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ÖGU Newsletter – Wissenschaft 02/2012

ÖGU Österreichische Gesellschaft für Unfallchirurgie

ÖGU Newsletter – Wissenschaft 02/2012
Der zweite Research Newsletter der ÖGU beschäftigt sich diesmal mit lesenswerten Publikationen aus dem Bereich Polytrauma und der Neurotraumatologie und Wirbelsäule, die im Jahr 2012 erschienen sind. Als österreichischer Schwerpunkt wurden rezente Publikationen der Universitätsklinik für Unfallchirurgie und Sporttraumatologie der PMU Salzburg aus dem Bereich der Schulter ausgewählt.

Für jede der Publikationen wird der Link zu der Fachzeitschrift angeboten, so dass bei Interesse der Volltext gelesen oder erworben werden kann. Ich wünsche den Mitgliedern der ÖGU eine spannende und erkenntnisreiche Lektüre.

Univ.-Doz. Dr. Stefan Marlovits
ÖGU Wissenschaftsreferent

Mitarbeiter dieser Ausgabe:

Prim. Univ.-Doz. Dr. Albert Kröpfl, Linz
Prim. Univ.-Prof. Dr. Mehdi Mousavi, Wien
Prim. Dr. Thomas Neubauer, Horn
Prim. Univ.-Prof. Dr. Herbert Resch, Salzburg

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Polytrauma
Injury. 2012 Feb;43(2):184-8. Epub 2011 Jun 22
The impact of BMI on polytrauma outcome

Hoffmann M, Lefering R, Gruber-Rathmann M, Rueger JM, Lehmann W; Trauma Registry of the German Society for Trauma Surgery

Source
Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany. mihoffma@uke.uni-hamburg.de

Abstract
BACKGROUND:
Varying results have been reported concerning the effect of body mass index (BMI) on polytrauma outcome. Although most studies focus on obesity and its associated preexisting medical diseases as a predictor for increased mortality rates, there is evidence that polytrauma patients with underweight also face an inferior outcome.
METHODS:
Records of 5766 trauma patients (minimum 18 years of age, Injury Severity Score ≥ 16, treated from 2004 to 2008) documented in the Trauma Registry of the German Society for Trauma Surgery were subclassified into 4 BMI groups and analysed to assess the impact of BMI on polytrauma outcome.
RESULTS:
Underweight (BMI Group I) as well as obesity (BMI Group IV) in polytraumatized patients are associated with significantly increased mortality by multivariate logistic regression analysis with hospital mortality as the target variable (adjusted odds ratio for BMI Group I, 2.1 (95% CI 1.2-3.8, p = 0.015); for BMI Group IV, 1.6 (95% CI 1.1-2.3, p = 0.009)). Simple overweight (BMI Group III) does not qualify as a predictor for increased mortality (odds ratio 1.0; 95% CI 0.8-1.3).
CONCLUSIONS:
There is a significant correlation between obesity, underweight, and increased mortality in polytraumatized patients. Efforts to promote optimal body weight may reduce not only the risk of chronic diseases but also the risk of polytrauma mortality amongst obese and underweight individuals.

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Z Orthop Unfall. 2012 Jun;150(3):296-301. Epub 2012 Feb 10
[Severe Polytrauma with an ISS ≥ 50]

[Article in German]
Wurm S, Röse M, von Rüden C, Woltmann A, Bühren V

Source
Unfallchirurgie, BG-Unfallklinik Murnau.

Abstract
In Germany 427,500 persons per year are injured in traffic accidents. So we analysed in a retrospective study the post-traumatic quality of life of patients suffering from a severe trauma (ISS ≥ 50). Highlights of interest were: (i) pattern of injury, (ii) injured part of the body, (iii) days in ICU, (iv) outcome, (v) actual state of health, (vi) mental health. Between 1/2000 and 12/2005, 1,435 patients with multiple trauma were hospitalised in the Trauma Center Murnau. 88 suffered from a severe trauma with ISS ≥ 50. 23 % of these patients had a good outcome and 36 % died. Actually, more than half of the patients were physically handicapped or suffered from pain. 41 % showed characteristics typical for a post-traumatic stress disorder. In conclusion the patients with severe trauma had a good survival rate, but they showed a poor post-traumatic quality of life. Thus, in the time after trauma it is important to treat the „whole patient“ and not only the physical lesions.

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World J Surg. 2012 May 19. [Epub ahead of print]
Overall Distribution of Trauma-related Deaths in Berlin 2010: Advancement or Stagnation of German Trauma Management?

Kleber C, Giesecke MT, Tsokos M, Haas NP, Schaser KD, Stefan P, Buschmann CT

Source
Center for Musculoskeletal Surgery, AG Polytrauma, Charité-Universitätsmedizin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany, christian.kleber@charite.de.

Abstract
BACKGROUND:
Trauma is the leading cause of death among children, adolescents, and young adults. The latest data from the German Trauma Registry reveals a constant decrease in trauma mortality, indicating that 11.6 % of all trauma patients in 2010 died in hospital. Notably, trauma casualties dying before admission to hospital have not been systematically surveyed and analyzed in Germany.
METHODS:
We conducted a prospective observational study of all traumatic deaths in Berlin, recording demographic data, trauma mechanisms, and causes/localization and time of death after trauma. Inclusion criteria were all deaths following trauma from 1 January 2010 to 31 December 2010.
RESULTS:
A total of 440 trauma fatalities were included in this study, with a mortality rate of 13/100,000 inhabitants; 78.6 % were blunt injuries, and fall from a height >3 m (32.7 %) was the leading trauma mechanism. 32.5 % died immediately, 23.9 % died within 60 min, 7.7 % died within 1-4 h, 16.8 % died within 4-48 h, 11.1 % died <1 week later, and 8 % died >1 week after trauma. The predominant causes of death were polytrauma (45.7 %), sTBI (38 %), exsanguination (9.5 %), and thoracic trauma (3.2 %). Death occurred on-scene in 58.7 % of these cases, in the intensive care unit in 33.2 %, and in 2.7 % of the cases, in the emergency department, the operating room, and the ward, respectively.
CONCLUSIONS:
Polytrauma is the leading cause of death, followed by severe traumatic brain injury (sTBI). The temporal analysis of traumatic death indicates a shift from the classic „trimodal“ distribution to a new „bimodal“ distribution. Besides advances in road safety, prevention programs and improvement in trauma management-especially the pre-hospital phase-have the potential to significantly improve the survival rate after trauma.

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Neurotraumatologie und Wirbelsäule
J Bone Joint Surg Am. 2012 Jun 20;94(12):1140-8
What’s New in Spine Surgery

Bridwell KH, Anderson PA, Boden SD, Vaccaro AR, Wang JC

Source
Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, Campus Box 8233, St. Louis, MO 63110. E-mail address: bridwellk@wudosis.wustl.edu.

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World Neurosurg. 2012 Jan;77(1):111-8. Epub 2011 Nov 1
Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas

Bellut D, Woernle CM, Burkhardt JK, Kockro RA, Bertalanffy H, Krayenbühl N

Source
Department of Neurosurgery, University Hospital of Zurich, Zurich, Switzerland. dbellut@gmail.com

Abstract
BACKGROUND:
Symptomatic chronic subdural hematoma (scSDH) is one of the most frequent diseases in neurosurgical practice, and its incidence is increasing. However, treatment modalities are still controversial.
OBJECT:
The aim of this retrospective single-center study is to compare for the first time two surgical methods in the treatment of subdural hematoma that have been proven to be efficient in previous studies in a direct comparison.
METHODS:
We analyzed the data of 143 scSDHs in 113 patients undergoing surgery for subdural hematoma with placement of subperiosteal or subdural drainage after double burr-hole trepanation for hematoma evacuation.
RESULTS:
Overall, there were no statistically significant differences regarding general patient characteristics, preoperative and postoperative symptoms, postoperative hematoma remnant, rates of recurrences, mortality, complications, and outcome at discharge and at 3-month follow up between the groups. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage system.
CONCLUSIONS:
Our study shows for the first time a direct comparison of two mainly used surgical techniques in the treatment of scSDH. Both methods proved to be highly effective, and general patient data, complications, outcome and mortality of both groups are equal or superior compared with previously published series. Because there is a clear tendency to less mortality and fewer serious complications, treatment with double burr-hole trepanation, irrigation, and placement of subperiosteal drainage is our treatment of choice in patients with predictable high risk of complications.

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J Trauma Acute Care Surg. 2012 May;72(5):1345-1349
The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury

Eriksson EA, Barletta JF, Figueroa BE, Bonnell BW, Sloffer CA, Vanderkolk WE, McAllen KJ, Ott M

Source
Charleston, South Carolina From the Division of General/Trauma Surgery (E.A.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Pharmacy Practice (J.F.B.), College of Pharmacy, Midwestern University, Glendale, Arizona; Department of Neurosurgery (B.E.F.), Spectrum Health, Grand Rapids, Michigan; Department of Surgical Critical Care (B.W.B.), Spectrum Health, GRMEC/MSU Surgical Critical Care Fellowship, Grand Rapids, Michigan; Department of Neurosurgery, Bronson Neuroscience center (C.A.S.), Kalamazoo, Michigan; Department of Trauma (W.E.V.), Saint Marys Health Care, Grand Rapids, Michigan; Department of Pharmacy (K.J.M.), Acute Critical Care, Spectrum Health, Grand Rapids, Michigan; and Division of Trauma and Surgical Critical Care (M.O.), Vanderbilt University Medical Center, Nashville, Tennessee.

Abstract
BACKGROUND:
Utilization of brain tissue oxygenation (pBtO2) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO2 values over the first 72 hours of monitoring are predictive of mortality.
METHODS:
Consecutive, adult patients with severe traumatic brain injury and pBtO2 monitors were retrospectively identified. Time-indexed measurements of pBtO2, cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO2, CPP, and ICP. The pBtO2 threshold most predictive for survival was determined.
RESULTS:
There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO2 values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO2 was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO2 was most predictive for mortality.
CONCLUSIONS:
The first 72 hours of pBtO2 neurologic monitoring predicts mortality. When the pBtO2 monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO2 that is predictive of outcome.
LEVEL OF EVIDENCE:
III, prognostic study.

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Br J Surg. 2012 Jan;99 Suppl 1:122-30. doi: 10.1002/bjs.7707
Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality

Hoffmann M, Lefering R, Rueger JM, Kolb JP, Izbicki JR, Ruecker AH, Rupprecht M, Lehmann W; Trauma Registry of the German Society for Trauma Surgery

Source
Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany. mi.hoffmann@uke.de.

Abstract
BACKGROUND:
Early diagnosis and prediction of traumatic brain injury (TBI) is essential for determining treatment strategies and allocating resources. This study evaluated the predictive accuracy of Glasgow Coma Scale (GCS) verbal, motor and eye components alone, or in addition to pupil size and reactivity, for TBI.
METHODS:
A retrospective cohort analysis of data from 51 425 severely injured patients registered in the Trauma Registry of the German Society for Trauma Surgery from 1993 to 2009 was undertaken. Only directly admitted patients alive on admission and with complete data on GCS, pupil size and pupil reactivity were included. The unadjusted predictive roles of GCS components and pupil parameters, alone or in combination, were modelled using area under the receiver operating characteristic (AUROC) curve analyses and multivariable logistic regression regarding presence of TBI and death.
RESULTS:
Some 24 115 patients fulfilled the study inclusion criteria. Best accuracy for outcome prediction was found for pupil reactivity (AUROC 0.770, 95 per cent confidence interval 0.761 to 0.779) and GCS motor component (AUROC 0.797, 0.788 to 0.805), with less accuracy for GCS eye and verbal components. The combination of pupil reactivity and GCS motor component (AUROC 0.822, 0.814 to 0.830) outmatched the predictive accuracy of GCS alone (AUROC 0.808, 0.800 to 0.815). Pupil reactivity and size were significantly correlated (r(s) = 0.56, P < 0.001). Patients displaying both unequal pupils and fixed pupils were most likely to have TBI (95.1 per cent of 283 patients). Good outcome (Glasgow Outcome Scale score 4 or more) was documented for only 1929 patients (8.0 per cent) showing fixed and bilateral dilated pupils.
CONCLUSIONS:
The best predictive accuracy for presence of TBI was obtained using the GCS components. Pupil reactivity together with the GCS motor component performed best in predicting death.

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J Am Coll Surg. 2012 Jun;214(6):950-7. Epub 2012 Apr 26
Intraparenchymal vs extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more?

Kasotakis G, Michailidou M, Bramos A, Chang Y, Velmahos G, Alam H, King D, de Moya MA

Source
Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.

Abstract
BACKGROUND:
Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device.
STUDY DESIGN:
We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay.
RESULTS:
There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device.
CONCLUSIONS:
Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications.

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Am J Surg. 2012 May;203(5):584-8. Epub 2012 Mar 15
Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury

Kunio NR, Differding JA, Watson KM, Stucke RS, Schreiber MA

Source
Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Mail Code L-223, Portland, OR 97239-3098, USA. kunion@ohsu.edu

Abstract
BACKGROUND:
The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury.
METHODS:
Patients admitted with a traumatic brain injury were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis.
RESULTS:
Sixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit-free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%).
CONCLUSIONS:
Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.

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J Neurotrauma. 2012 May 20;29(8):1539-47. Epub 2012 Mar 2
An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients

Bragge P, Chau M, Pitt VJ, Bayley MT, Eng JJ, Teasell RW, Wolfe DL, Gruen RL

Source
National Trauma Research Institute, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia.

Abstract
Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.

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Acad Emerg Med. 2012 Jan;19(1):2-10. doi: 10.1111/j.1553-2712.2011.01247.x
Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center

Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, Wells GA

Source
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA. lpstat@aol.com

Abstract
OBJECTIVES:
This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with „clinically important“ brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15.
METHODS:
This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of „any traumatic intracranial injury“ on CT. Secondary outcomes included „clinically important brain injury“ on CT and need for neurosurgical intervention.
RESULTS:
Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had „clinically important“ brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For „clinically important“ brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention.
CONCLUSIONS:
In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

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J Neurotrauma. 2012 Apr 10;29(6):1090-5. Epub 2012 Apr 5
Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications

Schuss P, Vatter H, Marquardt G, Imöhl L, Ulrich CT, Seifert V, Güresir E

Source
Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany. patrick.schuss@med.uni-frankfurt.de

Abstract
Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors‘ institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.

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J Neurosurg. 2012 May;116(5):1106-13. Epub 2012 Mar 6
Is aggressive treatment of traumatic brain injury cost-effective?

Whitmore RG, Thawani JP, Grady MS, Levine JM, Sanborn MR, Stein SC

Source
Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. robert.whitmore@uphs.upenn.edu

Abstract
OBJECT:
The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.
METHODS:
A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with „routine care,“ in which Brain Trauma Foundation guidelines are not followed. A „comfort care“ category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.
RESULTS:
For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.
CONCLUSIONS:
When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

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J Bone Joint Surg Br. 2012 Feb;94(2):227-30
The effects of an injury to the brain on bone healing and callus formation in young adults with fractures of the femoral shaft

Yang TY, Wang TC, Tsai YH, Huang KC

Source
Chang Gung Memorial Hospital at Chiayi, Chang Gung University College of Medicine, Department of Orthopaedics, No. 6, West Sec., Chia-Pu Road, Pu-Tz City, Chia-Yi 613, Taiwan.

Abstract
In patients with traumatic brain injury and fractures of long bones, it is often clinically observed that the rate of bone healing and extent of callus formation are increased. However, the evidence has been unconvincing and an association between such an injury and enhanced fracture healing remains unclear. We performed a retrospective cohort study of 74 young adult patients with a mean age of 24.2 years (16 to 40) who sustained a femoral shaft fracture (AO/OTA type 32A or 32B) with or without a brain injury. All the fractures were treated with closed intramedullary nailing. The main outcome measures included the time required for bridging callus formation (BCF) and the mean callus thickness (MCT) at the final follow-up. Comparative analyses were made between the 20 patients with a brain injury and the 54 without brain injury. Subgroup comparisons were performed among the patients with a brain injury in terms of the severity of head injury, the types of intracranial haemorrhage and gender. Patients with a brain injury had an earlier appearance of BCF (p < 0.001) and a greater final MCT value (p < 0.001) than those without. There were no significant differences with respect to the time required for BCF and final MCT values in terms of the severity of head injury (p = 0.521 and p = 0.153, respectively), the types of intracranial haemorrhage (p = 0.308 and p = 0.189, respectively) and gender (p = 0.383 and p = 0.662, respectively). These results confirm that an injury to the brain may be associated with accelerated fracture healing and enhanced callus formation. However, the severity of the injury to the brain, the type of intracranial haemorrhage and gender were not statistically significant factors in predicting the rate of bone healing and extent of final callus formation.

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PLoS One. 2012;7(2):e32037. Epub 2012 Feb 23
Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)

Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R

Source
Divisions of Neurosurgery and Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. michael.fehlings@uhn.on.ca

Abstract
BACKGROUND:
There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.
METHODS:
We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.
FINDINGS:
A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).
CONCLUSIONS:
Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.

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Eur Spine J. 2012 Apr 29. [Epub ahead of print]
Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies

Papanastassiou ID, Phillips FM, Van Meirhaeghe J, Berenson JR, Andersson GB, Chung G, Small BJ, Aghayev K, Vrionis FD

Source
H. Lee Moffitt Cancer Center and Research Institute, NeuroOncology Program and Department of Neurosurgery and Orthopaedics, University of South Florida College of Medicine, 12902 Magnolia Drive, Tampa, FL, 33647, USA, jpapa73@yahoo.gr.

Abstract
PURPOSE:
To determine if differences in safety or efficacy exist between balloon kyphoplasty (BKP), vertebroplasty (VP) and non-surgical management (NSM) for the treatment of osteoporotic vertebral compression fractures (VCFs).
METHODS:
As of February 1, 2011, a PubMed search (key words: kyphoplasty, vertebroplasty) resulted in 1,587 articles out of which 27 met basic selection criteria (prospective multiple-arm studies with cohorts of ≥20 patients). This systematic review adheres to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.
RESULTS:
Pain reduction in both BKP (-5.07/10 points, P < 0.01) and VP (-4.55/10, P < 0.01) was superior to that for NSM (-2.17/10), while no difference was found between BKP/VP (P = 0.35). Subsequent fractures occurred more frequently in the NSM group (22 %) compared with VP (11 %, P = 0.04) and BKP (11 %, P = 0.01). BKP resulted in greater kyphosis reduction than VP (4.8º vs. 1.7°, P < 0.01). Quality of life (QOL) improvement showed superiority of BKP over VP (P = 0.04), along with a trend for disability improvement (P = 0.08). Cement extravasation was less frequent in the BKP (P = 0.01). Surgical intervention within the first 7 weeks yielded greater pain reduction than VCFs treated later.
CONCLUSIONS:
BKP/VP provided greater pain relief and fewer subsequent fractures than NSM in osteoporotic VCFs. BKP is marginally favored over VP in disability improvement, and significantly favored in QOL improvement. BKP had a lower risk of cement extravasation and resulted in greater kyphosis correction. Despite this analysis being restricted to Level I and II studies, significant heterogeneity suggests that the current literature is delivering inconsistent messages and further trials are needed to delineate confounding variables.

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J Trauma Acute Care Surg Volume 73, Number 1
Spine injuries in polytraumatized pediatric patients: Characteristics and experience from a Level I trauma center over two decades

Hofbauer M, Jaindl M, Höchtl LL, Ostermann RC, Kdolsky R, Aldrian S

Abstract
BACKGROUND:
Spine injuries, a common component in polytrauma, are relatively rare in pediatric patients. Previous studies mainly described injuries to the cervical region, whereas information of injury patterns to the thoracic and lumbosacral region lack in the current literature. The aim of this study was to determine the incidence and characteristics of polytraumatized children and associated spine injuries in different pediatric development ages.
METHODS:
A cohort reviewof all pediatric patients with the diagnosis of polytrauma and associated spine injury, admitted to a urban Level I trauma center, was conducted over an 18-year period from January 1992 to December 2010. Patients were stratified into four developmental age groups: infants/toddlers (age 0Y4 years), preschool/young children (age 5Y9 years), preadolescents (age 10Y14 years), and adolescents (age 15Y17 years). Demographics, clinical injury data, patterns of spine injuries, associated injuries, treatment, and outcome were abstracted and analyzed.
RESULTS:
From a database of 897 severely (Injury Severity Score Q 16) injured pediatric patients, 28 children met the inclusion criteria. The mean age was 12.7 years (range, 1.3Y16.7 years), and there were 18 males and 10 females. Younger children (age 0Y9 years) sustained more injuries to the upper spine region, whereas injuries to the lumbar region were only seen in adolescents. Nine (32%) patients received surgical treatment for spine fracture or subluxation, and 15 (54%) were treated by nonoperative means. Four patients (14%) received only palliative treatment due to medical futility. Overall, the most commonly associated injury was thoracic injury (89%) followed by traumatic brain injury (64%).
CONCLUSION:
The age-related anatomy and physiology predispose younger children to upper spine injuries in contrast to lower spine injuries seen in adolescents. Predictors of mortality include pathologic pupillary light reflex, high Injury Severity Score and Abbreviated Injury Scale score, and a low Glasgow Coma Scale score at admission. Thoracic injuries were the most common associated injuries followed by traumatic brain injury. (J Trauma Acute Care Surg. 2012;73: 156Y161.
LEVEL OF EVIDENCE:
Prognostic study, level III.
KEY WORDS:
Spine injuries; polytrauma; pediatric; outcome.

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Schulter
Arthroscopy. 2012 Jan;28(1):138-44. Epub 2011 Nov 30
Failed arthroscopic repair of a large reverse Hill-Sachs lesion using bone allograft and cannulated screws: a case report

Moroder P, Resch H, Tauber M

Source
Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria. philipp.moroder@pmu.ac.at

Abstract
Anterior impression fractures of the humeral head (reverse Hill-Sachs lesions) are typical concomitant bony injuries of posterior shoulder dislocations. When more than 20% of the humeral articulating surface is affected, surgical treatment is required, typically necessitating open surgery. Recently, cases of successful arthroscopic treatment of small reverse Hill-Sachs lesions involving less than 30% of the articulating surface have been reported. This article presents a case of a large reverse Hill-Sachs lesion affecting over 40% of the articulating surface that was treated arthroscopically by retrograde elevation, bone allografting, and cannulated screw insertion. The postoperative radiographic images showed a successful reduction of the impacted articulating surface of the humeral head. However, at 6 months‘ follow-up, the patient presented with pain and symptoms of a frozen shoulder. Cross-sectional imaging showed necrosis, partial absorption, and loss of reduction of the formerly elevated segment requiring humeral head replacement. This case report shows that even though the arthroscopic retrograde elevation of large reverse Hill-Sachs lesions is technically achievable, the outcome can be unsatisfactory because of the limitations in biologic healing response associated with large lesions of the humeral articulating surface.

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Am J Sports Med. 2012 Jul;40(7):1544-50. Epub 2012 May 10
Restoration of anterior glenoid bone defects in posttraumatic recurrent anterior shoulder instability using the j-bone graft shows anatomic graft remodeling

Moroder P, Hirzinger C, Lederer S, Matis N, Hitzl W, Tauber M, Resch H, Auffarth A

Source
Philipp Moroder, Department of Traumatology and Sports Injuries, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg, 5020 Austria. philipp.moroder@pmu.ac.at.

Abstract
BACKGROUND:
The J-bone graft technique has previously been reported for anatomic restoration of the bony glenoid surface in cases of posttraumatic recurrent anterior shoulder instability with significant glenoid bone loss.
PURPOSE:
To analyze the physiological remodeling process of the J-bone graft over time.
STUDY DESIGN:
Case series; Level of evidence, 4.
METHODS:
Thirty-one consecutive patients treated with anatomic glenoid restoration surgery using the J-bone graft for posttraumatic recurrent anterior shoulder instability with a significant bony glenoid defect were included in this study. Twenty patients received 3-dimensional computed tomography scans of the affected shoulder preoperatively, postoperatively, and at 1-year follow-up. On „en face“ views of the glenoid, the change over time of the glenoid diameter, glenoid area, and glenoid defect size in relation to a best-fit circle indicating 100% was measured.
RESULTS:
The average glenoid diameter increased from 81.0% preoperatively to 110.4% postoperatively (P < .001). At 1-year follow-up, the diameter had decreased significantly to 100.6% (P < .001), which is concordant to a theoretical perfect glenoid diameter of 100% (P = .73). The average glenoid surface area increased from 80.8% preoperatively to 110.0% postoperatively (P < .001). At 1-year follow-up, a decrease to 102.2% (P < .005) was measured, which again is close to a theoretical perfect glenoid surface area of 100% (P = .15). By applying the J-bone graft, the average missing surface area of the glenoid was reduced from 19.2% preoperatively to 3.9% postoperatively (P < .001). At 1-year follow-up, an average of 3.6% was calculated, indicating no statistically significant change over time (P = .90).
CONCLUSION:
Anatomic glenoid reconstructive surgery using the J-bone graft technique benefits from a physiological remodeling process, molding the bone graft closely into the original shape of an uninjured anterior glenoid rim. While parts of the graft lying inside the projected former surface area of the glenoid are preserved, the parts lying outside are resorbed over time, suggestive of strain-adapted graft remodeling.

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Arch Orthop Trauma Surg. 2012 Jul;132(7):985-92. Epub 2012 Mar 25
The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation

Brunner A, Resch H, Babst R, Kathrein S, Fierlbeck J, Niederberger A, Schmölz W

Source
Department for Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria, a-r.brunner@web.de.

Abstract
BACKGROUND:
The Humerusblock NG represents a new semi-rigid angular stable fixation device for minimally invasive stabilization of proximal humeral fractures. This study evaluates the function and stability of the Humerusblock NG and its biomechanical properties on the basis of two different fracture models under cyclic loading.
METHODS:
Six fresh frozen human humeri were tested in a dynamic shoulder joint abduction motion test bench, simulating abduction between 15° and 45°. A stable wedge fracture with intact medial hinge and an unstable fracture with 5-mm gap were loaded for 500 cycles. Radiological measurement of implant migration was performed.
RESULTS:
The stable fracture model showed a slow constant fracture settling. The unstable fracture model showed initial fracture settling with closure of the medial fracture gap during the first 20 cycles. Thereafter, a slow constant settling of the fracture was measured comparable to the stable fracture model. Maximum varus tilt was 3.17° for the stable and 3.68° for the unstable fracture pattern. Radiological analysis showed no change in the tip apex distance and a significant settling of the implants fixation pins in the unstable fracture model. None of the specimen failed during the testing.
CONCLUSION:
The Humerusblock NG allows for angular stable dynamic fixation of two-part proximal humeral fractures. It enables closure of the fracture gap and maintains fracture compression during loading, a concept already established in the stabilization of femoral neck fractures (dynamic hip screw). Clinical trials will be necessary to evaluate the value of this device in daily practice.
LEVEL OF EVIDENCE:
Basic science study.

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