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1.  The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure 
Lower extremity acute compartment syndrome after gynecologic surgery in the lithotomy position is a rare, yet potentially devastating complication. A high level of suspicion is paramount for early recognition and mitigation of acute compartment syndrome originating from prolonged surgery in lithotomy position.
Case presentation
A 23-year-old female, gravida 1, para 0, underwent a laparoscopic salpingectomy for a ruptured ectopic pregnancy. Surgical time was 90 min. Postoperatively, the patient developed acute compartment syndrome of both legs necessitating emergent bilateral four-compartment fasciotomies, with repeated returns to the operating room for 2nd look procedures and delayed wound closures. The patient regained full function within 3 months and returned to an unrestricted baseline activity level.
Technical diligence in applying a lithotomy position is paramount for preventing postoperative lower extremity compartment syndrome. A high level of suspicion for this severe complication in conjunction with early recognition and immediate surgical management can mitigate long-term adverse sequelae and improve postoperative outcomes.
PMCID: PMC4960854  PMID: 27462369
Compartment syndrome; Fasciotomy; Lithotomy position; Surgical complication; Adverse event; Patient safety
2.  History of pelvic fracture management: a review 
High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore’s seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20th century, and provided the basis to current classification-guided treatment and life-saving “damage control” concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).
PMCID: PMC4855448  PMID: 27148396
Pelvic fracture; History; Management strategies; Retroperitoneal bleeding; Damage control
3.  Patient Safety in Surgery reviewer acknowledgement 2015 
Contributing reviewers
The editors of Patient Safety in Surgery would like to thank all of our reviewers who have contributed to the journal in Volume 9 (2015).
PMCID: PMC4790059  PMID: 26977175
4.  How to review a surgical paper: a guide for junior referees 
BMC Medicine  2016;14:29.
Reviewing a surgical manuscript is not an easy task, and there is no formal training available for young referees in the early stage of their careers. Accepting a peer review assignment represents a personal honor for the invited referee and a fundamental ethical responsibility towards the scientific community. Designated reviewers must be accomplished and knowledgeable in the area of the respective topic of investigation. More importantly, they must be aware and cognizant about the cardinal ethical responsibility and stewardship for ensuring the preservation of scientific knowledge of unbiased and unquestionable accuracy in the published literature. Accepting a review assignment should never be taken lightly or considered a simple task, regardless of the reviewer’s level of seniority and expertise. Indeed, there are multiple challenges, difficulties, and ‘hidden dangers’ that jeopardize the completion of a high-quality review, particularly in the hands of less experienced or novice reviewers. The present article was designed to provide a brief, concise, and practical guide on how to review manuscripts for the ‘junior referee’ in the field of surgery.
PMCID: PMC4753042  PMID: 26874834
Evidence-based medicine; Qualified referee; Peer-review process; Publication bias
6.  Osteoporosis and the orthopaedic surgeon: basic concepts for successful co-management of patients’ bone health 
International Orthopaedics  2014;38(8):1731-1738.
Osteoporosis has been recognised as a public health concern for at least three decades but it has been relatively recent that the push has been for orthopaedic surgeons to take a more active role in the diagnosis and treatment of patients with decreased bone mineral density (BMD). Most often these patients are encountered after they have suffered a fracture making secondary prevention the area where orthopaedists may exert the greatest influence on patient care. The purpose of this article is to provide a succinct framework for the diagnosis and treatment of patients with decreased BMD. Patients are deemed to have decreased BMD if they have suffered a fragility fracture, a fracture caused by a low-energy traumatic event. These patients are often encountered in the emergency department and admitted for further treatment of their fractures or recommended for follow-up in the clinic. Regardless of treatment course these are opportunities for the orthopaedic surgeon to intervene in the osteoporotic disease process and positively affect a patient’s bone health. This article compiles the available literature on osteoporosis and presents it succinctly with the incorporation of both a diagnosis algorithm and treatment profile table. With the use of these two tools, orthopaedic surgeons everywhere should be able to take a more active role in their patients’ bone health.
PMCID: PMC4115108  PMID: 24652422
Osteoporosis; Orthopaedic surgeon; Early management; Screening; Fragility fracture
7.  Peroxisome Proliferator-Activated Receptors: “Key” Regulators of Neuroinflammation after Traumatic Brain Injury 
PPAR Research  2008;2008:538141.
Traumatic brain injury is characterized by neuroinflammatory pathological sequelae which contribute to brain edema and delayed neuronal cell death. Until present, no specific pharmacological compound has been found, which attenuates these pathophysiological events and improves the outcome after head injury. Recent experimental studies suggest that targeting peroxisome proliferator-activated receptors (PPARs) may represent a new anti-inflammatory therapeutic concept for traumatic brain injury. PPARs are “key” transcription factors which inhibit NFκB activity and downstream transcription products, such as proinflammatory and proapoptotic cytokines. The present review outlines our current understanding of PPAR-mediated neuroprotective mechanisms in the injured brain and discusses potential future anti-inflammatory strategies for head-injured patients, with an emphasis on the putative beneficial combination therapy of synthetic cannabinoids (e.g., dexanabinol) with PPARα agonists (e.g., fenofibrate).
PMCID: PMC2276625  PMID: 18382619
8.  Challenging the Role of Adaptive Immunity in Neurotrauma: Rag1−/− Mice Lacking Mature B and T Cells Do Not Show Neuroprotection after Closed Head Injury 
Journal of Neurotrauma  2012;29(6):1233-1242.
The role of adaptive immunity in contributing to post-traumatic neuroinflammation and neuropathology after head injury remains largely unexplored. The present study was designed to investigate the pathophysiological sequelae of closed head injury in Rag1−/− mice devoid of mature B and T lymphocytes. C57BL/6 wild-type and Rag1−/− mice were subjected to experimental closed head injury, using a standardized weight-drop device. Outcome parameters consisted of neurological scoring, quantification of blood–brain barrier (BBB) function, measurement of inflammatory markers and mediators of apoptosis in serum and brain tissue, and assessment of neuronal cell death, astrogliosis, and tissue destruction. There was no difference between wild-type and Rag1−/− mice with regard to injury severity and neurological impairment for up to 7 days after head injury. The extent of BBB dysfunction was in a similar range for both groups. Quantification of complement activation fragments in serum revealed significantly attenuated C3a levels in Rag1−/− mice compared to wild-type animals. In contrast, the levels of pro- and anti-inflammatory cytokines and pro-apoptotic and anti-apoptotic mediators remained in a similar range for both groups, and the histological analysis of brain sections did not reveal a difference in reactive astrogliosis, tissue destruction, and neuronal cell death in Rag1−/− compared to wild-type mice. These findings suggest that adaptive immunity is not of crucial importance for initiating and sustaining the inflammatory neuropathology after closed head injury. The attenuated extent of post-traumatic complement activation seen in Rag1−/− mice implies a cross-talk between innate and adaptive immune responses, which requires further investigation in future studies.
PMCID: PMC3325549  PMID: 22335783
adaptive immunity; closed head injury; complement system; natural antibodies; Rag1
9.  Complement in Human Disease 
PMCID: PMC3562600  PMID: 23401704
10.  Patient Safety in Surgery Reviewer acknowledgement 2014 
Contributing reviewers
The Editors of Patient Safety in Surgery would like to thank all our reviewers who have contributed to the journal in Volume 8 (2014).
PMCID: PMC4369068  PMID: 25798195
11.  New Insights into the Role of Peroxisome Proliferator-Activated Receptors in Regulating the Inflammatory Response after Tissue Injury 
PPAR Research  2012;2012:728461.
Major trauma results in a strong inflammatory response in injured tissue. This posttraumatic hyperinflammation has been implied in the adverse events leading to a breakdown of host defense mechanisms and ultimately to delayed organ failure. Ligands to peroxisome proliferator-activated receptors (PPARs) have recently been identified as potent modulators of inflammation in various acute and chronic inflammatory conditions. The main mechanism of action mediated by ligand binding to PPARs is the inhibition of the nuclear transcription factor NF-κB, leading to downregulation of downstream gene transcription, such as for genes encoding proinflammatory cytokines. Pharmacological PPAR agonists exert strong anti-inflammatory properties in various animal models of tissue injury, including central nervous system trauma, ischemia/reperfusion injury, sepsis, and shock. In addition, PPAR agonists have been shown to induce wound healing process after tissue trauma. The present review was designed to provide an up-to-date overview on the current understanding of the role of PPARs in the pathophysiology of the inflammatory response after major trauma. Therapeutic options for using recombinant PPAR agonists as pharmacological agents in the management of posttraumatic inflammation will be discussed.
PMCID: PMC3317007  PMID: 22481914
12.  High-Energy Proximal Femur Fractures in Geriatric Patients 
Background: There is limited information in the literature on the outcomes and complications in elderly patients who sustain high-energy hip fractures. As the population ages, the incidence of high-energy geriatric hip fractures is expected to increase. The purpose of this study was to analyze the outcomes and complications in patients aged 65 years or older, who sustained a high-energy proximal femur fracture. Methods: Retrospective review of a prospective trauma database from January 2000 to April 2011 at a single US academic level-1 trauma center. Inclusion criteria consisted of all patients of age 65 years or older, who sustained a proximal femur fracture related to a high-energy trauma mechanism. Details concerning injury, acute treatment, and clinical course and outcome were obtained from medical records and radiographs. Results: We identified 509 proximal femur fractures in patients older than 65 years of age, of which 32 (6.3%) were related to a high-energy trauma mechanism. The mean age in the study group was 72.2 years (range 65-87), with a mean injury severity score of 20 points (range 9-57). Three patients died before discharge (9.4%), and 22 of 32 patients sustained at least one complication (68.8%). Blunt chest trauma represented the most frequently associated injury, and the main root cause of pulmonary complications. The patients' age and comorbidities did not significantly correlate with the rate of complications and the 1-year mortality. Conclusions: High-energy proximal femur fractures in elderly patients are not very common and are associated with a low in-hospital mortality rate of less than 10%, despite high rate of complications of nearly 70%. This selective cohort of patients requires a particular attention to respiratory management due to the high incidence of associated chest trauma.
PMCID: PMC3609398  PMID: 23569690
geriatric trauma; trauma surgery; fragility fractures; osteoporosis; anesthesia
13.  Peer review for biomedical publications: we can improve the system 
BMC Medicine  2014;12:179.
The lack of formal training programs for peer reviewers places the scientific quality of biomedical publications at risk, as the introduction of ‘hidden’ bias may not be easily recognized by the reader. The exponential increase in the number of manuscripts submitted for publication worldwide, estimated in the millions annually, overburdens the capability of available qualified referees. Indeed, the workload imposed on individual reviewers appears to be reaching a ‘breaking point’ that may no longer be sustainable. Some journals have made efforts to improve peer review via structured guidelines, courses for referees, and employing biostatisticians to ensure appropriate study design and analyses. Further strategies designed to incentivize and reward peer review work include journals providing continuing medical education (CME) credits to individual referees by defined criteria for timely and high-quality evaluations. Alternative options to supplement the current peer review process consist of ‘post-publication peer review,’ ‘decoupled peer review,’ ‘collaborative peer review,’ and ‘portable peer review’. This article outlines the shortcomings and flaws in the current peer review system and discusses new innovative options on the horizon.
See related article:
Electronic supplementary material
The online version of this article (doi:10.1186/s12916-014-0179-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4177268  PMID: 25270270
Peer review; Biomedical publications; Evidence-based medicine; Randomized controlled trials
15.  Deficiency of complement receptors CR2/CR1 in Cr2-/- mice reduces the extent of secondary brain damage after closed head injury 
Complement activation at the C3 convertase level has been associated with acute neuroinflammation and secondary brain injury after severe head trauma. The present study was designed to test the hypothesis that Cr2 -/- mice, which lack the receptors CR2/CD21 and CR1/CD35 for complement C3-derived activation fragments, are protected from adverse sequelae of experimental closed head injury. Adult wild-type mice and Cr2 -/- mice on a C57BL/6 genetic background were subjected to focal closed head injury using a standardized weight-drop device. Head-injured Cr2 -/- mice showed significantly improved neurological outcomes for up to 72 hours after trauma and a significantly decreased post-injury mortality when compared to wild-type mice. In addition, the Cr2 -/- genotype was associated with a decreased extent of neuronal cell death at seven days post-injury. Western blot analysis revealed that complement C3 levels were reduced in the injured brain hemispheres of Cr2 -/- mice, whereas plasma C3 levels remained unchanged, compared to wild-type mice. Finally, head-injured Cr2 -/- had an attenuated extent of post-injury C3 tissue deposition, decreased astrocytosis and microglial activation, and attenuated immunoglobulin M deposition in injured brains compared to wild-type mice. Targeting of these receptors for complement C3 fragments (CR2/CR1) may represent a promising future approach for therapeutic immunomodulation after traumatic brain injury.
PMCID: PMC4050415  PMID: 24885042
Closed head injury; Neuroinflammation; Complement receptor; Cr2 -/- mice; Secondary brain injury
16.  Pharmacology of Traumatic Brain Injury: Where Is the “Golden Bullet”? 
Molecular Medicine  2008;14(11-12):731-740.
Traumatic brain injury (TBI) represents a major health care problem and a significant socioeconomic challenge worldwide. In the United States alone, approximately 1.5 million patients are affected each year, and the mortality of severe TBI remains as high as 35%–40%. These statistics underline the urgent need for efficient treatment modalities to improve posttraumatic morbidity and mortality. Despite advances in basic and clinical research as well as improved neurological intensive care in recent years, no specific pharmacological therapy for TBI is available that would improve the outcome of these patients. Understanding of the cellular and molecular mechanisms underlying the pathophysiological events after TBI has resulted in the identification of new potential therapeutic targets. Nevertheless, the extrapolation from basic research data to clinical application in TBI patients has invariably failed, and results from prospective clinical trials are disappointing. We review the published prospective clinical trials on pharmacological treatment modalities for TBI patients and outline future promising therapeutic avenues in the field.
PMCID: PMC2527342  PMID: 18769636
18.  Reviewer Acknowledgement 2013 
Contributing reviewers
The Editors of Patient Safety in Surgery would like to thank all our reviewers who have contributed to the journal in Volume 7 (2013).
PMCID: PMC4120970  PMID: 25093040
19.  Safe surgical technique: reconstruction of the sternoclavicular joint for posttraumatic arthritis after posterior sternoclavicular dislocation 
Posttraumatic sternoclavicular arthritis related to chronic ligamentous instability after posterior sternoclavicular dislocation represents a rare but challenging problem. The current article in the Journal’s “Safe Surgical Technique” series describes a successful salvage procedure by partial resection of the medial clavicle and ligamentous reconstruction of the sternoclavicular joint with a figure-of-eight semitendinosus allograft interposition arthroplasty.
PMCID: PMC3898097  PMID: 24378156
20.  Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients 
Novel bone substitutes have challenged the notion of autologous bone grafting as the ‘gold standard’ for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones.
A retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting.
The autograft cohort had a statistically significant shorter time to union (198 ± 172–225 days) compared to allograft (416 ± 290–543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159–619 days) or rhBMP-2 (217 ± 158–277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05).
Autologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.
PMCID: PMC3847297  PMID: 24016227
Fracture nonunion; Autograft; Allograft; Bone morphogenetic protein
21.  A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral nailing 
Occult femoral neck fractures associated with femoral shaft fractures are frequently missed and may lead to adverse outcomes.
Case presentation
A 46-year old female presented to our institution with increasing groin pain one month after antegrade intramedullary nailing of a femoral shaft fracture at an outside hospital. Radiographic evaluation revealed a displaced ipsilateral femoral neck fracture, adjacent to the piriformis starting point of the nail. A revision fixation of the femoral shaft and neck fracture was performed. The patient sustained a series of complications requiring multiple revision surgeries, including a total hip arthroplasty. Despite the cascade of complications, the patient had an uneventful long-term recovery, without additional complications noted at one-year follow-up.
This case report illustrates the necessity of increased awareness with a high level of suspicion for the presence of associated femoral shaft and neck fractures in any patient undergoing antegrade femoral nailing. Arguably, the cascade of complications presented in this paper could have been prevented with early recognition and initial stabilization of the occult femoral neck fracture. Standardized diagnostic protocols include “on table” pelvic radiographs to rule out associated femoral neck fractures. The diagnosis must be enforced in case of equivocal radiographic findings, either by computed tomography scan or magnetic resonance imaging.
PMCID: PMC3666926  PMID: 23702305
Femoral neck fracture; Femoral shaft fracture; Missed injury; Complication
22.  Swiss flag or Red Cross emblem: why the confusion? 
PMCID: PMC3663670  PMID: 23648084
23.  Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report 
Heterotopic ossification is a rare complication of musculoskeletal injuries, characterized by bone growth in soft tissues. Percutaneous antegrade intramedullary nailing represents the ‘gold standard’ for the treatment of femur shaft fractures. Minor bone growth is frequently seen around the proximal end of reamed femoral nails (so-called ‘callus caps’), which are asymptomatic and lack a therapeutic implication. The occurrence of excessive, symptomatic heterotopic ossification around the entry site of an antegrade femoral nail is rarely described in the literature.
Case presentation
We present the case of a 28-year-old Caucasian woman who developed extensive heterotopic ossification around the reaming seeds of a reamed femoral nail. She developed severe pain and significantly impaired range of motion of the hip joint, requiring revision surgery for heterotopic ossification resection and adjunctive local irradiation. She recovered full function of the hip and remained asymptomatic at her two-year follow-up appointment.
Severe heterotopic ossification represents a rare but potentially detrimental complication after percutaneous femoral nailing of femur shaft fractures. Diligent care during the reaming procedure, including placement of a trocar to protect from osteogenic seeding of the soft tissues, may help decrease the risk of developing heterotopic ossification after reamed antegrade femoral nailing.
PMCID: PMC3623784  PMID: 23556500
Heterotopic ossification; Femoral nailing; Femur fracture; Complication
24.  Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients 
Inflation bone tamps are becoming increasingly popular as a reduction tool for depressed tibial plateau fractures. A number of recent publications have addressed the technical aspects of balloon inflation osteoplasty. However, no study has yet been published to describe the technical limitations, intraoperative complications, and surgical bailout strategies for this new technology.
Observational retrospective study of all patients managed with inflatable bone tamps for depressed tibial plateau fractures between October 1, 2010 and December 1, 2012. The primary outcome parameter was the rate of complications, which were stratified into “minor” and “major” depending on the necessity for altering the surgical plan intraoperatively, and based on the risk for patient harm. This study was approved by the Institutional Review Board of the State of Colorado.
A consecutive series of 20 patients were managed by balloon inflation osteoplasty for depressed tibial plateau fractures during the 15 months study period. The mean age was 42.8 years (range 20–79), with 9 females and 11 males. A total of 13 patients sustained an adverse intraoperative event (65%), with three patients sustaining multiple technical complications. Minor events (n = 8) included the burst of a balloon with extrusion of contrast dye, and the unintentional posterior wall displacement during balloon inflation. Major events (n = 5) included the intra-articular injection of calcium phosphate in the knee joint, and the inability to elevate the depressed articular fragment with the inflatable bone tamp.
The observed intraoperative complication rate of 65% reflects a steep learning curve for the use of inflation bone tamps to reduce depressed tibial plateau fractures. Specific surgical bailout options are provided in this article, based on our early anecdotal experience in a pilot series of 20 consecutive cases. Patients should be advised on the benefits and risks of this new technology as part of the shared decision-making process during the informed consent.
PMCID: PMC3605372  PMID: 23452513

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