European Journal of Trauma and Emergency Surgery最新文献

Background: Severely injured patients may suffer from acute disease-related or injury-related malnutrition involving a marked inflammatory response. This study investigated the prevalence and incidence of malnutrition and its relation with complications in severely injured patients admitted to the intensive care unit (ICU).

Methods: This observational prospective cohort study included severely injured patients (Injury Severity Score ≥ 16), admitted to the ICU of five level-1 trauma centers in the Netherlands and United States. Malnutrition was defined as a Subjective Global Assessment score ≤ 5. Complications included systemic-, surgery-, and fracture-related complications, pneumonia, urinary tract infection, deep venous thrombosis, and pulmonary embolism. In-ICU and in-hospital mortality were recorded separately. The complication rate was compared between patients who had or developed malnutrition and patients who remained well-nourished, using multivariable logistic regression analysis.

Results: Of 100 included patients, twelve (12%) were malnourished at admission. Of the 88 well-nourished patients, 44 developed malnutrition during ICU admission, (ICU incidence 50%, 95% confidence interval [CI] 40-60%). Another 18 patients developed malnutrition at the ward (overall in-hospital incidence 70%, 95% CI 61-80%). The 62 patients who developed malnutrition and 12 patients who were malnourished upon admission had more complications than the 26 patients who remained well-nourished (58% vs. 50% vs. 27% respectively; p = 0.03; Odds Ratio 3.4, 95% CI 1.2-9.6).

Conclusions: 50% of severely injured patients developed malnutrition during ICU admission, increasing to 70% during hospital admission. Malnutrition was related to an increased risk of complications. Recognition of sub-optimally nourished severely injured patients and assessment of nutritional needs could be valuable in optimizing their clinical outcomes.

Level of evidence: Level III, Prognostic/Epidemiological.

Background: Midfoot fractures in polytrauma patients are often an underappreciated injury relative to their other major injuries sustained. In this study, our aim was to explore the mechanisms and patterns of injury in polytrauma related midfoot fractures as compared to single limb injuries.

Setting: Multicentre observational study.

Methods: Data was retrospectively collected from four centres (two major trauma centres and two trauma units) on surgically treated midfoot fracture dislocations between 2011 and 2021. Polytrauma was defined as a patient presenting with an Injury Severity Score (ISS) threshold of 15 or greater. Radiographs were analysed using departmental PACS. All statistics were performed using SPSS 26.

Results: A total of 410 cases were included in the study. The rate of unstable midfoot injury was similar to simple falls, falls from height, crush injury, assault, sport and seizure. The only mechanisms that differ are a higher rate of midfoot injury in non-polytrauma patients undergoing a simple fall (19.71% vs. 6.78%) and higher rates of midfoot injury in polytrauma patients following motor vehicle collision (16.86% vs. 33.90%). Regarding patterns of injury, there was a significant increase in number of columns injured in polytrauma patients (polytrauma patient 3 column injury 77.97%, non-polytrauma patient 3 column injury 34.00%). There was no difference in the prevalence of central column injury (p = .623), although there were significantly more medial and lateral column injuries in the polytrauma group (p < .001 for both).

Conclusion: Polytrauma related Lisfranc joint midfoot injuries have a higher prevalence of medial and lateral column injury than non-polytrauma Lisfranc joint midfoot injuries. Non-polytrauma injuries can, however, have an equally significant force involved as polytrauma patients, with over 50% occurring as the result of high velocity injury. A high index of suspicion should be maintained for midfoot injuries in high velocity mechanisms, regardless of other injuries sustained.

Background: Complicated wrist amputation caused by severe trauma poses a real challenge for orthopedic and hand surgeons. This study aimed to evaluate a procedure of ulnoradial-metacarpal reconstruction as a rescue option in this challenging situation.

Methods: In total, 12 patients with complicated wrist amputation induced by serious injury were selected from 2015 to 2020 and followed up for 1∼6 years at a level 1 trauma center. All patients underwent initial treatment in the Emergency Department followed by transfer to the main operating theater for emergency ulnoradial-metacarpal reconstruction. Patient demographics, surgical techniques, clinical outcomes, and complications were also retrieved from medical records. Functional outcomes were assessed with Disabilities of Arm, Shoulder and Hand score (DASH) and Mayo Wrist Score (MWS). Descriptive statistics were used to calculate, including frequencies for categorial variables and mean values and ranges for continuous variables.

Results: The mean age of patients was 49.3 years (ranging from 41 to 61 years), with ten males and two females. The mean time to union was 4.8 months; 11 patients had a complete union. There was one case of nonunion due to bone resorption resulting from inadequate blood supply and smoking. Compared with the contralateral limb, the total active motion of the hand was 25% (ranging from 17 to 38%), and grip strength was 7% (ranging from 0 to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (ranging from 8 to 12 mm). All mean outcome scores indicated moderate disability, including disabilities of Arm, Shoulder, and Hand (12; ranging from 4 to 27). Based on Mayo Wrist Score, all patients were loss of wrist function forever. The majority of patients were satisfied with the hand function after recovery.

Conclusion: Despite all patients experiencing significant impairments in their overall hand function, ulnoradial-metacarpal fusion presents a viable option for hand replantation in instances where the carpus has been irreparably damaged.

Type of study/level of evidence: Therapeutic IV.

Purpose: To report the radiological outcomes and complications of the Masquelet induced membrane technique (IMT) for acute bone reconstruction in complex hand injuries.

Methods: We retrospectively reviewed 22 patients treated primarily by the IMT for bone defect of the phalanx and/or metacarpals bones in 26 injured digits. The median bone defect length was 17 mm (IQR 13-25). Given the severity and variability of the lesions, revision parameters focused on bone healing and postoperative complications.

Results: At the median follow-up of nine months (IQR, 6-14 months), bone union was achieved in 25 digits (96%) with a median delay of three months (IQR, 2.5-3.5 months) after stage 2. Postoperative complications occurred in 11 of 26 digits requiring revision surgery in nine of 26 digits (35%). Soft tissue coverage failure and infection were the main complications. A patient underwent a late amputation through the metacarpophalangeal joint due to an uncontrolled bone infection.

Conclusions: Despite a significant rate of complications, bone reconstruction using the IMT is a reliable procedure for achieving bone healing of phalanx or metacarpal bone defects in complex hand injuries.

Purpose: The aim of this study was to evaluate the feasibility of using patient-specific implants (PSI) for complex shaft corrective osteotomies in multiplanar deformities of long bones in the lower extremities. Additionally, it aimed to investigate the added value of these implants by quantifying surgical accuracy on postoperative CT, comparing their outcomes to two commonly used techniques: 3D virtual visualizations and 3D-printed surgical guides.

Methods: Six tibial and femoral shaft corrective osteotomies were planned and performed on three Thiel embalmed human specimen. Depending on the specimen a different respective technique was used; 1) '3D Visualization' using 3D virtual plan preoperatively and free-hand corrective osteotomy techniques with standard manually contoured plates; 2) '3D guided' utilizing 3D surgical guides and manually contouring of conventional implant; and 3)'3D PSI' utilizing a 3D surgical guide with a patient-specific implant. Accuracy of the corrections was assessed through measurements for varus/valgus angulation, ante/recurvation, rotation and osteotomy plane error as quantified on postoperative CT-scans.

Results: Twelve corrective osteotomies were performed. For, the median difference between the surgical plan and postoperative CT assessment was 3.4°, 4.6°, and 2.2° for the '3D visualization', '3D guided', and '3D PSI' methods respectively. Regarding ante/recurvation, the differences were 3.8°, 43.8°, and 1.2°, respectively. For rotation, the differences were 11.9°, 18.7°, and 3.5°, respectively. Discrepancies between planned and executed levels of osteotomy plane were 6.2 mm, 3.2 mm, and 1.4 mm, respectively.

Conclusion: PSIs with 3D-printed drilling guides for complex multiplanar corrective osteotomies of femoral and tibial shaft malunions is feasible and achieves accurate corrections. This technique enables precise determination of the osteotomy plane, guides correction in all three planes, and ensures satisfactory implant fitting; thus accurately translating the virtual surgical plan into clinical practice. The 3D PSI method is beneficial for complex cases with significant multiplanar deformities in bone anatomy, particularly with rotational malalignment.

Purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is beneficial for uncontrollable torso bleeding; however, prolonged REBOA causes ischemia-reperfusion injury. The purpose of this study is to examine the hypothesis that continuous renal replacement therapy (CRRT) with a cytokine-adsorbing hemofilter would improve mortality due to hemorrhagic shock with REBOA-reperfusion injury by controlling metabolic acidosis, hyperkalemia, and hypercytokinemia.

Methods: Hemorrhagic shock with 40% blood loss was induced by phlebotomy in eight female swine. CRRT was performed on four swine after 90 min of REBOA, and the remaining four swine (control group) underwent the same procedures except for CRRT. We evaluated the survival time and trends of pH, HCO^3-, potassium, lactate, circulatory inflammatory cytokines, and histopathology of the intestine for 180 min after REBOA deflation.

Results: Two swine in the CRRT group and one in the control group survived; no significant difference were observed in survival rates between the groups (p = 0.45). Furthermore, no significant differences in the transition of biomarkers and histopathological grades were observed between the groups. The CRRT group showed a tendency of increasing pH and HCO^3-, decreasing lactate, lower elevation of potassium and cytokine levels (interleukin 6, CRRT: 1008.5 [770.4-1246.6], control; 1636.7 [1636.7-1636.7] pg/mL at t = 270), and lower intestine histopathological grade (jejunum, CRRT; 1.5 [1.3-1.8], control; 4.0 [4.0-4.0], ileum, CRRT; 1.5 [1.3-1.8], control; 4.0 [4.0-4.0] at t = 270) than the control group.

Conclusions: CRRT may mitigate acute-REBOA-related ischemia-reperfusion injury by controlling biomarkers. Further research is required to evaluate the impact on long-term mortality.

Purpose: Severe thorax trauma including multiple rib fractures and flail chest deformity are leading causes of death in trauma patients. Increasing evidence supports the use of surgical stabilisation of rib fractures (SSRF) in these patients. However, there is currently a paucity of evidence for its use in non-ventilator-dependent patients.

Methods: A retrospective propensity-matched analysis of the data of the TraumaRegister DGU^® for non-ventilator-dependent patients with severe rib injury (abbreviated injury score ≥ 3) was performed. Subgroup analyses with respect to injury severity score, American society of anaesthesiologists physical status classification and age were performed. Furthermore, the effect of time to surgery was analysed.

Registration: TR-DGU project ID 2023-007; ClinicalTrials.gov protocol ID: NCT06464289.

Results: SSRF led to reduced mortality compared to conservative treatment (1.6% vs. 4.8%; p = 0.002) and in comparison to the mortality prognosis of the revised injury severity classification II (RISC II) of 5.2%. Interestingly, SSRF was associated with increased length of hospital and intensive care unit stay, higher rates of organ failure and secondary intubation. The patients with organ failure received SSRF later than those without organ failure.

Conclusion: Here we report on the largest currently published dataset of non-intubated patients receiving SSRF, which showed reduced mortality in the SSRF cohort. The data indicates that SSRF is a viable treatment option for non-intubated patients. The observed late surgical time points, which may be due to cross over after failed conservative treatment, might be the cause for the observed increased rate of organ failure.

Background: The role of beta-blockers in severe, traumatic brain injury (TBI) management is debated. Severe TBI may elicit a surge of catecholamines, which has been associated with increased morbidity and mortality. We hypothesize administering propranolol, a non-selective beta-blocker, within 48 h of TBI will reduce patient mortality within 30 days of injury. The TriNetX database was leveraged to determine if administering a propranolol within 48 h of severe TBI improves outcomes within 30 days of injury.

Methods: The TriNetX Research Network was used to form two cohorts using retrospective data from 106,294,356 patient profiles from 9/10/2022, which included patients from years 2022 to 2022. The propranolol-receiving cohort included all patients who received the first-instance diagnosis of severe TBI (defined by a Glascow coma scale score of 3-8) and propranolol within 48 h of injury. The non-propranolol-receiving cohort included all patients with the same diagnosis of severe TBI but did not receive beta-blockers. The primary outcome of interest was mortality at 30 days. Secondary outcomes included gastrostomy tube placement, neurosurgical intervention in the form of craniotomy, craniectomy, burr hole drainage, seizure, and cardiac arrest.

Results: After propensity score-matching, 381 patients were identified for both cohorts. At 30 days post-severe TBI, 22.7% (84) of patients from the cohort that received propranolol, and 30.77% (116) from the cohort that did not, were deceased (OR 0.66), 95% CI [0.48, 0.92]), (p 0.01). TBI patients who received propranolol also had lower odds of requiring neurosurgical intervention, experience seizures, and cardiac arrest.

Conclusion: The results of this study demonstrate significantly reduced mortality within 30 days of injury and fewer neurosurgical interventions, seizures, and episodes of cardiac arrest in severe TBI patients who received propranolol within 48 h of injury.

Purpose: Emergency laparotomy (EL) is a high-risk procedure, especially in frail patients. This study investigates the prevalence of frailty in referral facilities, evaluates the impact of frailty on postoperative morbidity and mortality, and assesses the long-term effect of EL on patients' functional status.

Methods: This prospective multicentre cohort study included patients aged 50 years and older who underwent EL. Frailty was assessed using the Clinical Frailty Scale (CFS). The primary outcome measure was the prevalence of frailty and its impact on the 180-day mortality rate after EL. Secondary outcomes were 30- and 90-day mortality, complications requiring invasive procedures, length of hospital stay (LOS), and changes in CFS and in living arrangement at six months post-operation.

Results: The study enrolled 251 patients with a median age of 73 years. Frailty was prevalent, with 57.8% of patients classified as frail (CFS 5-9). In Cox regression analysis, the hazard ratios of 180-day mortality with 95% confidence intervals were 2.4 (0.8-7.1) for CFS 4, 7.5 (2.8-20.0) for CFS 5, 14.4 (5.5-37.8) for CFS 6-8, and 28.7 (9.7-84.6) for CFS 9, compared to non-frail patients. Increasing frailty was also associated with higher 30 and 90- day mortality, increased risk of complications, and prolonged LOS. Additionally, at six months post-EL, patients experienced a further decline in functional status compared to their preoperative state.

Conclusion: The 180-day mortality after EL is significantly higher for patients on higher levels of frailty. Likewise, the preoperative frailty has a significant negative impact on postoperative outcomes both short- and long-term.

Purpose: This study investigates the risk of contrast-associated acute kidney injury (CA-AKI) in trauma patients, focusing on the impact of cumulative contrast medium doses.

Methods: A retrospective review was conducted at a level 1 trauma center (2019-2021). The study included patients who underwent intravascular contrast-enhanced examinations for torso trauma within 7 days post-injury. The total contrast medium volume within 7 days was calculated. Multivariate logistic regression (MLR) identified AKI risk factors.

Results: Among the 264 patients, 7.2% (19/264) developed AKI, with 3.4% (9/264) classified as KDIGO stage 3. Approximately 42.8% of patients underwent at least two contrast-enhanced examinations. The mean total contrast medium given was 129.5mL (range 80-410 ml). Multiple logistic regression (MLR) analysis identified four independent risk factors for AKI: diabetes mellitus, initial eGFR < 30, use of inotropic agents, and contrast medium exposure. The odds ratio of AKI increased by 2.92 (95% CI 1.30-6.53) for every 100 ml increase in contrast dose. The contrast volume exposure only plays an important role in severe trauma patients (ISS ≥ 25). Moreover, when correlated with eGFR, the contrast medium exposure volume demonstrated better predictive ability for AKI with a best cut-off value of Contrast volume to eGFR ratio > 1.86.

Conclusion: While repetitive contrast-enhanced examinations are sometimes inevitable, they do come with costs. The CA-AKI risk increases as the amount of contrast medium accumulates in trauma patients who require repetitive examinations.