Multiple trauma patients with severe chest trauma are at increased risk for tracheostomy. While the risk factors associated with the need for tracheostomy are well established in the general critical care population, they have not yet been validated in a cohort of patients suffering severe thoracic trauma. This retrospective cohort study analysed data on patients aged 18 years or older who were admitted to one of the six participating academic level I trauma centres with multiple injuries, including severe thoracic trauma (AISThorax ≥ 3) between 2010 and 2014. A multivariable binary regression was used to identify predictor variables for tracheostomy and to develop the Tracheostomy in Thoracic Trauma Prediction Score (T3P-Score). The study included 1019 adult thoracic trauma patients, of whom 165 underwent tracheostomy during their intensive care unit (ICU) stay. Prehospital endotracheal intubation (adjusted OR [AOR]: 2.494, 95% CI [1.412; 4.405]), diagnosis of pneumonia during the ICU stay (AOR: 4.374, 95% CI [2.503; 7.642]), duration of mechanical ventilation (AOR: 1.008/hours of intubation, 95% CI [1.006; 1.009]), and an AISHead ≥ 3 (AOR 1.840, 95% CI [1.039; 3.261]) were independent risk factors for tracheostomy. Patients with sepsis had a lower risk of tracheostomy than patients without sepsis (AOR 0.486, 95% CI [0.253; 0.935]). The T3P-Score had high predictive validity for tracheostomy (ROCAUC = 0.938, 95% CI [0.920, 0.956]; Nagelkerke's R2 was 0.601). The T3P-Score's specificity was 0.68, and the sensitivity was 0.96. The severity of thoracic trauma did not predict the need for tracheostomy. Follow-up studies should validate the T3P-Score in external data sets and study the reasons for the reluctant use of tracheostomy in patients with severe thoracic trauma and subsequent sepsis.Trial registration: The study was applied for and registered a priori with the respective ethics committees.

Background: Yet, we couldn´t find any reported case of a trauma patient, that describes a late onset complete paraplegia of the lower limbs caused by spinal chord ischaemia without a spinal (chord) injury. Leading causes are dissections of the aorta and their reconstructions. Case presentation: Here, we present a case of a 43 year old male patient with traumatic dissection of the external iliac artery and demolition of the iliac vein on the left side . Moreover, he was in hypovolemic shock. Injuries of the spine or the spinal chord were not apparent. He was able to move both legs on demand. After performance of damage control surgery at the day of the accident, the patient presented a complete sensoric and motoric deficit 7 days after surgery, the MRI showed a vascular myelopathy. Conclusion: The myelopathy could be caused by impaired arterial perfusion due to hypovolaemia and disrupted arterial flow on the Adamkiewicz artery. A venious congestion as well as fibrocartilary embolisation are causes that also need to be dicussed.

Jährlich werden in Deutschland mehr als 20.000 Patienten mit Polytrauma behandelt. Hierunter wird eine gleichzeitig entstandene Verletzung mehrerer Körperregionen, die einzeln oder in Summe lebensbedrohlich für den Patienten ist, verstanden. Die Einschätzung erfolgt nach entsprechenden Scoringsystemen. Zur adäquaten Behandlung bedarf es nicht nur einer medizinischen Versorgung auf höchstem Niveau, sondern auch der Koordination der organisatorischen/logistischen Abläufe. Das Bindeglied zwischen präklinischer und klinischer Versorgung ist die Behandlung im Schockraum, der durch einem festgelegten erfahrenen „trauma leader“ geleitet werden sollte. Den Behandlungsalgorithmen liegen eine aktuelle S3-Leitlinie und das Weißbuch zur Schwerstverletztenversorgung zugrunde. Hier werden Empfehlungen bezüglich der personellen, räumlichen, logistischen und materiellen Anforderungen definiert. Jedes Schockraumteam sollte regelmäßig geschult werden und über theoretische und praktische Kenntnisse zur Anwendung der Schockraumalgorithmen verfügen. So kann die Behandlungsqualität und damit die Überlebenswahrscheinlichkeit kritisch kranker Patienten verbessert werden. Im Schockraum selbst steht die standardisierte und prioritätenorientierte Einschätzung und Stabilisierung des Patienten im Vordergrund. Aufgrund der qualitativ unterschiedlich guten Versorgung vom Schwerverletzten in Deutschland wurde zur Verbesserung der Behandlung polytraumatisierter Patienten die Initiative TraumaNetzwerk DGU® initiiert, um Standards zu definieren und die Prozesse und Organisation in der Schwerstverletztenversorgung zu verbessern. In Deutschland gibt es aktuell 615 teilnehmende Kliniken, die in 52 lokalen Traumanetzwerken teilweise grenzübergreifend organisiert sind.

Background Parenteral antibiotic administration in the treatment of periprosthetic joint infections (PJI) often requires inpatient settings. This is associated with significant costs to the healthcare system. Objective The costs of inpatient parenteral antibiotic treatment (IPAT) and simulated costs of outpatient parenteral antibiotic treatment (OPAT) were compared in patients with PJI. Evaluations were carried out from the perspectives of cost bearers (insurances) and healthcare providers (hospitals). Material and methods The analysis and simulations were performed for all cases with the ICD-10 diagnosis T84 in the treatment year 2015. Results The simulated reduction of 159 bed-days in the 12 patients included in the study resulted in a reduction of the total costs of>18,000& x202f;euro from the perspective of the health insurance. From the perspective of the hospitals the pure proceeds were improved by >22,000x202f;euro. The total costs of OPAT were >57,000& x202f;euro for the health insurance. For hospitals the difference of policlinic proceeds and costs of OPAT showed a loss of >1500x202f;euro. Conclusion For hospitals the OPAT is overall financially advantageous. Further advantages due to opportunity costs seem to be interesting. For cost bearers OPAT is associated with an additional financial expenditure, particularly due to costs of outpatient medication. The private sector should be considered due to the assumed additional burden as well as the assumed patient comfort.

Objective Preoperative digital templating is a standard procedure in total hip arthroplasty. Deviations between template size and final implant size may result from inaccurate calibration, templating as well as intraoperative decisions. So far, the explicit effect of calibration errors on templating has not been addressed adequately. Materials and Methods A mathematical simulation of calibration errors up to ± 24% was applied to the templating of acetabular cups (38 to 72 mm diameter). The effect of calibration errors on template component size as deviation from optimal size was calculated. Results The relationship between calibration error and component size deviation is inverse and linear. Calibration errors have a more pronounced effect on larger component sizes. Calibration errors of 2–6% result in templating errors of up to two component sizes. Common errors of up to 12% may result in templating errors of 3–4 sizes for common implant sizes. A tabular matrix visualizes the effect. Conclusion Calibration errors play a significant role in component size selection during digital templating. Orthopedic surgeons should be aware of this effect and try to identify and address this source of error.

Zusammenfassung Hintergrund Die parenterale Antibiotikagabe im Rahmen der Therapie von periprothetischen Infektionen erfordert in der Regel eine stationäre Behandlung und geht mit hohen Kosten einher. Fragestellung Es wurden tatsächliche stationäre Behandlungskosten („inpatient parenteral antibiotic therapy“ [IPAT]) mit simulierten Kosten einer ambulanten Behandlung („outpatient parenteral antibiotic therapy“ [OPAT]) von Patienten mit periprothetischen Gelenkinfektionen verglichen. Die Auswertung erfolgte aus Perspektive der Kostenträger (gesetzliche Krankenversicherung [GKV]) und Leistungserbringer (Krankenhäuser). Material und Methoden Die Analyse und Simulation erfolgten auf Grundlage einer ICD-10 (Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision) für das Behandlungsjahr 2015 mit der Diagnose T84. Ergebnisse Die simulierte Reduktion von 159 Bettentagen bei den in die Studie eingeschlossenen 12 Patienten erbrachte aus Sicht der Kostenträger eine Reduktion der Gesamtkosten um >18.000 €. Aus Perspektive der Leistungserbringer verbesserte sich der Reinerlös um >22.000 €. Die Gesamtkosten der OPAT für den Kostenträger beliefen sich auf >57.000 €. Für den Leistungserbringer zeigte sich in der Differenz von Poliklinikerlös und -kosten der OPAT ein Verlust von >1500 €. Diskussion Die OPAT ist für Leistungserbringer insgesamt finanziell vorteilhaft. Weitere Vorteile durch Opportunitätskosten erscheinen interessant. Für den Kostenträger ist die OPAT insbesondere durch die ambulanten Medikamentenkosten mit einem finanziellen Mehraufwand verbunden. Der niedergelassene Sektor sollte durch die anzunehmende Mehrbelastung ebenso wie der anzunehmende Patientenkomfort bedacht werden.

Cuff tear arthritis and complex proximal humeral fractures are common pathologies that are frequently addressed by the implantation of a reversed shoulder prosthesis. The present cadaveric study aimed to analyze the effect of cement augmentation of the glenoid component on the primary stability in geriatric patients. Cement augmentation of glenoid baseplate screws has an influence on primary stability in reversed shoulder arthroplasty (RSA). Glenoid base plates (Delta Xtend, DePuy Synthes, Westchester, USA) were implanted in 6 pairs of formalin-fixated scapulae of 4 female and 2 male donors (average age 83 years). Two angle stable screws were placed at the superior and inferior position. Cement augmentation was performed with 2 ml bone cement (Kyphon, Medtronic, Minneapolis, USA) per screw in right specimens. Afterwards, biomechanical testing with 600 to 1000 N (100 cycles) at a 65° abduction angle was performed. Finally, a load-to-failure analysis was conducted. No implant loosening was observed during cyclic tests from 600 N to 1000 N. In addition no difference in the plastic deformation was detected at 600 N (p = 0.301), 700 N (p = 0.522), 800 N (p = 0.480), 900 N (p = 0.521) and 1000 N (p = 0.748). Load- to- failure analyses revealed implant loosening at 3314 N (SD 823 N) in the cement-augmented implants and at 3059 N (SD 974 N) in scapulae with non-cemented screws (p = 0.522). Cement- augmented fixation of the glenoid component did not result in an increased primary stability in this study. Thus, the application of cement should be critically assessed considering associated risks and increased costs. Basic science study, Controlled laboratory study.

While the incidence and aspects of pneumonia in ICU patients has been extensively discussed in the literature, studies on the occurrence of pneumonia in severely injured patients are rare. The aim of the present study is to elucidate factors associated with the occurrence of pneumonia in severely injured patients with thoracic trauma.

Introduction: The optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed. Hypothesis: Certain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures. Patients and methods: All patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity. Results: 82 patients (42 male, 40 female) were eligible for further analyses. Median follow-up was 8.0 +/- 39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7 +/- 15.5, group 2: 68.3 +/- 14.3; p < 0.001) and had significantly more shoulder dislocations (p = 0.024), whereas gender (p = 0.299), side of fracture (p = 0.189) and fragment/head ratio (p = 0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement. Discussion: The present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement. (C) 2018 Published by Elsevier Masson SAS.

The optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed. Certain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures. All patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head-ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity. Eighty-two patients (42 male, 40 female) were eligible for further analyses. Median follow up was 8.0 ± 39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7 ± 15.5, group 2: 68.3 ± 14.3; p < 0.001) and had significantly more shoulder dislocations (p = 0.024), whereas gender (p = 0.299), side of fracture (p = 0.189) and fragment/head ratio (p = 0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement. The present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement. III, Retrospective comparative study.

BACKGROUND Increasing numbers of total joint arthroplasties and consecutive revision surgery are associated with the risk of periprosthetic joint infections (PPJI). Treatment of PPJI is complex and associated with immense socio-economic burden. One treatment aspect is parenteral antiinfective therapy, which usually requires an inpatient setting [Inpatient parenteral antibiotic therapy (IPAT)]. An alternative is outpatient parenteral treatment [Outpatient parenteral antibiotic therapy (OPAT)]. To conduct a health economic cost-benefit analysis of OPAT, a detailed cost analysis of IPAT and OPAT is required. So far, there is a lack of knowledge on the health economic effects of IPAT and OPAT for PPJI. AIM To review an economic comparison of IPAT and OPAT. METHODS A systematic literature review was performed through Medline following the PRISMA guidelines. RESULTS Of 619 identified studies, 174 included information of interest and 21 studies were included for quantitative analysis of OPAT and IPAT costs. Except for one study, all showed relevant cost savings for OPAT compared to IPAT. Costs for IPAT were between 1.10 to 17.34 times higher than those for OPAT. CONCLUSION There are only few reports on OPAT for PPJI. Detailed analyses to support economic or clinical guidelines are therefore limited. There is good clinical evidence supporting economic benefits of OPAT, but more high quality studies are needed for PPJI.

BackgroundThe incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare.MethodsTherefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described.ResultsIn the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating.ConclusionsTherefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures.Level 3: Retrospective case- control study.

INTRODUCTION:Cuff tear arthritis and complex proximal humeral fractures are common pathologies that are frequently addressed by the implantation of a reversed shoulder prosthesis. The present cadaveric study aimed to analyze the effect of cement augmentation of the glenoid component on the primary stability in geriatric patients. HYPOTHESIS:Cement augmentation of glenoid baseplate screws has an influence on primary stability in reversed shoulder arthroplasty (RSA). MATERIALS AND METHODS:Glenoid base plates (Delta Xtend, DePuy Synthes, Westchester, USA) were implanted in 6 pairs of formalin-fixated scapulae of 4 female and 2 male donors (average age 83 years). Two angle stable screws were placed at the superior and inferior position. Cement augmentation was performed with 2ml bone cement (Kyphon, Medtronic, Minneapolis, USA) per screw in right specimens. Afterwards, biomechanical testing with 600 to 1000N (100 cycles) at a 65° abduction angle was performed. Finally, a load-to-failure analysis was conducted. RESULTS:No implant loosening was observed during cyclic tests from 600N to 1000N. In addition no difference in the plastic deformation was detected at 600N (p=0.301), 700N (p=0.522), 800N (p=0.480), 900N (p=0.521) and 1000N (p=0.748). Load-to-failure analyses revealed implant loosening at 3314N (SD 823N) in the cement-augmented implants and at 3059N (SD 974N) in scapulae with non-cemented screws (p=0.522). DISCUSSION:Cement-augmented fixation of the glenoid component did not result in an increased primary stability in this study. Thus, the application of cement should be critically assessed considering associated risks and increased costs. LEVEL OF PROOF:Basic science study, controlled laboratory study.

Purpose The aim of this study was to evaluate a standardised algorithm to assess and treat impaired limb perfusion prior to surgical fixation of geriatric ankle fractures and determine the prevalence of peripheral arterial disease (PAD) in geriatric patients presenting with ankle fractures. Methods Eighty-four patients >65 years pre-operatively diagnosed and treated according to an algorithm (study group) were compared with 84 patients diagnosed and treated before the algorithm was introduced (control group). Results In 14 patients of the study group, clinical noninvasive examination revealed signs of relevant PAD, which was confirmed with computed tomographic angiography (CTA) in nine patients, all of whom had successful angioplasty prior to surgical fixation of the ankle fracture. In three of these patients, PAD had previously been diagnosed. After standardised diagnostics and treatment of malperfusion, a significantly reduced overall and, particularly, wound complication rate was found. Conclusion PAD is an underdiagnosed condition in geriatric patients presenting with ankle fractures. This study underlines the relevance of limb perfusion for adequate wound healing in geriatric ankle fractures. Therefore, special attention should be paid to diagnose and—if indicated—optimise limb perfusion prior to surgical fixation of geriatric ankle fractures.

Background: The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment.Methods: We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016.Results: The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo-dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized.Conclusion: The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.

INTRODUCTION:Hemorrhagic shock remains one of the most common causes of death in severely injured patients. It is unknown to what extent the presence of a blood bank in a trauma center influences therapy and outcome in such patients.MATERIAL AND METHODS:We retrospectively analyzed prospectively recorded data from the TraumaRegister DGU® and the TraumaNetzwerk DGU®. Inclusion criteria were Injury Severity Score (ISS) ≥ 16, primarily treated patients, and hospital admission 2 years before or after the audit process.RESULTS:Complete data sets of 18,573 patients were analyzed. Of 457 hospitals included, 33.3% had an in-house blood bank. In trauma centers with a blood bank (HospBB), packed red blood cells (PRBCs) (21.0% vs. 17.4%, p < 0.001) and fresh frozen plasma (FFP) (13.9% vs. 10.2%, p <0.001) were transfused significantly more often than in hospitals without a blood bank (Hosp0). However, no significant difference was found for in-hospital mortality (standard mortality ratio [SMR, 0.907 vs. 0.945; p = 0.25). In patients with clinically apparent shock on admission, no difference of performed transfusions were present between HospBB and Hosp0 (PRBCs, 51.4% vs. 50.4%, p = 0.67; FFP, 32.7% vs. 32.7%, p = 0.99), and no difference in in-hospital mortality was observed (SMR, 0.907 vs. 1.004; p = 0.21).DISCUSSION:In HospBB transfusions were performed more frequently in severely injured patients without positively affecting the 24h mortality or in-house mortality. Easy access may explain a more liberal transfusion concept.

Background: The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures. Methods: Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined. Results: In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications. Conclusion: The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications. Level of Evidence: Level III, retrospective cohort study.

INTRODUCTION:The distal radial fracture is a common fracture and frequently seen in geriatric patients. During the last years, volar plating has become a popular treatment option. While the application of locking screws at the distal fragment is widely accepted, there is no evidence for their use at the radial shaft.MATERIALS AND METHODS:In six osteoporotic pairs of matched human cadaver radii an extra-articular model creating an AO 23-A2.1 fracture was employed. Osteosynthesis were performed using the APTUS 2.5 Adaptive TriLock Distal Radius System (Medartis AG) with locking (LS) or non-locking screws (NLS) for proximal fixation. Biomechanical testing was performed in a staircase fashion: starting with 50 cycles at 200N, the load was continuously increased by 50N every 80 cycles up to a maximum force of 400N. Finally, load to failure was analyzed with failure defined as sudden loss of force measured (20%) or major deformation of the radii (10mm).RESULTS:At 200N, 250N, 300N, 400N and load to failure, the NLS group showed a higher degree of elastic modulus. In contrast, the LS group showed higher elastic modulus at 350N. Maximum force was higher in the LS group without reaching statistical significance. Reasons for loss of fixation were longitudinal shaft fractures, horizontal peri-implant fractures and distal cutting out. No difference was seen between the two groups concerning the development of the above mentioned complications.CONCLUSION:Our study did not show biomechanical superiority for distal radius fracture fixation by using locking screws in the proximal holes in an osteoporotic cadaver study. At load to failure, longitudinal shaft fractures and peri-implant fractures seemed to be a more relevant problem rather than failure of the proximal fixation.