European Journal of Trauma and Emergency Surgery最新文献

Introduction: Targeted muscle reinnervation (TMR) is a technique that has proven effective for the treatment and prevention of chronic pain following amputation, though its adoption remains limited. The authors report on their initial experience using TMR.

Methods: A prospective study was conducted in a military trauma center involving traumatic amputees treated with either curative or preemptive TMR. Their outcomes were compared to those of control patients who underwent neuroma burial or simple neurectomy during primary amputation. Data included a numerical rating scale (NRS) and patient-reported outcomes measurement information System (PROMIS) scores evaluating residual limb pain (RLP) and phantom limb pain (PLP).

Results: Eighteen patients with a median age of 45.5 years were included and followed up for a median period of 13 months. The curative TMR group consisted of 8 patients whose results were compared to those of 9 control patients. There was a significant reduction in almost all pain scores with TMR and only in RPL NRS scores with neuroma burial. Reduction in RLP and PLP scores was significantly greater with TMR. The preemptive TMR group included 10 patients whose results were compared to those of 18 control patients. No significant difference was observed in the postoperative evolution of RLP or PLP.

Conclusion: These results confirm the benefits of TMR for the curative treatment of RLP and PLP. However, within the limits of this small sample size, preemptive TMR did not show added value. TMR appears to be a complex technique that requires a learning curve.

Purpose: Many patients originally transported to non-trauma centers (NTC) require transfer to a trauma center (TC) for treatment. The aim was to analyze injury characteristics and outcomes of transfer patients and investigate the secondary overtriage (SOT).

Methods: Study included 2,056 transfers to an urban level 1 TC between 01/2016 and 06/2020. Analyzed variables included: demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), transfer reason and timing, computed tomography (CT) scans, surgery rate, intensive care unit (ICU) admissions, hospital lengths of stay (HLOS), mortality and SOT. SOT was defined as discharge within 48 h without surgery or ICU admission.

Results: Transfers constituted 32.1% of TC admissions. Mean age was 66.7 and 60.7% were geriatric (≥ 65 years). Mean ISS was 11.6 and GCS was 14.3. The average time between NTC and TC admission was 4.2 h. Main reason for transfer was a head injury (57.9%), followed by a spine injury (19.2%). CT scans were repeated at the TC in 76.1% of patients. Surgical interventions were necessary in 18.5% of patients, with lowest rate in head (13.8%) and spine (15.4%) injuries. 45.9% of patients required ICU admissions. Overall mortality was 7.2%. SOT was 30.5%, being the highest in patients with spine (43.0%) and head (29.4%) injuries. Short HLOS affected SOT rates the most.

Conclusions: Transfers constituted a third of all TC admissions. The main reasons for transfer were head and spine injuries. SOT accounted for one third of transfers and occurred primarily in patients with spine and head injuries.

Background: Cementless hip hemiarthroplasty is one of the options for the treatment of osteoporotic femoral neck fractures. Intraoperative periprosthetic femoral calcar fractures sometimes occur during the surgery, and the use of cerclage wiring to maintain the position and stability of the femoral stem and prevent the progression of the fracture. This study examines the outcomes of cerclage wiring to treat intraoperative periprosthetic calcar fractures in cementless hip hemiarthroplasty in osteoporotic femoral neck fractures.

Materials and methods: A retrospective review of femoral neck fractures treated with cementless hemiarthroplasty was conducted. Twenty-one calcar fractures that underwent cerclage wiring were compared with a demographically similar control group of 21 patients without intraoperative fractures. Radiological parameters, including proximal femoral morphology and stem subsidence, and Harris Hip score were evaluated for clinical outcomes.

Results: A tapered wedge-shaped type cementless stem was used in all of the cases. The most common femur types were Dorr B in both groups. The average stem subsidence of wires applied below a lesser trochanter was less than above (p = 0.905). The fracture group had a mean HHS of 83.85 ± 6.62, and the control group had a mean HHS of 88.00 ± 5.76 (p = 0.067).

Conclusions: Using cerclage wiring in treating intraoperative periprosthetic femoral calcar fractures provides adequate fixation for the stability of the femoral stem either above or below the lesser trochanter.

Purpose: Osteosynthesis seems to have effects regarding clinical outcomes in trauma patients. However, current knowledge on chest wall osteosynthesis in polytrauma patients is insufficient, leaving its potential unanswered. Therefore, the objective of this systematic review is to assess the safety and effects of chest wall osteosynthesis compared to conservative treatment on clinical outcomes in adult polytrauma patients.

Methods: We searched PubMed to identify completed and ongoing studies from inception of each database to May, 2022. We included systematic reviews including RCTs comparing chest wall osteosynthesis to conservative treatment in adult polytrauma patients.

Results: We included one RCT with 50 patients (n_{osteosyntheses} = 25, n_control = 25, median age 37.4 years, 82% male). We found that surgical rib fixation makes little or no difference to in-hospital mortality compared to conservative treatment (RR 2.00, 95% CI 0.40 to 9.95; RD 80 more per 1,000, 95% CI 48 fewer to 716 more; 1 study, 50 participants, low quality of evidence). We found that surgical rib fixation makes little or no difference to the need for mechanical ventilation compared to conservative treatment (RR 0.90, 95% CI -0.66 to 1.23; RD 80 fewer per 1,000, 95% CI 272 fewer to 184 more; 1 study, 50 participants, low certainty of evidence).

Conclusion: There is limited evidence regarding chest wall osteosynthesis compared to conservative treatment in polytrauma patients. One RCT shows no effect of surgical rib fixation compared to conservative treatment regarding mortality and clinical status, but a potential benefit regarding ICU length of stay.

Purpose: Currently, no gold standard exists for 3D analysis of virtually planned surgery accuracy postoperatively. The aim of this study was to present a new, validated and standardised methodology for 3D postoperative assessment of surgical accuracy in patients undergoing 3D virtually planned and guided corrective osteotomies.

Methods: All patients who underwent 3D planned corrective osteotomy in 2021-2022 at our center with a postoperative CT were included. Postoperative surgical outcome was analysed with a postoperative CT and compared to the preoperative virtual surgical planning to determine achieved accuracy. Validation of the analysis was performed by evaluating the individual assessment of six experienced observers. A postoperative quantification was performed according to the proposed innovative methodology based on rotation axes of a virtual postoperative bone model aligned to the virtual preoperative bone model and virtual surgical planned bone model. To evaluate the intra-observer variability, one observer performed the assessment twice.

Results: Quantification of 13 patients according resulted in measurements with a median range (and its interquartile range) for 3D translation of: 2.43 mm (3.17), for the angle deviations: 3D rotation, 2D coronal, 2D sagittal and 2D axial were: 0.66° (1.66°), 0.74° (0.44°), 0.99° (1.27°), 2.37° (5.00°), respectively. The inter- and intraobserver reliability established with the Intraclass correlation coefficient was for all measurements excellent (> 0.76).

Conclusion: The proposed 3D CT technique provides an significant more accurate and objective method for assessment of surgical outcome of a guided corrective osteotomy. The present proposed novel methodology showed excellent inter- and intra-observer reliability with clinically acceptable absolute surgical outcome measurements.

Purpose: Ligamentous elbow dislocations often affect young patients with high functional and athletic demands. After reduction and clinical examination of joint stability, further treatment options are, therefore, the subject of controversial debate. In order to be able to advise patients adequately, an assessment of the possible return-to-sport based on experience is necessary. This study examines the medium to long-term return-to-sports after conservative treatment of a ligamentous elbow dislocation.

Methods: In this clinical study, 42 patients (47.6% female, 52.4% male) who were treated conservatively for a ligamentous elbow dislocation at our clinic were surveyed. Conservative treatment was carried out for at least 6 weeks. Exclusion criteria were concomitant bony lesions requiring surgery, a tendency to dislocate between 30 and 130° of flexion after reduction, a positive apprehension test after reduction, and athletes with medial pop-up/instability and high valgus stress as part of their sporting activities. The Disabilities of the arm, shoulder and hand (DASH), the sport-DASH and the subjective elbow value (SEV) were tested. The sport-DASH was correlated with gender, age, arm dominance, and the type of sport practiced. Descriptive statistics and significant differences were determined using statistical analyses.

Results: The average age was 42.7 years (range 22-75). After an average follow-up after 4.5 years, the mean value of DASH was 2.44 (SD 4.77), the mean value of sports DASH was 4.17 (SD 11.04) and the mean value of SEV was 94.93% (SD 6.40). There were no significant differences in sports DASH depending on gender (p = 0.81), age (p = 0.68), dislocation side in relation to the dominant arm (p = 0.54) or the type of sport practiced (p = 0.94, p = 0.65, p = 0.71). 2 patients (4.8%) underwent surgery after 6 and 8 weeks of conservative treatment due to persistent elbow stiffness.

Conclusion: In our patient cohort, a very good return-to-sports after conservative treatment of ligamentous elbow dislocation was demonstrated, taking into account the above exclusion criteria. Factors such as age, gender, the side of the dislocation in relation to the arm dominance, and the type of sport had no influence on the outcome of our study. The data help practitioners to advise patients better when deciding on treatment and the question of a possible return to sport.

Purpose: To evaluate frequency and timing of post-discharge complications in patients with traumatic rib fractures undergoing operative or nonoperative management.

Methods: We retrospectively reviewed adult patients with rib fractures admitted to a Level 1 trauma center from 1/2020 to 12/2021. Outcomes included rib-related complications, pneumonia within 1 month, new diagnosis of opioid- or alcohol-use disorder, and all-cause mortality. Patients were stratified on whether they underwent surgical stabilization of rib fractures (SSRF). Associations between risk factors and outcomes were evaluated through Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk.

Results: Of 976 patients admitted with rib fractures, 904(93%) underwent non-operative therapy and 72(7%) underwent SSRF. Nonoperative patients had less-severe injuries and shorter ICU length-of-stay. Rib-related complications occurred in 13(1%) nonsurgical patients and 4(6%) surgical patients. In the nonsurgical group, presence of hemo/pneumothorax on admission was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95(1.8, 19.67)]. Pneumonia within 1 month occurred in 9(1%) nonsurgical patients and 1(1%) surgical patient. New diagnosis of alcohol or opioid-use disorder was made in 14(2%) nonsurgical patients and 1(1%) surgical patients. All-cause mortality was 68(8%) in the nonsurgical group and 2(3%) in the surgical group. Older age was associated with mortality in the nonsurgical cohort [SHR (95% CI): 1.83(1.46, 2.28)].

Conclusion: Post-discharge rib-related complications were rare in both groups, but occurred primarily within 2 weeks, suggesting concentrated earlier follow-up may be beneficial. These findings help inform recommendations for follow-up in this population.

Purpose: Equal level trauma centers in the same country might have significant differences regarding their demographics and types of trauma. Understanding geographic variations in injury patterns are essential for optimal care. Here we describe the differences in injury patterns and associated outcomes of thoracic trauma patients between rural and urban level-II trauma centers in a single country.

Method: A retrospective analysis of patients with thoracic trauma over a three-year period in a rural level-II and an urban level-II in Israel were compared. Demographics, mechanism of injury, prehospital care, transport, hospitalization course, discharge disposition, and outcomes were all analyzed.

Results: There were significant differences between the demography, mechanisms of injury, and sustained injuries. The urban population was older, with more pedestrians hit by motor vehicles, falls from standing or sitting, and penetrating injuries. The rural population suffered from more motor vehicle crashes and falls from heights, with injuries related to higher velocity mechanisms such as lung contusions, sternal fractures, and liver injuries. There was no significant difference in transportation time or injury severity scores. More advanced life support ambulances were utilized in the rural setting together with more transfers to a higher level of care, while more patients in the urban center were lost to follow-up.

Conclusion: Understanding the differences between geographic locations is crucial towards optimizing trauma care. The complexities of thoracic trauma patients are an important example of the variations between rural and urban trauma centers. Respecting these differences will help to improve preparedness and treatment for trauma patients.

Purpose: Evaluating sacral fractures is crucial in fragility fractures of the pelvis. Dual-energy CT (DECT) is considered useful for diagnosing unclear fractures on single-energy CT (SECT). This study aims to investigate the effectiveness of DECT in diagnosing sacral fractures.

Methods: Thirty cases with suspected sacral fractures underwent SECT, DECT, and MRI. The exams were evaluated by two groups: three inexperienced surgeons (Group I) and three experienced surgeons (Group E). Diagnoses were made initially using SECT (pre-DECT) and then reassessed including DECT (post-DECT). This process was repeated twice. Presence of fractures was determined based on MRI. Sensitivity, specificity, inter-rater and intra-rater reliability, and diagnostic accuracy were calculated. Diagnostic accuracy was statistically compared between two groups.

Results: Sensitivity was 0.73 in pre-DECT and 0.9 in post-DECT, while specificity was 0.83 in pre-DECT and 0.91 in post-DECT. Sensitivity significantly improved with the addition of DECT (McNemar test: p < 0.001). Intra-rater reliability (Fleiss' kappa coefficient) was 0.44 in pre-DECT and 0.76 in post-DECT. Inter-rater reliability (Cohen's kappa coefficient) was 0.6 in pre-DECT and 0.81 in post-DECT. Diagnostic accuracy was significantly lower in group I than group E in pre-DECT (P = 0.019, 0.048), but there was no significant difference between two groups in post-DECT.

Conclusion: Combined use of DECT with SECT improved the detection rate of sacral fractures and enhanced intra-rater and inter-rater reliability. High diagnostic accuracy was achieved regardless of the observer's experience. These results indicate that DECT is a useful imaging modality for diagnosing sacral fractures.

Introduction: Trauma patients frequently may be transported significant distance to receive care at a level one trauma center. Increasing distance may cause delays in care. We sought to investigate whether distance traveled for level 1 trauma care affected rates of intervention for renal trauma.

Methods: We queried our institutions reportable trauma database from the years 2015 to 2022. This data was filtered for all patients that had ICD codes pertaining to renal trauma. All renal trauma patients with zip codes where they sustained their injury were included. We then calculated the distance traveled to our hospital via Google Maps for each patient. We aggregated diagnosis codes for percutaneous angioembolism and nephrectomy. Injury severity scores (ISS) were collected. We divided patients into two groups based on distance traveled (0-30 miles and 31 + miles). We also analyzed the number of angioembolizations and open renal surgery completed for each mile distance category and analyzed for a difference between the groups.

Results: Our database yielded 307 cases of renal trauma that met inclusion criteria. We found no difference in rates of percutaneous angioembolism and open renal surgery between patients that traveled different distances for renal trauma care.

Conclusions: Few studies have assessed distance traveled for trauma care and need for intervention. Our findings that an increased travel distance did not lead to a significantly increased risk for intervention are reassuring. Based on these findings, distance traveled for appropriate trauma care may not be a factor when deciding on transfers for renal trauma.