mSTaRT Trauma & Intox

Background

Any kind of mass casualty incident poses a tremendous challenge to emergency medical services regarding both material and human resources. The possible presence of hazardous materials on the scene aggravates such a severe incident significantly. Therefore a triage system should adequately address this problem without needlessly complicating the triage procedure.

Methods

Following a tear gas assault in a shopping arcade in Munich, an expert group has identified and included this relevant aspect as an essential and necessary improvement to the new mSTaRT-Algorithm Trauma & Hazmat. The algorithm has come into effect as new official operational standard for all Munich fire and emergency medical services regarding mass casualty incidents. It covers the aspects of identifying the possible presence of hazardous materials, triage, emergency treatment and transport priorities. The recognition of a possible contamination as well as the appropriate reaction are implemented for each patient category. Moreover, the specific diagnoses of head trauma, inhalation trauma with stridor and possible intoxication have been included as part of the retriage procedure, taking evidence of recent studies into account.

Results

This new algorithm for mass casualty incidents adequately covers any possible contamination with chemical agents.     

Osteosynthese und Pfannenwechsel bei periprothetischer Azetabulumfraktur über einen Kocher-Langenbeck-Zugang

Objective

Reconstruction/stable fixation of the acetabular columns to create an adequate periacetabular requirement for the implantation of a revision cup.

Indications

Displaced/nondisplaced fractures with involvement of the posterior column. Resulting instability of the cup in an adequate bone stock situation.

Contraindications

Periprosthetic acetabulum fractures with inadequate bone stock. Extended periacetabular defects with loss of anchorage options. Isolated periprosthetic fractures of the anterior column. Septic loosening.

Surgical technique

Dorsal approach. Dislocation of hip. Mechanical testing of inlaying acetabular cup. With unstable cup situation explantation of the cup, fracture fixation of acetabulum with dorsal double plate osteosynthesis along the posterior column. Cup revision. Hip joint reposition.

Postoperative management

Early mobilization; partial weight bearing for 12 weeks. Thrombosis prophylaxis. Clinical and radiological follow-ups.

Results

Periprosthetic acetabular fracture in 17 patients with 9 fractures after primary total hip replacement (THR), 8 after revision THR. Fractures: 12 due to trauma, 5 spontaneously; 7 anterior column fractures, 5 transverse fractures, 4 posterior column fractures, 1 two column fracture after hemiendoprosthesis. 5 type 1 fractures and 12 type 2 fractures. Operatively treated cases (10/17) received 3 reinforcement ring, 2 pedestal cup, 1 standard revision cup, cup-1 cage construct, 1 ventral plate osteosynthesis, 1 dorsal plate osteosynthesis, and 1 dorsal plate osteosynthesis plus cup revision (10-month Harris Hip Score 78 points). Radiological follow-up for 10 patients: consolidation of fractures without dislocation and a fixed acetabular cup. No revision surgeries during follow-up; 2 hip dislocations, 1 transient sciatic nerve palsy.

     

Mortality in open abdominal aortic surgery in patients with morbid obesity

BackgroundOpen abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients.ObjectivesThis study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity.SettingA retrospective analysis of 2007–2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.MethodsWe included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses.ResultsA total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50–8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001).ConclusionsMorbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.     

Rekonstruktion bei schweren Weichteilverletzungen an der Hand

Background

Severe soft tissue defects of the hand are often caused by occupational trauma and frequently lead to considerable functional impairment.

Objective

Which reconstructive options and what supportive treatment measures are available for severe soft tissue defects of the hand?

Material and methods

A representative summary of treatment measures concerning primary care and further covering of defects as exemplified by selected cases from our own patients and additional recommendations for treatment are presented.

Results

The reconstruction of severe soft tissue defects of the hand usually consists of several steps and is performed according to individual patient needs. For this purpose, different types of local, pedicled and free flaps are available.

Conclusion

Hand surgery provides a wide range of options for the reconstruction of tissue defects of different etiologies. The spectrum of operative procedures encompasses both local and pedicled flaps as well as free flaps taken from other regions of the body with microvascular connection to the recipient region. Free flaps are an essential pillar in the reconstructive treatment and due to the safety in the execution, the application of free flaps should not only be seen as a last resort. Many kinds of free flaps can be harvested with parts from different tissue types or as a combination of several free flaps. As a result individual solutions can be provided depending on patient needs. Supportive measures following free flap surgery can help to improve the postoperative result with respect to blood supply, complaints and function.

     

Diagnostik und Management des Endoprotheseninfekts am Schultergelenk

Periprosthetic infections represent a rare but severe complication after shoulder arthroplasty. Depending on the timing of the occurrence and the clinical symptoms, classification into early, delayed, and late infections as well as low- and high-grade infections can be made. Common causes of infection are Staphylococcus aureus, streptococci, enterococci, and gram-negative rods. Additionally, skin flora bacteria can be encountered including coagulase-negative staphylococci (e.?g., Staphylococcus epidermidis) and anaerobes (e.?g. Propionibacterium acnes). Besides clinical and radiological examination, laboratory tests are the main aid in the diagnosis of shoulder arthroplasty infections. The most important factor is the harvesting of tissue samples for microbiological examination. Additionally, general inflammation markers, histological examinations of tissue samples, as well as the leukocyte count of aspirated joint fluid can contribute important information to find the right diagnosis. In the case of an early or newly developed acute infection, an attempt can be made to preserve the endoprosthesis while performing radical debridement and inlay change. If the criteria for preservation of the endoprosthesis are not met, a two-stage revision including removal of the endoprosthesis, temporary spacer implantation, and reimplantation along with antibiotic therapy is recommended. In the case of low-grade infection, known low-pathogenic bacteria with susceptibility to antibiotics, and good soft-tissue status, a single-stage revision can be performed.     

Highly Cross-Linked Polyethylene Reduces Osteolysis Incidence and Wear-Related Reoperation Rate in Cementless Total Hip Arthroplasty Compared With Conventional Polyethylene at a Mean 12-Year Follow-Up

Background

A number of studies on total hip arthroplasty have compared highly cross-linked polyethylene (HXLPE) with conventional polyethylene (CPE) liners beyond 10 years. However, the impact of HXLPE on the wear-related reoperation rate is unclear. The purpose of this study was to evaluate the clinical advantage of using a single manufacturer's HXLPE in terms of reducing the reoperation rate.