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1.  Improvement of research quality in the fields of orthopaedics and trauma—a global perspective 
International Orthopaedics  2013;37(7):1205-1212.
The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon’s knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today’s “Cross Check Era”, too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.
doi:10.1007/s00264-013-1897-2
PMCID: PMC3685675  PMID: 23689761
2.  Prolonged operative time increases infection rate in tibial plateau fractures 
Injury  2012;44(2):249-252.
Background
Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as identify other surgical risk factors.
Methods
We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution’s level I trauma center during a recent five year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection.
Results
Mean operative time in the infection group was 2.8 hours vs. 2.2 hours in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p<0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p<0.001) as independent predictors of surgical site infection.
Conclusions
Operative times approaching three hours and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.
doi:10.1016/j.injury.2012.10.032
PMCID: PMC4034524  PMID: 23200030
Tibia; plateau; infection; operative time; fasciotomy
3.  Inducible Nitric Oxide Synthase Contributes to Immune Dysfunction following Trauma 
Shock (Augusta, Ga.)  2012;38(5):499-507.
Trauma results in a persistent depression in adaptive immunity which contributes to patient morbidity and mortality. This state of immune paralysis following trauma is characterized by a change in cell-mediated immunity, specifically a depression in T-cell function and a shift towards Th2 T-cell phenotype. Upregulation of iNOS is well-recognized after injury and contributes to the inflammatory response and organ damage early after trauma. However, it is unknown whether iNOS plays a role in adaptive immune dysfunction after trauma. This study utilized a murine model of severe peripheral tissue injury to show that iNOS is rapidly upregulated in macrophages and a (Gr-1hi-CD11bhi) MDSC subpopulation in the spleen. Through the use of iNOS knockout mice, a specific iNOS inhibitor and an NO scavenger this study demostrates that iNOS-derived NO is required for the depression in T lymphocyte proliferation, interferon-gamma and interleukin-2 production within the spleen at 48hr after trauma. These findings support the hypothesis that iNOS regulates immune suppression following trauma, and suggest that targeting the sustained production of NO by iNOS may attenuate post-traumatic immune depression.
doi:10.1097/SHK.0b013e31826c5afe
PMCID: PMC3475737  PMID: 23042189
Injury; T lymphocyte; Immunosuppression; MDSC; iNOS
4.  Radiographic changes in the operative treatment of acute acromioclavicular joint dislocation – tight rope technique vs. K-wire fixation 
Polish Journal of Radiology  2013;78(4):15-20.
Summary
Background
Operative treatment of higher degree acromioclavicular joint luxation is common. A new option is made available by the tight rope technique. It claims to provide adequate outcome with the use of a minimally invasive technique. First clinical studies justified its medical use, but the equivalence to established surgical methods remains unclear. We therefore analyzed radiographic data from patients that were treated with the tight rope system (TR) and compared them to those treated with K-wires (KW) fixation.
Material/Methods
Retrospective study with inclusion criteria: surgery for acromioclavicular joint luxation between 2004 and 2011, classified as Rockwood type III, no concomitant injury, first event injury. We compared pre- and post-operative X-rays with those taken at the end of treatment. Clinical data from follow-ups and radiographic data were evaluated. The main outcome variable was the remaining distance between the acromion and clavicle (ACD), as well as the coracoid process and clavicle (CCD).
Results
27 patients (TR: n=16; KW: n=11) with comparable demographics and injury severity were included. Surgery reduced ACD (TR: p=0.002; KW: p<0.001) and CCD (TR: p=0.001; KW: p=0.003). Heterotopic ossification or postoperative osteolysis was not significantly associated with either one of the procedures. Three patients (18.75%) in the TR group showed impaired wound healing, migrating K-wires were recorded in 2 patients (18.2%) and impingement syndrome occurred in 1 patient (9.1%) with K-wires. Posttraumatic arthritis was not seen. There was a loss of reduction in 2 cases within the TR-group (12.51%) and 1 in the KW-group (9.1%). At last follow up, ACD and CCD were wider in both groups compared to the healthy side.
Conclusions
This study shows that the Tight rope system is an effective alternative in the treatment of higher degree acromioclavicular luxation and comparable to the established methods.
doi:10.12659/PJR.889615
PMCID: PMC3908503  PMID: 24505220
radiographic changes; K-wire; tight rope
5.  Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures? 
Background
Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.
Questions/purposes
We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.
Methods
We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24–30 months).
Results
We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.
Conclusions
Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2268-9
PMCID: PMC3392400  PMID: 22311725
6.  Risk stratification by injury distribution in polytrauma patients – does the clavicular fracture play a role? 
Background
Thoracic and extremity injuries are common in polytraumatized patients. The clavicle limits the upper thoracic cage and connects the body and upper extremities. It is easy to examine and is visible on standard emergency room radiographs. We hypothesize that clavicular fracture in polytrauma patients indicates the presence of further injuries of the upper extremities, head, neck and thorax.
Material and methods
Retrospective study including patients admitted between 2008 and 2012 to a level-I trauma center. Inclusion criteria: ISS > 16, two or more injured body regions, clavicular fracture. Control group: patients admitted in 2011, ISS > 16, two or more injured body regions, no clavicular fracture. Patient information was obtained from the patients’ charts; evaluation of radiographic findings was performed; scoring was based on the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) AIS/ISS; data were analyzed using Pearson’s correlation and the Mann–Whitney U-test in SPSS (version 11.5.1); graphs were drawn using EXCEL®.
Results
Thirty-four patients with clavicular fracture (C+) and 40 without (C-) were included; the mean ISS was 25 (range 16–57), m = 70%, f = 30%; age 43.3 years (range 9–88); clavicular fractures were positively correlated with severe thoracic (p = 0.011, OR 4.5: KI 1.3–15.3), external (p < 0.001, OR 9.2: KI 2.7–30.9) and upper extremity injuries (p < 0.001, OR 33.2: KI 6.9–16.04 resp. p = 0.004, OR 12.5: KI 1.5–102.9). C + showed a lower head/neck AIS (p = 0.033), higher thorax AIS (p = 0.04), arm/shoulder AIS (p = 0.001) and external AIS (0.003) than C-. Mean hospital stay and ICU treatment time were longer in the C + group (p = 0.001 and p = 0.025 respectively).
Conclusion
A clavicular fracture can be diagnosed easily and may be used as a pointer for further thoracic and upper extremity injuries in polytrauma patients that might have been otherwise missed. Special attention should be paid on second and tertiary survey.
doi:10.1186/1754-9493-7-23
PMCID: PMC3704959  PMID: 23822875
7.  Operative treatment of acute acromioclavicular joint injuries graded Rockwood III and IV: risks and benefits in tight rope technique vs. k-wire fixation 
Background
Operative treatment of acromioclavicular joint injuries is recommended for higher degree dislocations. Recently a new option has become available with the minimally-invasive tight rope technique. Whereas clinical studies justify the medical use, risks and benefits remain unclear. Therefore, this study analyzed these facts associated with this procedure and compared them to K-wire fixation.
Material and Methods
A retrospective analysis was performed of patients surgically treated either with the TightRope™-technique (TR) or K-wires (KW) for a first event isolated Rockwood type III or higher acromioclavicular joint dislocation between 2004 and 2011. Timing for surgery, surgical duration, length of hospital stay, costs, complications and outpatient visits were recorded.
Results
41 patients were included (TR: n = 18; KW: n = 23) with comparable demographics and injury severity. A trend towards shorter operation time was seen in the TR group (TR: 64.3 ±19.8 min. vs. KW: 80.9 ±33.7 min., n.s.) A tendency for lower total operation theater costs was seen in the TR group (TR: 474 ±436.5€ vs. KW: 749.1 ±31.2€, n.s.). Patients from the TR group left hospital earlier (TR: 2 ±1d vs. KW: 3.6 ±1.8d, p = 0.002). Severe complications (i.e. a fracture of the clavicle or nerve damage) occurred in neither of the groups. Early loss of reduction (n = 1) and impaired wound healing (n = 2) was seen in the TR group. Migrating K-wires (n = 4), loss of reduction (n = 1) and impingement syndrome (n = 1) were recorded in the KW group.
Conclusion
Usage of the tight rope technique offered advantages, such as being a safe minimally-invasive technique and showed a tendency towards shorter operation time, and lower physician- and total operation and theater costs. Material costs were significantly higher for this device but patients were discharged earlier. The influence of different clinical long-term results on the financial outcome needs to be evaluated in further studies.
doi:10.1186/1754-9493-7-18
PMCID: PMC3681720  PMID: 23721404
Tight rope technique; K-wires; Costs; Acromioclavicular joint dislocation; Reconstruction; Surgery; Comparison; Analysis
8.  Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial 
European Spine Journal  2012;21(5):992-998.
Purpose
To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students.
Methods
In 2007–2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE).
Results
Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts.
Conclusions
The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.
doi:10.1007/s00586-011-2140-8
PMCID: PMC3337919  PMID: 22223196
Peer teaching; Gender differences; Randomised controlled trial; Complex motor skills; Spinal manipulative therapy
9.  Predictors of poor outcome after both column acetabular fractures: a 30-year retrospective cohort study 
Background and Purpose
Acetabular fractures are often combined with associated injuries to the hip joint. Some of these associated injuries seem to be responsible for poor long-term results and these injuries seem to affect the outcome independent of the quality of the acetabular reduction. The aim of our study was to analyze the outcome of both column acetabular fractures and the influence of osseous cofactors such as initial fracture displacement, hip dislocation, femoral head lesions and injuries of the acetabular joint surface.
Methods
A retrospective cohort study in patients with both column acetabular fractures treated over a 30 year period was performed. Patients with a follow-up of more than two years were invited for a clinical and radiological examination. Displacement was analyzed on initial and postoperative radiographs. Contusion and impaction of the femoral head was grouped. Injuries of the acetabular joint surface consisting of impaction, contusion and comminution were recorded. The Merle d’Aubigné Score was documented and radiographs were analysed for arthritis (Helfet classification), femoral head avascular necrosis (Ficat/Arlet classification) and heterotopic ossifications (Brooker classification).
Results
115 patients were included in the follow up examination. Anatomic reduction (malreduction ≤ 1mm) was associated with a significantly better clinical outcome than nonanatomical reduction (p = 0.001). Initial displacement of more than 10mm (p = 0.031) and initial intraarticular fragments (p = 0.041) were associated with worse outcome. Other associated injuries, such as the presence of a femoral head dislocation, femoral head injuries and injuries to the acetabular joint surface showed no significant difference in outcome individually, but in fractures with more than two associated local injuries the risk for joint degeneration was significant higher (p < 0.001) than in cases with less than two of them.
In the subgroup of anatomically reconstructed fractures no significant influence of the analyzed cofactors could be observed.
Conclusion
Anatomical reduction appears to be an important parameter for a good clinical outcome in patients with both column acetabular fractures. Additional fracture characteristics such as the initial displacement and intraarticular fragments seem to influence the results. Patients should also be advised that both column acetabular fractures with more than two additional associated factors have a significantly higher risk of joint degeneration.
doi:10.1186/1754-9493-7-9
PMCID: PMC3606597  PMID: 23510122
Both column acetabular fractures; Outcome prediction; Long term results
10.  The role of stem cells in fracture healing and nonunion 
International Orthopaedics  2011;35(11):1587-1597.
Nonunion and large bone defects present a therapeutic challenge to the surgeon and are often associated with significant morbidity. These defects are expensive to both the health care system and society. However, several surgical procedures have been developed to maximise patient satisfaction and minimise health-care-associated and socioeconomic costs. Integrating recent evidence into the diamond concept leads to one simple conclusion that not only provides us with answers to the “open questions” but also simplifies our entire understanding of bone healing. It has been shown that a combination of neo-osteogenesis and neovascularisation will restore tissue deficits, and that the optimal approach includes a biomaterial scaffold, cell biology techniques, a growth factor and optimisation of the mechanical environment. Further prospective, controlled, randomised clinical studies will determine the effectiveness and economic benefits of treatment with mesenchymal stem cells, not in comparison to other conventional surgical approaches but in direct conjunction with them.
doi:10.1007/s00264-011-1338-z
PMCID: PMC3193959  PMID: 21863226
11.  Outcome after thoracoscopic ventral stabilisation of thoracic and lumbar spine fractures 
Background and Purpose
Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery.
Methods
We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI).
Results
Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups.
Interpretation
The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.
doi:10.1186/1752-2897-6-10
PMCID: PMC3489793  PMID: 23072274
Spine; Thoracoscopic surgery; Thoracolumbar fractures; Outcome
12.  A 72-year-old patient with bilateral Maisonneuve fractures 
Clinics and Practice  2012;2(3):e72.
Maisonneuve fractures result from a disruption of the medial ankle structures and a proximal fibular fracture. Patient complaints can be misleading and there is a significant rate of delayed diagnosed injuries. We present a case of bilateral Maisonneuve fractures after a fall due to a syncopal collapse. A precise clinical examination led to this rare diagnosis. The injuries were treated with syndesmotic screw fixation, removal of hardware followed after 6 weeks. The patient was asymptomatic at three-months follow up. Patients with bilateral injuries undergoing standard surgical treatment can gain full recovery, but high suspicion in clinical examination is needed to detect this uncommon bilateral injury.
doi:10.4081/cp.2012.e72
PMCID: PMC3981324  PMID: 24765471
maisonneuve fracture; bilateral; ankle injury.
13.  Novel Model of Peripheral Tissue Trauma Induced Inflammation and Gastrointestinal Dysmotility 
Background
Trauma is a leading cause of death and although the gut is recognized as the “motor” of post-traumatic systemic inflammatory response syndrome and multiple organ failure, studies on the gastrointestinal tract are few. Our objectives were to create a precisely controllable tissue injury model in which gastrointestinal motility, systemic inflammation and wound fluid can be analyzed.
Methods
A non-narcotic murine trauma model was developed by the subcutaneous dorsal trans-implantation of a devitalized donor syngeneic harvested tissue-bone matrix (TBX), which was precisely adjusted to % total body weight and studied after 21 hrs. Gastrointestinal transit histograms were plotted after the oral administration of non-digestible FITC-dextran and geometric centers calculated. Organ bath evaluated jejunal circular muscle contractility. Multiplex electrochemiluminescence measurements of serum and TBX wound fluid inflammatory mediators were performed.
Key Results
Increasing TBX amounts progressively delayed transit, whereas TBX heat denaturation or decellularization prevented ileus and death. In the TBX17.5% model, jejunal muscle contractility was suppressed and a systemic inflammatory response developed as significant serum elevations in IL-6, keratinocyte cytokine and IL-10 compared to sham. Additionally, inflammatory responses within the wound fluid showed elevated levels of preformed IL-1β and TNF-α, whereas, 21 hours after implantation IL-1β, IL-6 and keratinocyte cytokine were significantly increased in the wound.
Conclusions & Inferences
A novel donor tissue-bone matrix trauma model was developed that is precisely adjustable and recapitulates important clinical phenomena. The non-narcotic model demonstrated that increasing tissue injury progressively caused ileus, initiated a systemic inflammatory response and developed inflammatory changes within the wound.
doi:10.1111/j.1365-2982.2011.01675.x
PMCID: PMC3105173  PMID: 21303433
trauma; inflammation; ileus; tissue injury; wound fluid; gastrointestinal motility
14.  Measuring depression and PTSD after trauma: Common scales and checklists 
Injury  2011;42(3):288-300.
Traumatic injury is an important public health problem secondary to high levels of mortality and morbidity. Injured survivors face several physical, emotional, and financial repercussions that can significantly impact their lives as well as their family. Depression and posttraumatic stress disorder (PTSD) are the most common psychiatric sequelae associated with traumatic injury. Factors affecting the prevalence of these psychiatric symptoms include: concomitant TBI, the timing of assessment of depression and PTSD, the type of injury, premorbid, sociodemographic, and cultural factors, and co-morbid medical conditions and medication side effects. The appropriate assessment of depression and PTSD is critical to an understanding of the potential consequences of these disorders as well as the development of appropriate behavioral and pharmacological treatments. The reliability and validity of screening instruments and structured clinical interviews used to assess depression and PTSD must be considered. Common self-report instruments and structured clinical interviews used to assess depression and PTSD and their reliability and validity are described. Future changes in diagnostic criteria for depression and PTSD and recent initiatives by the National Institute of Health regarding patient-reported outcomes may result in new methods of assessing these psychiatric sequelae of traumatic injury.
doi:10.1016/j.injury.2010.11.045
PMCID: PMC3295610  PMID: 21216400
15.  Inhalative IL-10 Attenuates Pulmonary Inflammation following Hemorrhagic Shock without Major Alterations of the Systemic Inflammatory Response 
Mediators of Inflammation  2011;2012:512974.
Several studies report immunomodulatory effects of endogenous IL-10 after trauma. The present study investigates the effect of inhalative IL-10 administration on systemic and pulmonary inflammation in hemorrhagic shock. Male C57/BL6 mice (8 animals per group) were subjected to pressure-controlled hemorrhagic shock for 1.5 hrs followed by resuscitation and inhalative administration of either 50 μL PBS (Shock group) or 50 μg/kg recombinant mouse IL-10 dissolved in 50 μL PBS (Shock + IL-10 group). Animals were sacrificed after 4.5 hrs of recovery and serum IL-6, IL-10, KC, and MCP-1 concentrations were measured with ELISA kits. Acute pulmonary inflammation was assessed by pulmonary myeloperoxidase (MPO) activity and pulmonary H&E histopathology. Inhalative IL-10 administration decreased pulmonary inflammation without altering the systemic concentrations of IL-6, IL-10, and KC. Serum MCP-1 levels were significantly reduced following inhalative IL-10 administration. These findings suggest that inhalative IL-10 administration may modulate the pulmonary microenvironment without major alterations of the systemic inflammatory response, thus minimizing the potential susceptibility to infection and sepsis.
doi:10.1155/2012/512974
PMCID: PMC3199193  PMID: 22046081
16.  Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective 
Background
With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.
Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.
Discussion
The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.
In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.
Summary
It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.
doi:10.1186/1754-9493-5-23
PMCID: PMC3196685  PMID: 21943304
Global perspective; Future trends and needs; Algorithms of patient care; Quality assurance in Patient care; Registries
17.  Caspase-1 Is Hepatoprotective during Trauma and Hemorrhagic Shock by Reducing Liver Injury and Inflammation 
Molecular Medicine  2011;17(9-10):1031-1038.
Adaptive immune responses are induced in liver after major stresses such as hemorrhagic shock (HS) and trauma. There is emerging evidence that the inflammasome, the multiprotein platform that induces caspase-1 activation and promotes interleukin (IL)-1β and IL-18 processing, is activated in response to cellular oxidative stress, such as after hypoxia, ischemia and HS. Additionally, damage-associated molecular patterns, such as those released after injury, have been shown to activate the inflammasome and caspase-1 through the NOD-like receptor (NLR) NLRP3. However, the role of the inflammasome in organ injury after HS and trauma is unknown. We therefore investigated inflammatory responses and end-organ injury in wild-type (WT) and caspase-1−/−mice in our model of HS with bilateral femur fracture (HS/BFF). We found that caspase-1−/− mice had higher levels of systemic inflammatory cytokines than WT mice. This result corresponded to higher levels of liver damage, cell death and neutrophil influx in caspase-1−/− liver compared with WT, although there was no difference in lung damage between experimental groups. To determine if hepatoprotection also depended on NLRP3, we subjected NLRP3−/− mice to HS/BFF, but found inflammatory responses and liver damage in these mice was similar to WT. Hepatoprotection was also not due to caspase-1–dependent cytokines, IL-1β and IL-18. Altogether, these data suggest that caspase-1 is hepatoprotective, in part through regulation of cell death pathways in the liver after major trauma, and that caspase-1 activation after HS/BFF does not depend on NLRP3. These findings may have implications for the treatment of trauma patients and may lead to progress in prevention or treatment of multiple organ failure (MOF).
doi:10.2119/molmed.2011.00015
PMCID: PMC3188860  PMID: 21666957
18.  Socio-economic outcome after blunt orthopaedic trauma: Implications on injury prevention 
Background
Several large studies have identified factors associated with long-term outcome after orthopaedic injuries. However, long-term social and economic implications have not been published so far. The aim of this investigation is to study the long-term socio-economic consequences of patients sustaining severe trauma.
Methods
Patients treated at a level one trauma center were invited for a follow-up (at least 10 years) examination. There were 637 patients who responded and were examined. Inclusion criteria included injury severity score (ISS) ≥ 16 points, presence of lower and upper extremity fractures, and age between 3 and 60 years. Exclusion criteria included the presence of amputations and paraplegia. The socio-economic outcome was evaluated in three age groups: group I (< 18 years), group II (19 - 50 years), and group III (> 50 years). The following parameters were analyzed using a standardized questionnaire: financial losses, net income losses, pension precaution losses, need for a bank loan, and the decrease in number of friends.
Results
510 patients matched all study criteria, and breakdown of groups were as follows: 140 patients in group I, 341 patients in group II, and 29 patients in group III. Financial losses were reported in all age groups (20%-44%). Younger patients (group I) were associated with less income losses when compared with other groups (p < 0.05). Financial deterioration was more frequently reported in age group II (p < 0.05). Social consequences (number of friends decreased) were predominantly stated in patients younger than 18 years old (p < 0.05).
Conclusions
Economic consequences are reported by polytraumatized patients even ten or more years after injury. Financial losses appear to be common in patients between 19 and 50 years. In contrast, social deprivation appears to be most pronounced in the younger age groups. Early socio-economic support and measures of injury prevention should focus on these specific age groups.
doi:10.1186/1754-9493-5-9
PMCID: PMC3105957  PMID: 21569475
19.  A civilian perspective on ballistic trauma and gunshot injuries 
Background
Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities.
Methods
A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed.
Results
Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.
With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference.
Conclusion
The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.
doi:10.1186/1757-7241-18-35
PMCID: PMC2898680  PMID: 20565804
20.  Case Report: The Prone Reduction of a Sacroiliac Disruption with a Pelvic C-clamp 
The pelvic C-clamp traditionally is reserved for the temporizing stabilization of posterior ring injuries and reportedly has assisted in closed reduction of sacroiliac diastases, for patients who are in the supine position. We report a patient with a severely displaced Zone II sacral fracture and associated acetabular fracture who initially underwent fixation of the acetabulum in the prone position. By using the pelvic C-clamp as a tool for successfully reducing the sacrum, definitive closed fixation of the pelvic wing subsequently was performed without having to reposition the patient. In this case report, we review the literature on this device and for alternative reduction maneuvers for disrupted sacral injuries. The C-clamp may be a useful adjunct in select cases to facilitate closed reduction of sacral or sacroiliac joint disruptions, as may particularly apply in cases of severe displacement or when a reduction is hampered by obesity.
doi:10.1007/s11999-008-0508-9
PMCID: PMC2650064  PMID: 18810568
21.  Risk of symptomatic heterotopic ossification following plate osteosynthesis in multiple trauma patients: an analysis in a level-1 trauma centre 
Background
Symptomatic heterotopic ossification (HO) in multiple trauma patients may lead to follow up surgery, furthermore the long-term outcome can be restricted. Knowledge of the effect of surgical treatment on formation of symptomatic heterotopic ossification in polytrauma is sparse. Therefore, we test the effects of surgical treatment (plate osteosynthesis or intramedullary nailing) on the formation of heterotopic ossification in the multiple trauma patient.
Methods
We retrospectively analysed prospectively documented data of blunt multiple trauma patients with long bone fractures which were treated at our level-1 trauma centre between 1997 and 2005. Patients were distributed to 2 groups: Patients treated by intramedullary nails (group IMN) or plate osteosynthesis (group PLATE) were compared. The expression and extension of symptomatic heterotopic ossifications on 3-6 months follow-up x-rays in antero-posterior (ap) and lateral views were classified radiologically and the maximum expansion was measured in millimeter (mm). Additionally, ventilation time, prophylactic medication like indomethacine and incidence and correlation of head injuries were analysed.
Results
101 patients were included in our study, 79 men and 22 women. The fractures were treated by intramedullary nails (group IMN n = 50) or plate osteosynthesis (group PLATE n = 51). Significantly higher radiologic ossification classes were detected in group PLATE (2.9 ± 1.3) as compared to IMN (2.2 ± 1.1; p = 0.013). HO size in mm ap and lateral showed a tendency towards larger HOs in the PLATE group. Additionally PLATE group showed a higher rate of articular fractures (63% vs. 28% in IMN) while IMN demonstrated a higher rate of diaphyseal fractures (72% vs. 37% in PLATE; p = 0.003). Ventilation time, indomethacine and incidence of head injuries showed no significant difference between groups.
Conclusion
Fracture care with plate osteosynthesis in polytrauma patients is associated with larger formations of symptomatic heterotopic ossifications (HO) while intramedullary nailing was associated with a higher rate of remote HO. For future fracture care of multiply injured patients these facts may be considered by the responsible surgeon.
doi:10.1186/1757-7241-17-55
PMCID: PMC2765935  PMID: 19825174
22.  Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review 
Background
Work-hour limitations have been implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003 in order to minimize fatigue related medical adverse events. The effects of this regulation are still under intense debate. In this literature review, data of effects of limited work-hours on the quality of life, surgical education, and patient care was summarized, focusing on surgical subspecialities.
Methods
Studies that assessed the effects of the work-hour regulation published following the implementation of ACGME guidelines (2003) were searched using PubMed database. The following search modules were selected: work-hours, 80-hour work week, quality of life, work satisfaction, surgical education, residency training, patient care, continuity of care. Publications were included if they were completed in the United States and covered the subject of our review. Manuscrips were analysed to identify authors, year of publication, type of study, number of participants, and the main outcomes.
Review Findings
Twenty-one articles met the inclusion criteria. Studies demonstrate that the residents quality of life has improved. The effects on surgical education are still unclear due to inconsistency in studies. Furthermore, according to several objective studies there were no changes in mortality and morbidity following the implementation.
Conclusion
Further studies are necessary addressing the effects of surgical education and studying the objective methods to assess the technical skill and procedural competence of surgeons. In addition, patient surveys analysing their satisfaction and concerns can contribute to recent discussion, as well.
doi:10.1186/1754-9493-3-3
PMCID: PMC2654871  PMID: 19232105
23.  Femoral Nailing-related Coagulopathy Determined by First-hit Magnitude 
We asked whether coagulopathy worsened during femoral intramedullary nailing in the presence of lung contusion and hemorrhagic shock and whether reamed or unreamed nailing influenced these results. In 30 Merino sheep, we induced hemorrhagic shock and/or standardized lung contusion followed by femoral nailing. Six groups of five each were assigned as follows: thoracotomy control groups treated with reamed or unreamed nailing, lung contusion groups treated with reamed or unreamed nailing, and shock and lung contusion groups treated with reamed or unreamed nailing. After lung contusion alone (first hit), the serum values of antithrombin III, factor V, and fibrinogen were considerably altered after reamed and unreamed femoral nailing (second hit) 4 hours postoperatively. In the lung contusion and shock groups, we found a substantial reduction for all serum coagulative parameters between baseline and fixation after reamed and unreamed nailing. The magnitude of the first hit is increased if hemorrhagic shock is added to a lung contusion determined by hemostatic reactions. The magnitude of the injury appears equally important as the type of subsequent surgery and should be considered in planning for fracture fixation in patients at high risk for complications.
doi:10.1007/s11999-007-0066-6
PMCID: PMC2505120  PMID: 18196434
24.  Missed injuries in trauma patients: A literature review 
Background
Overlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries.
Methods
Manuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980–1990), (n = 6, 1990–2000), and (n = 9, 2000-Present).
Results
We found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade.
Conclusion
The lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.
doi:10.1186/1754-9493-2-20
PMCID: PMC2553050  PMID: 18721480
25.  Selective Roles for Toll-Like Receptors 2, 4 and 9 in the Systemic Inflammation and Immune Dysfunction Following Peripheral Tissue Injury 
Background
Toll-like receptors (TLRs) detect endogenous ligands released after trauma and contribute to the proinflammatory response to injury. Post-traumatic mortality correlates with the extent of the immuno-inflammatory response to injury which is comprised of a complex regulation of innate and adaptive immune responses. Although TLRs are known to modulate innate immune responses, their role in the suppression of lymphocyte responses following traumatic tissue injury is unclear.
Methods
This study used a murine model of severe peripheral tissue injury, involving muscle crush injury and injection of fracture components, to evaluate the roles of TLR2, 4 and 9 in the early and delayed immuno-inflammatory phenotype. Post-traumatic immune dysfunction was measured in our trauma model using the following parameters: ex-vivo splenocyte proliferation, Th1 cytokine release and iNOS induction within splenic myeloid-derived suppressor cells (MDSC). Systemic inflammation and liver damage were determined by circulating interleukin-6 levels and hepatocellular injury.
Results
Suppression of splenocyte responses after injury was dependent on TLR4 and 9 signaling as was post-traumatic iNOS upregulation in splenic MDSC. TLR2 was found to have only a partial role through contribution to inhibition of splenocyte proliferation. This study also reveals the involvement of TLR2 and 4 in the initial systemic inflammatory response to traumatic tissue injury, however, this response was found to be TLR9-independent.
Conclusions
These findings demonstrate the previously unidentified role of TLR2, 4 and 9 in the T-cell associated immune dysfunction following traumatic tissue injury. Importantly, this study also illustrates that TLRs play differing and selective roles in both the initial proinflammatory response and adaptive immune response after trauma. Furthermore, the results in the TLR9-deficient mice establishes that the upregulation of early pro-inflammatory markers do not always correlate with the extent of sustained immune dysfunction. This suggests potential for targeted therapies that could limit the immune dysfunction through selective inhibition of receptor function following injury.
doi:10.1097/TA.0b013e3182905ed2
PMCID: PMC3670589  PMID: 23694872
Injury; Toll-like receptor; lymphocyte; MDSC; immune dysfunction

Results 1-25 (28)