Gerhard Schmidmaier

Purpose: As the number of elderly major trauma patients (EMTP) increases continuously, this study sought to determine the incidence of organ failure (OF) and multiple organ failure (MOF) and their impact on mortality and recovery status in this cohort. Methods: Based on the German TraumaRegister DGU ^® database this study included EMTP aged between 65 and 99 years with an Injury Severity Score (ISS) of ≥ 16 between 2014 and 2023. OF was defined as Sequential Organ Failure Assessment (SOFA) score of ≥ 3 and MOF as failure of ≥ 2 organs. Results: The database revealed 34,469 EMTP, here 37% suffered from OF (16.0%) or MOF (21.0%). Mortality was significantly higher in OF and MOF patients compared to non-OF patients (non-OF: 7.4%; OF: 45.0%; MOF: 59.0%; p < 0.001). 80.9% of all deaths were associated with failure of at least one organ and 51.1% of non-survivors suffered from MOF. Highest odds ratios (OR) for mortality were found for liver (OR: 5.13, p < 0.001), central nervous system (OR: 3.63, p < 0.001) and renal failure (OR: 3.25, p < 0.001), followed by cardiovascular (OR: 1.95, p < 0.001) and lung failure (OR: 1.16, p = 0.010). Haemostatic failure had no impact on mortality. Conclusion: OR and mortality differ significantly between distinct OFs due to varying degrees of success in treatment options and systemic impact of these OFs. Clinicians should be aware that OF and MOF occur frequently in EMTP and that these patients have a high risk of dying. Therefore, close screening for and prompt treatment of OF and MOF could be a key strategy to lower mortality of EMTP.

Background: Non-unions after fractures are known to be a devastating complication in trauma surgery and studies assessing long-term patient-reported, clinical, and radiological outcome measures are scarce. Most evidence-based research on non-unions and their long-term follow-up evaluate the first two post-operative years while excluding subsequent years and their impact on the overall outcome. This study aimed to evaluate the functional, clinical and radiological outcomes five years post-operative. Methods: In this prospective study, all patients treated operatively between June 2018 and December 2020 for non-unions including every site were systematically reviewed for inclusion and summoned for a follow-up after 5 years. The outcome was evaluated using the modified Lane-Sandhu-Score (LSS), the short-form 12 (SF-12), active range of motion (ROM) and visual analogue scale (VAS). Furthermore, data on complications was collected. For all analyses, a p -value < 0.05 was evaluated as significant. Results: A total of 45 patients were included in the study with a follow-up time of 63 months (IQR: 55; 66). The LSS median after five years was 4 (IQR: 4; 4) and of the VAS 0 (IQR: 0; 4). 95.6% of patients were satisfied with the therapy after five years. Regarding the SF-12, the median score for the mental component was 55.2 (IQR: 48.7; 58.8) and the physical component averaged at 44 ± 10.84. From the second to the fifth post-operative year, patients showed significant improvements in the LSS (Z = − 4.334, p < 0.0001). Additionally, improvements in VAS (3 [IQR: 0.5; 4.5] at one year vs. 0 [IQR: 0; 4.5] at five years; p = 0.008) as well as quality of life (SF12m median at 1 year 54.05 [IQR: 47.4; 57.05] vs. SF-12 m median at 5 years 56.2 [IQR: 50.7; 57.6, p = 0.08]; mean SF-12p at 1 year 42.77 ± 9.15 vs. mean SF-12p at 5 years 45.4 ± 9.91, p = 0.0468) were evident. 31% of the patients experienced an improvement in ROM compared to the last follow-up. Conclusion: This study demonstrates that even beyond the second postoperative year, significant progress in both radiological and clinical findings continues. As a result, patients with non-unions should continue to be examined in special out-patient clinics even after completing the first two years of follow-up.

Background: Non-unions (NU) after fractures, especially in cases with the need of surgical intervention, represent one of the most severe complications in traumatology. As previous studies estimate post-fracture NU risk between 2% and 10% data inconsistencies persist. In particular, the data on the influence of different anatomical regions, age and sex on fracture associated NU is scarce. Therefore, this study aims to provide a comprehensive descriptively assessment of the ratio of surgically treated tibia and femur NU to tibia and femur fractures based on a nationwide dataset, with a specific focus on differences across anatomical regions. Methods: This retrospective, population-based, cross-sectional analysis of the German InEK database (2019–2023) was conducted, including 888,442 fractures and 3,017 NU cases. The study focused on ICD- (International Statistical Classification of Diseases and Related Health Problems-) coded diagnoses of femur and tibia NU and their associated fractures. To enhance precision, fracture and NU sites were grouped according to different anatomical regions assessed by documented OPS- (Operation and Procedure Classification System) codes. Subgroup analyses were performed for age and sex. Results: Surgically treated femoral shaft NU had the highest incidence (0.18 cases per 100,000 residents and year), followed closely by tibial shaft NU (0.16). The highest NU/100-fractures ratio was observed in tibial shaft (1.277), followed by distal tibia (1.095) and distal femur (0.996). Across all localisations, men had clearly higher NU/100-fractures ratios than women. NU/100-fractures ratios also varied with age, with highest ratio in the economically active population, followed by a generally decline in older patients. Conclusion: This nationwide database study indicates that surgically treated NU/fracture ratios of femur and tibia are generally low. The proportion of NU to fracture differ between different anatomical regions. In general, proximal localisations showed lower NU/100-fractures ratios than distal localisations within the femur and in comparison of femur and tibia. Independently of the anatomical localisation men had a higher NU/100-fractures ratio than women. As highest NU/100-fractures ratios were detected in the economically active population, this highlights the substantial socioeconomic burden associated with this condition.

Purpose: Overtriage in the trauma resuscitation room (TRR) is often a consequence of admission based solely on trauma mechanism criteria. As interleukin-6 (IL-6) can assess injury severity in critically injured patients, the hypothesis of this study was that IL-6 can differentiate upon admission between mild (Injury Severity Score (ISS) 0–8) and moderate (ISS 9–15) trauma and that the parameter correlates with injury severity in lower injury severity groups (ISS < 16) during the first 24 h. Subsequently, we evaluated the ability to define IL-6 cut-off values with an adequate sensitivity, specificity, and negative predictive value to distinguish between moderate and mild injuries. Methods: Fifty patients admitted to the TRR solely based on trauma mechanism criteria and with an ISS < 16 were included in the study. IL-6 was measured at admission, 1, 6, 12 and 24 h later. Results: Thirty-one patients were mildly injured (ISS 0–8), while nineteen patients sustained moderate injuries (ISS 9–15). IL-6 correlated significantly with ISS at all time points. Moderately injured patients showed significantly higher IL-6 levels than mildly injured patients during the first 6 h. IL-6 levels at admission predicted moderate injuries for the IL-6 cut-off value of 2.9pg/ml with a sensitivity of 0.933, specificity of 0.370 and a negative predictive value of 0.970 resulting in undertriage rates of 6.6% and overtriage rates of 54.8%. Conclusion: The data of this feasibility study indicates that IL-6 has the potential to be employed in clinical workflows for early determination between patients with mild and moderate injuries, who are admitted to TRR based on trauma mechanism criteria to abort as early as possible TRR treatment and therefore free resources immediately while preserving patients’ safety.

Purpose: This study compares the proliferative and osteogenic activity of human bone marrow derived mesenchymal stem cells (MSCs) obtained from atrophic non-unions and from healthy autologous bone graft tissue (harvested from iliac crest or femoral canal) of the same patient in an in-vitro setting utilizing a matched control study design. Methods: MSCs underwent osteogenic differentiation over 3 weeks in-vitro ( n = 6 donors; n = 36 samples/group) and the proliferative activity was accessed using DAPI-based immunofluorescence microscopy and WST-1 assay. All results regarding the osteogenic activity were normalized to 10 ⁴ cells to eliminate a proliferation bias. The late osteogenic activity was evaluated by radioactive ^99m Technetium-hydroxydiphosphonate labelling of depleted hydroxyapatite, while early osteogenic markers (calcium concentration and alkaline phosphatase activity) were analysed in supernatants of cell culture media. Results: The early and late-stage osteogenic activity of atrophic non-union MSCs was significantly higher compared to healthy control graft MSCs on day 21 of osteogenic differentiation in-vitro, both in absolute numbers (early/late: p < 0.001) and after normalization to 10 ⁴ cells (early/late: p < 0.001). After lower proliferative activity during the first week, non-union MSC regained good proliferative activity during the second week resulting in comparable absolute cell counts to healthy control graft MSCs after three weeks. Conclusion: The results emphasize that the in-vitro osteogenic and proliferative activity of atrophic non-union MSCs is not impaired as clinically assumed but the osteogenic potential of atrophic non-union MSCs is in fact significantly higher compared to graft derived MSCs. This might be an important basic-science insight for the optimization of clinical non-union therapies.

Aims: The aim of this study was to evaluate the radiological outcome of patients with large bone defects in the femur and tibia who were treated according to the guidelines of the diamond concept in our department (Centre for Orthopedics, Trauma Surgery, and Paraplegiology).Methods: The following retrospective, descriptive analysis consists of patients treated in our department between January 2010 and December 2021. In total, 628 patients were registered, of whom 108 presented with a large-sized defect (≥ 5 cm). A total of 70 patients met the inclusion criteria. The primary endpoint was radiological consolidation of nonunions after one and two years via a modified Lane-Sandhu Score, including only radiological parameters.Results: The mean defect size was 6.77 cm (SD 1.86), with the largest defect being 12.6 cm. Within two years after surgical treatment, 45 patients (64.3%) presented consolidation of the previous nonunion. After one year, six patients (8.6%) showed complete consolidation and 23 patients (32.9%) showed a considerable callus formation, whereas 41 patients (58.6%) showed a Lane-Sandhu score of 2 or below. Two years after surgery, 24 patients (34.3%) were categorized as Lane-Sandhu score 4, another 23 patients (32.9%) reached a score of 3, while 14 patients (20.0%) remained without final consolidation (score ≤ 2). A total of nine patients (12.9%) missed the two-year follow-up. The mean follow-up was 44.40 months (SD 32.00). The mean time period from nonunion surgery to consolidation was 16.42 months (SD 9.73)Conclusion: Patients with presentation of a large-sized nonunion require a structured and sufficiently long follow-up to secure the consolidation of the former nonunion. Furthermore, a follow-up of at least two years is required in order to declare a nonunion as consolidated, given that a significant part of the nonunions declared as not consolidated at one year showed consolidation within the second year. Moreover, the proven “gold standard” of a two-step procedure, so called Masquelet technique, shows effectiveness.Cite this article: Bone Jt Open 2024;6(1):26–34.

The treatment of fungal bone infections and infected non-unions is a huge challenge in modern trauma and orthopedics, which normally contain the local and systemic administration of anti-fungal drugs. Although frequently used, little is known about the impact of systemic and locally administered fungicides on the osteogenic regenerative capabilities of infected bone tissue, especially upon the osteogenesis of human bone marrow mesenchymal stem cells (BM-hMSCs). This study evaluates the effects of the three most common fungicides for the systemic treatment of bone infections, Voriconazole (VOR), liposomal Amphotericin B (LAMB), and Fluconazole (FLU), as well as the effects of VOR and LAMB-loaded Polymethylmethacrylate (PMMA) cement chips in different concentrations upon the osteogenic response of BM-hMSCs in vitro. Within this study, we compared the ability of BM-hMSC to differentiate into osteoblast-like cells and synthesize hydroxyapatite as assessed by radioactive ^99mTechnetium-Hydroxydiphosphonate (^99mTc-HDP) labeling, cell proliferation, and analyses of supernatants upon various osteogenic parameters. Our results revealed that VOR added to the cell culture medium affects the osteogenic potential of BM-hMSC negatively, while there were no detectable effects of LAMB and FLU. Moreover, we showed dose-dependent negative effects of high- and extended-dose fungicide-loaded PMMA cement due to cytotoxicity, with a higher cytotoxic potential of VOR than LAMB, while low-dose fungicide-loaded PMMA had no significant effect on the osteogenic potential of BM-hMSC in vitro.

Antibiotic-loaded PMMA bone cement is frequently used in modern trauma and orthopedic surgery. Although many of the antibiotics routinely applied are described to have cytotoxic effects in the literature, clinical experience shows no adverse effects for bone healing. To determine the effects of antibiotic-loaded PMMA spacers on osteogenesis in vitro, we cultivated human bone marrow mesenchymal stem cells (BM-hMSCs) in the presence of PMMA spacers containing Gentamicin, Vancomycin, Gentamicin + Clindamycin as well as Gentamicin + Vancomycin in addition to a blank control (agarose) and PMMA containing no antibiotics. The cell number was assessed with DAPI staining, and the osteogenic potential was evaluated by directly measuring the amount of hydroxyapatite synthesized using radioactive ^99mTc-HDP labelling as well as measuring the concentration of calcium and phosphate in the cell culture medium supernatant. The results showed that Gentamicin and Vancomycin as well as their combination show a certain amount of cytotoxicity but no negative effect on osteogenic potential. The combination of Gentamicin and Clindamycin, on the other hand, led to a drastic reduction in both the cell count and the osteogenic potential.

Background: Managing bone defects in non-union surgery remains challenging, especially in cases of large defects exceeding 5 cm in size. Historically, amputation and compound osteosynthesis with a remaining PMMA spacer have been viable and commonly used options. The risk of non-union after fractures varies between 2% and 30% and is dependent on various factors. Autologous bone grafts from the iliac crest are still considered the gold standard but are limited in availability, prompting consideration of artificial grafts. Objectives: The aims and objectives of the study are as follows: 1. To evaluate the radiological outcome of e.g., the consolidation and thus the stability of the bone (three out of four consolidated cortices/Lane-Sandhu-score of at least 3) by using S53P4-type bioactive glass (BaG) as a substitute material for large-sized bone defects in combination with autologous bone using the RIA technique. 2. To determine noticeable data-points as a base for future studies. Methods: In our clinic, 13 patients received bioactive glass (BaG) as a substitute in non-union therapy to promote osteoconductive aspects. BaG is a synthetic material composed of sodium, silicate, calcium, and phosphate. The primary endpoint of our study was to evaluate the radiological consolidation of bone after one and two years. To assess bone stabilization, we used a modified Lane-Sandhu score, considering only radiological criteria. A bone was considered stabilized if it achieved a minimum score of 3. For full consolidation (all four cortices consolidated), a minimum score of 4 was required. Each bone defect exceeded 5 cm in length, with an average size of 6.69 ± 1.92 cm. Results: The mean follow-up period for patients without final bone consolidation was 34.25 months, with a standard deviation of 14.57 months, a median of 32.00 months and a range of 33 months. In contrast, patients with a fully consolidated non-union had an average follow-up of 20.11 ± 15.69 months and a range of 45 months. Overall, the mean time from non-union surgery to consolidation for patients who achieved final union was 14.91 ± 6.70 months. After one year, six patients (46.2%) achieved complete bone consolidation according to the Lane-Sandhu score. Three patients (23.1%) displayed evident callus formation with expected stability, while three patients (23.1%) did not develop any callus, and one patient only formed a minimal callus with no expected stability. After two years, 9 out of 13 patients (69.2%) had a score of 4. The remaining four patients (30.8%) without expected stability either did not heal within two years or required a revision during that time. Conclusions: Bioactive glass (BaG) in combination with autologous bone (RIA) appears to be a suitable filler material for treating extensive non-unions of the femur and tibia. This approach seems to show non-inferiority to treatment with Tricalcium Phosphate (TCP). To ensure the success of this treatment, it is crucial to validate the procedure through a randomized controlled trial (RCT) with a control group using TCP, which would provide higher statistical power and more reliable results.

Background: ultrasound diagnostics have a broad spectrum of applications, including among diseases of the musculoskeletal system. Accordingly, it is important for the users to have a well-founded and up-to-date education in this dynamic examination method. The right balance between online and in-class teaching still needs to be explored in this context. Certifying institutions are currently testing digitally transformed teaching concepts to provide more evidence. Methods: this study compared two musculoskeletal ultrasound blended learning models. Model A was more traditional, with a focus on in-person teaching, while Model B was more digitally oriented with compulsory webinar. Both used e-learning for preparation. Participants completed evaluations using a seven-point Likert scale, later converted to a 0–1 scale. Digital teaching media (e-learning) were used for preparation in both courses. Results: the analysis included n = 41 evaluations for Model A and n = 30 for Model B. Model B received a better overall assessment (median: 0.73 vs. 0.69, p = 0.05). Model B also excelled in “course preparation” (p = 0.02), “webinar quality” (p = 0.04), and “course concept” (p = 0.04). The “gain of competence” (p = 0.82), “learning materials” (p = 0.30), and “tutor quality” (p = 0.28) showed no significant differences. Conclusion: participants favorably assessed blended learning in ultrasound teaching. Certifying institutions should consider accrediting models that combine digital methods (e.g., internet lectures/webinars) and materials (e.g., e-learning) with hands-on ultrasound training. Further research is needed to validate these subjective findings for a stronger evidential basis.