Abstracts DGU

Are hypoxia and oxidative stress the pathogenic mechanisms underlying Posttraumatic Dystrophy (PTD)?

(Abstract ID: 210)

E. Scola¹, A. Scola², M. Huber-Lang³

¹Prof. Dr. E. Scola, Neumarkt

²Klinik Immenstadt

³Institut für klinische und experimentelle Trauma-Immunologie (ITI), Ulm

Background:

The Posttraumatic Dystrophy (PTD) is a well defined and described entity. The definition entails the evidence of peripheral AV shunts in the microcirculation. These are unresolved phenomena and need an explanation regarding the pathophysiology and causal therapy.

Materials and methods:

10 patients (8 f, 2 m) were treated with distal radius fractures (7 type A, 3 type C according AO classification). Together with 5 test persons (single examination) the venous pO2 was measured in comparison with the opposite side after admission, postoperatively, 2 weeks and 6 weeks after surgery. Simultaneously samples were taken for examination and screening concerning neuropeptides (CGRP, VIP, substance P, ACh) as well as mediators of inflammation (IL-1β, IL-6).

Results:

The clinical outcome was very good in all patients according the normalization of the pO2 values as described in a former work of the authors. All results were very inhomogeneous without statistical evidence except IL-6, which showed in all assays positive delta-values in respect to the uninjured opposite side and test persons. This finding could be interpreted as a hint for involvement of granulocytes.

Conclusion:

Discussion: It seems unlikely that neurotransmitters are involved in the development of posttraumatic dystrophy. The clinical symptoms coincide rather with an aseptic inflammation. Lesions of microcirculation lead to hypoxia with activation of oxidative stress factors like reactive oxygen species ROS, first of all by NADPH oxidase2 (NOX2), activated in endothelial cells and vascular smooth muscles cells as well. Intermittent hypoxia increases the activation of ROS. Furthermore ROS activate the redoxsensitive transcription factors hypoxia inducible factor1 (HIF1) and nuclear factor κB (NFκB), each of both communicates with the other (crosstalk). Hypoxia resistant myeloid cells leave the vascular lumen (diapedesis) and induce a paravascular inflammation response. Gene induced autacoids may be able to render a forced vasodilation together with the HIF1 transcript vascular endothelial growth factor (VEGF). Mast cells, localized in close vicinity of capillaries and nerve endings, are stimulated by autacoids, free ATP etc. and liberate a plethora of mediators from their granules. Mast cells are the only cells in the human body, that have the potential to build up and store the cytokine tumor necrosis factor (TNF), which is capable to separate NFκB from its complex with inhibitor κB (IκB). Additionally the mitogen-activated protein-kinase pathway is activated and target genes of the cell cycle are transcribed. Cross connections with other signaling pathways like phosphatidyl-inositol-3-kinase (PI3K) / protein-kinase B (AKT), receptor-tyrosine-kinase, tyrosine-associated receptors of cytokines like IL-6 (with transcription of HIF-1α) may support the formation of vicious circles.

Conclusions: Taken together it seems most likely that the development of PTD is based on a triangle relationship of 1. hypoxia / ROS, 2. HIF1 / NFκB and 3. mast cells and other granulocytes. The functional entity of endothelial cells and vascular smooth muscle cells could be responsible for the upstream and downstream transmission of vasodilation signals via connexins in the vascular tree of microcirculation (conducted vasodilation). Further analysis will be planned with the aim to find a causal treatment, for this kind of dystrophy is only reversible with early treatment.

Proximal humeral head dislocation fractures – fracture morphology and classification

(Abstract ID: 653)

S. F. Hertling¹, G. Matziolis¹, M. Bungartz¹, O. Brinkmann¹

¹Waldkliniken Eisenberg

Background:

The proximal humeral fracture is the third most common of all fractures. It belongs to the osteoporotic fracture in geriatric traumatology. Different classification systems are established. A special fracture entity of the proximal humerus is the shoulderjoint dislocation fracture If the established classifications are compared, there is a gap. Because none of these forms exactly the fracture entity of the upper limb. The aim of thisstudy is to create a classification describing the shoulder joint dislocation fractures togetherwith glenohumeral combination fractures.

Materials and methods:

In the form of a retrospective, monocentric study, all proximal humeral fractureswere recorded, which were surgically treated from 2007 to May/2019. 403 patients were included. 296 women and 107 men. Evaluated were conventional X-ray and a computer tomography of the broken shoulder. In 403 proximal humeral head fractures, 46 showed the image of a humeral head dislocation fracture. 28 of the 46 showed at least one more glenohumeral combination fracture.

Results:

Of 403 humeral head fractures, 46 showed a humeral head dislocation fracture. 28 in turn, at least one additional glenohumeral combination fracture: in 22 cases a glenoid fracture. In 4 of these, the head of the humeral head was twisted by 180 degrees with simultaneous impression fracture of the calotte in the humeral shaft. In 1 case fracture of glenoid + proc. coracoideus, in 1 case fracture of the scapular corpus + proc. coracoideus. In 3 cases a fracture of the acromion ans in 1 case fracture of the acromion + proc. coracoid.

Conclusion:

11 percent of all fractures in the proximal humerus area were diagnosed as a humeral head dislocation fracture. These shown in more than 50 percent fractures of other joint partners. Known classification systems do not allow classification of this type of fracture, and therefore, based on the present results of this study, a newly modified score has been developed.

Proximal Humeral Dislocation Fractures – Epidemiology and Pathomechanism

(Abstract ID: 655)

S. F. Hertling¹, O. Brinkmann¹, M. Bungartz¹, G. Matziolis¹

¹Waldkliniken Eisenberg

Background:

The proximal humeral fracture is the third most common of all fractures. It belongs to the osteoporotic fracture in geriatric traumatology. Different classification systems are established. A special fracture entity of the proximal humerus is the shoulder joint dislocation fracture. Little is known about epidemiology and its pathomechanism. This should be explained in more detail with this study.

Materials and methods:

In the form of a retrospective, monocentric study, all proximal humeral fractures were recorded, which were surgically treated from 2007 to May/2019. 403 patients were included. 296 women and 107 men. In 403 proximal humeral head fractures, 46 showed the image of a humeral head dislocation fracture. 28 of the 46 showed at least one more glenohumeral combination fracture. Epidemiological data and trauma mechanism were evaluated.

Results:

Of the 403 proximal humeral head fractures, 73 percent were affected by women, 27 percent were affected by males. Of the 46 patients with a humeral headfracture, 28 showed at least one more glenohumeral combination fracture. Of these 28, 19 were men and 9 were women. Almost 68 percent of humeral dislocation fractures with glenohumeral combination fractures are of male origin, with only 32 percent of these fractures affecting female patients. The mean age of men is 62.5 years, whereas women are 74.8 years. Men with a humeral head dislocation fracture and a glenohumeral combination fracture were on average younger than men with a single humeral head fracture fracture. The average age was 53.3 years.

Conclusion:

The more complex the glenohumeral combination fractures were, the younger the affected patient age was. In contrast to the classic proximal humeral head fracture, the humeral dislocation fracture is a fracture of the younger human. Especially men are affected and go along with a corresponding trauma mechanism. So men are also more likely to be affected by combination fractures.

Prophylactic embolization of the splenic artery for traumatic lesions diagnosed in CT and/or MRI imaging can prevent a two-stage rupture

(Abstract ID: 471)

C. E. M. Pothmann¹, F. Allemann¹, H.-C. Pape¹, H.-P. Simmen¹, V. Neuhaus¹

¹Universitätsspital Zürich

Background:

The two-stage splenic rupture is seldom, its risk is unpredictable and even with a precise diagnosis of a CT and/or MRI imaging unexpectable or unexcludable. There are no existing guidelines about how long a patient with a splenic injury should be observed. Generally, and due to our experience and current literature, a two-stage rupture occurs within one week after trauma. However, dramatic courses after two or three weeks are described. A prophylactic angioembolization in (still) hemodynamically stable patients with a positive finding in a CT and/or MRI imaging may be an option. We describe our experience.

Materials and methods:

In a retrospective study in a level-one trauma centre of Switzerland all patients that underwent a prophylactic angioembolization after a clear diagnosis by CT and/or MRI of a splenic parenchymal lesion after trauma between 2010 and 2016 were analysed. Further inclusion criteria were hemodynamical stability (systolic blood pressure >90 mmHg) and the missing indication for immediate laparotomy.

Results:

Eleven patients (4 f, 7 m) with an average age of 44 +/- 15 years underwent pre-emptive angioembolization after traumatic lesions of the spleen. The injury severity of the abdomen (AIS) was 3 in nine and 4 in two patients. Besides a splenic injury, three patients did also have a kidney injury. The overall injury severity was ISS 22 +/- 5 points. Eight patients did suffer from additional thoracic or head trauma. In five patients, the angioembolization was performed on the day of admission, in one patient on the 1st, in three patients at the 2nd and respectively one patient in the 3rd and 4th day of hospitalisation. In one case an uncomplicated selective embolization of a main duct of the splenic artery was performed. In ten patients, the uneventful proximal embolization of the splenic artery was completed. The average length of stay was 11 +/- 6.0 days. There were no deaths or complications seen due to angioembolisation or splenic rupture. There were also no complications or operative procedures necessary in the median follow-up time of 3 month (0 - 36 month).

Conclusion:

The angioembolization of the splenic artery is a possible and minimal invasive but still uncommon method to prevent the feared and risky complication of a two-stage splenic rupture after abdominal trauma.

Does the immunosuppressive therapy influence postoperative fracture healing after organ transplantation?

(Abstract ID: 473)

C. E. M. Pothmann¹, H.-C. Pape¹, H.-P. Simmen¹, V. Neuhaus¹

¹Universitätsspital Zürich

Background:

Within the last years, the number of people with transplanted organs, as well as their lifetime and quality of life after organ transplantation (TPL) increased. Organ transplant recipients actively participate in everyday life, can have accidents und suffer fractures. The purpose of this study was to evaluate if patients after organ transplantation and under immunosuppressive therapy have impaired fracture healing and an increased postoperative complication rate.

Materials and methods:

A retrospective analysis of the trauma database of a level-one trauma centre was made. Immunosuppressed patients after TPL treated with an osteosynthesis between 2004 and 2016 were included in the analysis. Patients had regular radiological and clinical follow-up. The fracture healing time was assessed and compared with patients without immunosuppressive therapy of this hospital and of standard surgical reference works.

Results:

29 patients (15 male, 14 females, mean age 43 years) with overall 40 fractures were included in the analysis. 13 kidney-TPL, 6 lung-TPL, 5 liver-TPL, 3 heart-TPL, 2 kidney/pancreas-TPL. All patients got treated with at least two immunosuppressive drugs.

Cause of accident: 37.5% sports/leisure, 35% work/household, 12.5% traffic accidents, 5% without trauma.

The operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. Patients were hospitalized for an average duration of 11.3 days and were also examined by the particular organ specialists.

Osteosynthesis: in 90% primary operative fracture treatment, in 10% two-step procedure. 11 plates distal radius and ulna [healing period (h) 14 weeks (w)], 3 plates tibia [h 20 w], 3 plates fibula [h 11 w], 9 nails femur [h 51 w], 3 plates clavicle [h 51 w], 4 spondylodesis spinal column [h 24 w], 3 plates/screws pelvis/sacrum [h 7 w], 1 tension band wiring patella [h 49 w], 3 plates humerus [h 34 w].

Complications: 1 wound infection, 2 hematomas, 1 non-union, 2 times persistent pains, 2 times secondary displacement/lysis/material breakage. An operative revision had to be performed in 3 patients.

Conclusion:

The fracture healing under immunosuppressive therapy after organ transplantation was possible but significantly delayed. The wound healing took longer. The immunosuppressive therapy may be responsible for these problems. We recommend that the surgical standard techniques should be applied. The rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing.

Are there easy predictors of the simultaneous presence of hollow viscus organ lesions in patients with abdominal parenchymal organ lesions?

(Abstract ID: 474)

C. E. M. Pothmann¹, K. Sprengel¹, K. O. Jensen¹, H.-P. Simmen¹, H.-C. Pape¹, V. Neuhaus¹

¹Universitätsspital Zürich

Background:

Abdominal trauma patients presenting with hypotension or peritonitis must undergo a laparotomy. In isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. It is a constant fear to miss a hollow viscus organ lesion. The aim of this study was to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions.

Materials and methods:

Data of over 20'000 inpatients of a level-one-trauma centre between 2008 and 2016 were analysed. Only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. Significant predictors were detected in bi- and multivariant analysis.

Results:

Of the 341 patients with an average age of 42 +/- 20 years, 49% (n=168) suffered a liver, 43% (n=148) a splenic, and 23% (n=79) a kidney rupture. The total ISS was 30 +/- 16 points. In 52 patients (15%) a hollow viscus injury could be found (stomach n=5, small bowel n= 29, colon n=22, rectum n=4). Injuries of the thorax (76%), the extremities (70%), the head (70%), the vertebra column (43%) and the pelvis (30%) were diagnosed as concomitant injuries. Due to multivariant analysis neither age, gender, heart frequency at admission, GCS, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion.

Conclusion:

Clinical parameters taken at admission are not useful to predict hollow viscus injuries. The CT-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first 60 minutes after trauma. Repetitive clinical examination is necessary. If in doubt, a diagnostic laparoscopy or even laparotomy has to be performed.

Relevant abdominal injuries in polytraumatized patients

(Abstract ID: 552)

C. E. M. Pothmann¹, K. Sprengel¹, K. O. Jensen¹, H.-P. Simmen¹, H.-C. Pape¹, V. Neuhaus¹

¹Universitätsspital Zürich

Background:

A severe abdominal trauma is associated with a high morbidity and mortality. The aim of this study was to analyse the abdominal injury patterns and concomitant injuries in polytraumatized patients as well as to identify risk factors of death.

Materials and methods:

Data of over 20'000 inpatients of a level-one trauma centre between 2008 and 2016 were retrospectively analysed. Only patients with a relevant abdominal trauma (AIS abdomen >=3) were included. The AIS score was determined either with a contrast enhanced computed tomography or intraoperatively. Significant risk factors were detected in bi- and multivariate analysis.

Results:

315 patients with an average age of 43 +/- 18 years were included. 48% (n=155) had an AIS abdomen of 3, 40% (n=127) of 4 and 10% (n=33) of 5. The overall ISS was 31 +/- 16 points. The mechanism of injury was mainly blunt (87%). A splenic rupture was present in 40% (n=128), a liver rupture in 35% (n=112) and a kidney rupture in 26% (n=68). Hollow viscus injuries were present in 13% (small bowel n= 44, colon n=33, stomach n=13, rectum n=7, bladder n=14). Concomitant injuries were determined in 88% of the patients. Of these 70% were diagnosed a thoracic injury, 66% injuries at the extremities, 55% head injuries. 47% spinal injuries and 31% pelvic injuries. The mortality was 16% (n=51). A liver rupture (p=0.031, OR 4.0), pelvic injuries (p=0.02, OR 4.4), higher age (p=0.043, OR 1.032), hypotension at admission (systolic blood pressure <90mmHg) (p=0.003, OR 8.2) and a low GCS at admission (p<0.001, OR 0.67) were determined to be significant risk factors.

Conclusion:

In our trauma department life threatening abdominal traumata are treated on average every tenth day. Lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. Due to our experience we recommend the use of an early CT-scan as thereby the injury severity can be fast and precisely assessed.

Safe and sustainable: Limb salvage and modified rotationplasty as therapy for osteosarcoma in distal femur in developing countries – first cases in Myanmar

(Abstract ID: 89)

L. Sommerauer¹, N. Aung², W. Than², V. Brébant¹, L. Prantl¹, T. Aung¹

¹Universitätsklinikum Regensburg

²University of Medicine Mandalay

Background:

Amputation still is the most common therapy of osteosarcoma in developing countries, although limb salvage surgeries e.g. Van Nes-Borggreve Rotationplasty for malignant tumour around the knee are currently the standard therapy. To establish a complex surgical technique like rotationplasty in third world countries with limited infrastructure and resources, a safe and reliable operation method is critical. The authors present three case reports in order to evaluate an approach for rotationplasty in osteosarcoma patients with a focus on a safe surgical technique and sustainability.

Materials and methods:

In February 2019 (20th, 21st, 22nd February), three young patients with osteosarcoma of distal femur were treated with rotationplasty in the Orthopaedics Hospital in Mandalay, Myanmar. A safe and simplified surgical technique for given circumstances in developing countries as well as outcomes and complications were evaluated.

Results:

We report on three cases with rotationplasty due to osteosarcoma of distal femur. The first patient was a 20-year-old female, second and third patients were nine and 13-year-old males. One out of the three patients needed one more debridement due to postoperative impairment of wound healing. All three patients showed good aesthetic and functional results.

Conclusion:

A simplified and safe operation technique conformed to the given circumstances in developing countries for rotationplasty is possible and showed good results.

Oncologic impact of wound complications in soft tissue sarcomas of the extremities

(Abstract ID: 362)

M. Dadras¹, P. Koepp¹, C. Wallner¹, J. M. Wanger¹, A. Sogorski¹, K. Harati¹, M. Lehnhardt¹, B. Behr¹

¹BG Universitätsklinikum Bergmannsheil, Bochum

Background:

In various oncological conditions, complications correlate with diminished prognosis, however literature on soft tissue sarcomas is limited and inconclusive. The aim of this study was to assess risk factors and the oncologic impact of wound complications in primary extremity soft-tissue sarcomas.

Materials and methods:

Patients with primary extremity soft tissue sarcomas without dissemination and with clear surgical margins (R0) were analyzed. Groups with and without wound complications were compared by univariate and multivariate analysis to identify risk factors. Uni- and multivariate analysis of factors associated with 5-year local recurrence free survival (LRFS), metastases free survival (MFS) and disease specific survival (DSS) were performed.

Results:

682 patients were included in the study, wound complications occurred in 94 patients (13.7%) within 90 days. Age, ASA-stage, high tumor size and grade, tumor location in the foot, neoadjuvant radiation therapy and operation time represented independent risk factors for wound complications. Patients with wound complications had a significantly worse estimated 5-year LRFS of 43.9±6.4% versus 77.1±2.1%. Wound complications could be identified as a strong independent risk factor for LRFS (HR 3.02[CI 2.03-4.49], p<0.001). 5-year MFS and 5-year DSS were significantly lower for patients with wound complications in univariate analysis but wound complications were not significant in multivariate analysis for MFS or DSS.

Conclusion:

Wound complications after soft tissue sarcomas of the extremities are associated with worse local oncological outcome. Patients with high risk of wound complications should be identified and strategies implemented to reduce surgical complications and possibly improve oncologic prognosis.

Incisional negative pressure wound therapy for soft tissue tumors – a randomized controlled trial

(Abstract ID: 365)

M. Dadras¹, D. Ufton¹, J. M. Wagner¹, C. Wallner¹, K. Harati¹, M. Lehnhardt¹, B. Behr¹

¹BG Universitätsklinikum Bergmannsheil, Bochum

Background:

Wound healing after resection of large soft tissue tumors is often impaired by large dead space and fluid collection, potentially resulting in seroma formation and infection. Recently, we were also able to show a negative oncologic impact of wound complications on oncologic outcome in soft tissue sarcomas. Aim of the study is to compare negative pressure wound therapy to standard wound dressing in terms of quantity of drainage fluid and wound healing complications.

Materials and methods:

Patients who were planned for resection of a soft tissue tumor of the extremities or the trunk of at least 10cm diameter were randomly allocated to one of two groups. After wound closure, patients of the study group received incisional negative pressure wound therapy for a duration of 5 days while the control group received regular dressings. Amount of drainage fluid, course of wound healing and wound edge perfusion at postoperative 5 measured by near infrered spectroscopy were compared.

Results:

In the preliminare evaluation, 40 patients could be included in the study with even distribution to both study arms. Taking resection volume into account, amount of drainage fluid was significantly lower in the therapy group with significantly earlier drain removal. Rate of wound complications was significantly higher in the control group while no differences in the near infrared spectroscopy analysis of the wound edges could be observed. No complications of the incisional negative pressure wound therapy could be observed except for an occasional erythema of the skin under the dressing that quickly resolved spontaneously after dressing removal.

Conclusion:

Incisional negative pressure wound therapy is a safe procedure that reduces drainage volume and wound complications after resection of large soft tissue tumors. Its use can therefore be recommended for this indication.