integration of new technologies, and the vital role of surgical involvement in intensive care units (ICUs). Structured education and continuous professional development are critical to improving outcomes for trauma patients. ESTES, Polytrauma, Whitebook.

Purpose: There is increasing evidence that use of ECMO is beneficial in major trauma patients with refractory organ failure. Hence, increased numbers of ECMO support following major trauma are reported. We set out to determine the use of ECMO among major trauma patients submitted to the TraumaRegister DGUr^® as well as patient features associated with ECMO support.

Methods: The TraumaRegister DGU^® is a multinational database compiling trauma related health care data from point-of-injury, initial and critical care to outcome. Major trauma cases (AIS ≥ 3 irrespective of injury location) with subsequent critical care as well as respiratory and/or circulatory failure (SOFA score ≥ 3 per respective category) enrolled in the TraumaRegister DGU^® between 2015 and 2022 were reviewed. A logistic regression model was carried out to evaluate patient features associated with ECMO support.

Results: 410/ 22,548 individuals (1.8%) received ECMO support. Survival among ECMO patients was 46.1%. At discharge, good functional outcome as indicated by a Glasgow outcome scale > 3 was observed for 97 ECMO patients (23.6%). Age > 65 (OR 95%-CI 1.90, 1.52-2.60), male sex (OR 1.49, 95%-CI 1.41-1.95), coagulopathy at admission to the emergency department (OR 2.37, 95%-CI 1.88-3.00), chest trauma (OR 2.12, 95%-CI 1.61-2.81), sepsis (OR 2.94, 95%-CI 1.93-2.97), as well as massive transfusion (OR 2.23, 95%-CI1.56-3.19) were associated with the use of ECMO following trauma.

Conclusion: In the TraumaRegister DGU^®, ECMO for trauma related organ failure remains rare. Among ECMO patients, good functional outcome was observed infrequently. However, the design of the registry did not allow for capturing granular data on ECMO management and timing of organ failure. Hence, outcome data should be interpreted with caution. Nevertheless, evaluation of factors associated with ECMO support after trauma might contribute to early identification of ECMO candidates and improve patient distribution for trauma centers without ECMO capability.

Purpose: Ankle fractures represent about 10% of all adult fractures, with increasing incidence. Dislocated ankle fractures often require delayed open reduction and internal fixation due to swelling, necessitating temporary stabilization using a cast or an external fixator. This study aims to assess risk factors for insufficient preliminary reduction immobilized by a cast, focusing on medial clearspace and posterior malleolus fragment size, to identify fractures that would benefit from initial stabilization with an external fixator.

Methods: Patients treated for dislocated ankle fractures at our level-1 trauma center from 2011 to 2023 were retrospectively reviewed. The primary outcome was the rate of insufficient reduction during immobilization in a cast. Secondary outcomes included time to definitive surgery, length of surgery and hospital stay.

Results: 134 patients met the inclusion criteria. The most common fracture type was AO 44B3, with 71.6%. Sufficient reduction was achieved in 53.7% of patients. Multiple regression analyses revealed the initial medial clearspace at the time of dislocation as an independent risk factor for insufficient reduction after reduction. ROC-analysis revealed that a initial medial clearspace at the time of dislocation of 9 mm is a predictor for insufficient reduction with a sensitivity of 88% and a specificity of 55%.

Conclusion: Initial medial clearspace was an important predictor for insufficient reduction in a cast, with 9 mm being identified as the cutoff for critical initial medial clearspace. Therefore, we recommend primary external fixation or acute internal fixation, if the soft tissue allows it for those patients with initial medial clearspace of > 9 mm. This approach may prevent secondary dislocation, reduce swelling, and expedite definitive surgery.

Purpose: Despite varying impact of high- and low-energy traumas, research comparing patient and fracture characteristics as well as patient-reported functional outcomes following these trauma mechanisms is limited. From a patient, doctor, and legal perspective, assessing the association between trauma mechanism and clinical outcome is important for managing expectations.

Methods: A multicenter cross-sectional study was performed including 1066 patients treated for a tibial plateau fracture between 2003 and 2019. Patients completed the Knee injury and Osteoarthritis Outcomes Score (KOOS) at a mean follow-up of 6 ± 4 years. Trauma mechanisms were classified according to ATLS guidelines. Independent- samples t-test and chi-square test were used to assess differences in patient and fracture characteristics after high- or low-energy trauma. Linear regression analyzed the relationship between trauma mechanisms and KOOS-scores. The Fisher's exact assessed differences in complications and conversion to total knee arthroplasty (TKA).

Results: High-energy trauma mostly occurred in younger males and low-energy trauma in older females. High-energy trauma caused more Schatzker IV-VI fractures, resulted in more initial fracture displacement and needed more often surgical treatment (81% versus 67%; p = 0.002). Linear regression showed that high-energy trauma was associated with lower KOOS-scores. Patients after high-energy trauma had more complications (e.g. revision surgery [8% versus 2%; p =  < 0.001], mal- or nonunion [8% versus 2%; p =  < 0.001]) and conversion to TKA (15% versus 10%; p = 0.144).

Conclusion: Only 12% of patients with tibial plateau fractures sustained these injuries due to high-energy trauma, which predominantly involved younger males and resulted in more severe fractures. High-energy trauma resulted in worse patient-reported outcomes, more complications, and conversions to TKA.

Level of evidence: Level III, prognostic study.

Purpose: Our aim was to develop new evidence-based and consensus-based recommendations for imaging strategies in patients with multiple and/or severe injuries in the resuscitation room. 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 August 2021.

Inclusion criteria: patients with multiple and/or severe injuries in the resuscitation room, randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies; comparison of interventions for imaging strategies; patient-relevant clinical outcomes such as diagnostic test accuracy and mortality. Further literature reports were obtained from clinical experts. We considered patient-relevant clinical outcomes such as diagnostic test accuracy and mortality. 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: Twenty-one studies with a total of 55,227 patients were identified. There were studies with low risk (n = 2), high risk (n = 5) and unclear risk of bias (n = 14). Relevant topics were sonographic imaging of the chest and abdomen (n = 8 studies), X-ray of the chest (n = 1), indications for whole-body computed tomography (n = 6), CT scanner location (n = 1), whole-body computed tomography in haemodynamically unstable patients (n = 3), and prehospital sonography (n = 2). There were studies with low risk (n = 2), high risk (n = 5) and unclear risk of bias (n = 14). One new recommendation was developed, six were modified. All achieved strong consensus.

Conclusion: While extended focused assessment with sonography for trauma should be performed for diagnostic purposes after blunt and/or penetrating thoracic and/or abdominal trauma as part of the primary survey in the resuscitation room, whole-body computed tomography (WBCT) gains highest importance as part of the diagnostic procedures for severely injured patients. WBCT with a trauma-specific protocol must be performed in a timely manner if the patient does not require an immediate intervention. Magnetic resonance imaging can be indicated as a further primary diagnostic tool for specific conditions. Two studies were judged to be of low risk of bias in all domains. The risk of selection bias was high in two studies and unclear in seven studies.

Purpose: The most common early complication of operative treatment of ankle fractures is a surgical site infection (SSI) with an incidence rate varying between 1.5 and 16%, depending on various risk factors. A SSI has multiple disadvantages, including worse outcome and a socio-economic burden. The aim of this review is to provide an updated overview of the current concepts pertinent to SSI in ankle fractures.

Methods: A descriptive literature review was performed to provide the overview.

Results: Well known risk factors for SSI are higher age, diabetes, open fractures and fracture dislocation. Diagnostic testing for infection include laboratory results (CRP, white blood cell count, leucocyte count), radiological imaging methods (conventional imaging, CT-scan, MRI-scan, 3-phase bone scan, FDG-PET) and microbiological deep tissue sampling. Treatment options for SSI are varied and include fracture reduction, antibiotic therapy with intravenous and oral treatment, surgical debridement and irrigation, transposition flaps in case of soft tissue defects with implant exposure and arthrodesis in severe infection with septic arthritis. Multiple studies show worse outcome scores in patients who develop a SSI. Prevention is important to reduce the rate of SSI. Surgery within 24 h decreases the risk of complications, compared to surgery performed in a delayed fashion. Appropriate timing and dosing of preoperative antibiotic prophylaxis is necessary.

Conclusion: This review described the most frequent risk factors, appropriate diagnostic testing methods, an oversight of treatment options, gives insight in the outcome and mentioned prevention measurements for SSI after ORIF in ankle fractures.