Christian Kleber

Background: Chest tube dislodgement remains a relevant complication in emergency, trauma, and intensive care medicine. In a previous biomechanical study, the Modified Johannesburg technique using Mersilene USP 1 demonstrated superior fixation strength compared with other chest tube fixation techniques. The present study aimed to determine whether suture size, suture material, and chest tube diameter influence fixation strength. Methods: A prospective interventional biomechanical cadaveric study was performed using fresh porcine thoracic wall specimens. A total of 320 load-to-failure tests were conducted under standardized laboratory conditions. Two fixation techniques, Modified Johannesburg and Purse String, were compared using two chest tube diameters (20/28 Ch) and four non-absorbable braided suture configurations: Mersilene USP 1, Mersilene USP 2 − 0, Silk USP 1, and Silk USP 2 − 0. Each experimental group consisted of 20 specimens. Specimens were tested in a uniaxial testing machine until construct failure. Force [N] and elongation [mm] at failure were measured. The experiments were videotaped, and the failure mechanism was analyzed. Results: The Modified Johannesburg technique demonstrated significantly higher pull-out forces compared to the Purse String technique (125.0 vs. 66.4 N; p < 0.001), as did larger suture sizes (USP 1 vs. 2 − 0; p < 0.001) and Mersilene compared to Silk (114.6 vs. 76.9 N; p < 0.001). Chest tube size had only a very small and inconsistent effect on pull-out strength. The predominant failure mode was suture rupture (94.7%). Conclusions: Chest tube fixation strength is significantly influenced by fixation technique, suture size, and suture material. The effect of chest tube diameter on fixation strength appeared negligible. The Modified Johannesburg technique, size 1 sutures, and Mersilene material provided superior biomechanical stability. Since failure occurred predominantly by suture rupture, the suture appears to represent the weakest link of the fixation construct.

BACKGROUND: The World Health Organization surgical safety checklist (WHO SSC) provides a standardized framework for preoperative safety procedures. However, studies have revealed substantial variation in adherence, with items being skipped or misunderstood and nurses likely to be less involved than other operating room (OR) professional groups. We introduce a 16-item team timeout checklist (TTOC) that clarifies and adds safety-critical items to the existing WHO before skin incision timeout and is led by nurses to improve information exchange, closed-loop communication, and encouraging participation of all professional groups. METHODS: Using a prospective pre–post interventional design, we live-coded all team communication during on-site observations in the OR focusing on the pre-incision phase. Surgical teams were first observed during a pre-intervention period without the TTOC checklist and subsequently during a post-intervention period after implementation of the TTOC checklist. The TTOC was evaluated on four communication outcomes critical for patient safety: information exchange of checklist items, measured as the percentage of the 16 items that were verbally communicated among team members (eg, team introduction, surgical site, allergies), participation rates of different professional groups, frequency of explicit coordination behaviors (eg, instruction, information request, speaking up) and the frequency of closed-loop communication sequences, defined as information request followed by information upon request within 30 seconds. RESULTS: A total of 155 teams were observed, including 78 teams in the pre-intervention phase without TTOC use and 77 teams in the post-intervention phase using the TTOC, resulting in 13,127 coded communication events. The median information exchange increased from 62.5% (interquartile range [IQR] 50–68.8) in the pre-intervention phase to 100% (IQR 100–100) in the post-intervention phase ( P < .001). For 15 of all 16 subitems, the odds of exchanging information were significantly higher after TTOC implementation than before TTOC implementation (odds ratios range 10.8–1896, all 95% confidence intervals [CIs] excluded 1). Participation rates increased for circulating nurses, scrub nurses, surgical residents, and anesthesia (all P < .05) but not for lead surgeons. Mean (standard deviation [SD]) closed-loop communication patterns per operation were more frequent with (20.4 [10.7]) than without the TTOC (16.4, [7.24]), P = .004. CONCLUSIONS: In our study, the nurse-led TTOC significantly improved the exchange of safety-critical items during the pre-incision phase, facilitated closed-loop communication, and empowered the participation of various professional groups. These findings suggest integrating the TTOC with the WHO SSC before-incision protocol may have important advantages.

Background: Despite standardization of treatment for ankle fractures, postoperative complications continue to pose a challenge. Previous studies focused on the association between patient-specific factors and early complications; less is known about fracture- and treatment-related factors. This study aimed to identify independent predictors of early postoperative complications in ankle fractures by including patient, fracture, and treatment-related factors. Methods: This was a retrospective single-center analysis of consecutive patients with surgically treated ankle fractures at a Level 1 trauma center (2013–2019). The main outcome was the time to the occurrence of an early post-operative complication, defined as an event requiring emergency medical consultation within the first 90 days after definitive fracture stabilization, deviating from the hospital’s standard aftercare protocol. Four different Cox regression analyses were performed to identify significant independent risk factors with the best fit. Results: Around 25% of the patients with ankle fractures developed an early postoperative complication. The multivariable Cox regression analysis revealed the following predictors of early complications: diabetes, substance abuse, older age, type of fracture, and insufficient/missing plaster reduction. Conclusion: Nearly one quarter of our patients developed an early postoperative complication. While some of the predictors of early complications cannot be modified, others might serve as targets for improving outcomes and reducing morbidity of ankle fracture surgeries.

Background: Intravenous anti-infectives are an important part of postoperative care, but discrepancies between prescribed and documented administrations remain widespread and require systematic evaluation. Methods: In an exploratory study, prescribed and documented intravenous anti-infective administrations were retrospectively analyzed using patient charts, digital nursing reports and, in cases of deviations, consultations with the responsible staff. The discrepancies were classified into three categories: (I) documentation, (II) administration, and (III) a combination of both. The relationship between discrepancies and dosing interval, time of administration (weekday and shift assignment), and intravenous administration route was statistically analyzed (Χ² test, residual analysis). Results: Of 5016 anti-infective administrations in 219 patients, 1135 (22.6%) had at least one discrepancy, of which 68.2% (774 of 1135) belonged to category I. Significant differences in the frequency of discrepancies between surgical wards and the dosing intervals were observed. On weekdays, 23.6% of drug administrations (832 of 3519) showed discrepancies compared to 20.2% on weekends (303 of 1497, OR = 1.22, 95% CI 1.05–1.42, p = 0.008). Although the early shift had the lowest administration rate, it showed significantly more discrepancies than expected (313.6 expected vs. 553 observed; adjusted standardized residual +18.1; p < 0.001). Drug administration via the peripheral venous route was more susceptible to discrepancies than the central venous administration route (23.2% [963 of 4149] vs. 19.8% [172 of 867]), OR 1.18; 95% CI 1.01–1.38; p = 0.031). Conclusions: Approximately a quarter of anti-infective administrations were affected by discrepancies, predominantly in category I, with the highest incidences occurring during the early shift and on weekdays. This requires a multi-step improvement program.

Background: Chest tube dislodgement is a frequent and potentially life-threatening complication after thoracic trauma. Reliable fixation is essential, particularly in emergency and combat casualty care. Several suture techniques exist, but comparative biomechanical evidence is limited. Methods: This prospective biomechanical cadaveric study compared three fixation techniques—Purse String (PS), Roman Sandal (RS), and Modified Johannesburg (JO) technique —across three tube sizes (20, 24, 28 Charrière) and two materials (polyvinyl chloride (PVC) and silicone). A total of 360 tests were performed on porcine thoracic wall specimens under standardized conditions. Specimens were subjected to vertical load-to-failure testing with continuous measurement of force and elongation. Results: The Modified Johannesburg technique consistently demonstrated the highest pull-out strength across all tube sizes and materials, significantly outperforming both RS and PS ( p < 0.0001). RS ranked second and showed significantly greater stability than PS in all conditions ( p < 0.0001). Effect size analysis revealed large differences between JO and PS ( r = 0.87) and between RS and PS ( r = 0.50), and a medium effect between JO and RS ( r = 0.36). PVC tubes provided significantly greater pull-out strength than silicone tubes (147.0 ± 54.2 N vs. 128.5 ± 42.2 N; p = 0.01071), although silicone tubes exhibited greater elongation prior to failure. Tube size had a modest influence on stability, with larger tubes tending toward higher pull-out strength, but pairwise differences did not reach significance. The predominant failure mechanism was suture rupture (78.9%), followed by tube rupture (11.1%), knot loosening (8.1%), and skin failure (1.9%). Conclusions: The Modified Johannesburg Technique offers superior biomechanical stability for chest tube fixation, regardless of tube size or material. This technique should be considered the preferred method in high-risk environments, including military and emergency care, to minimize dislodgement and enhance patient safety.

Background: Factor XIII (FXIII) deficiency increases bleeding risk and delays wound healing, yet its recognition, diagnosis, and treatment remain challenging in the complex clinical routine. Objective: To determine real-world diagnosis and management strategies of acquired FXIII deficiency. Methods: Adult patients undergoing FXIII activity testing (diagnostic phase) and FXIII supplementation (treatment phase) for acquired FXIII deficiency were consecutively enrolled in this retrospective data collection. Treatment outcomes were analyzed in patients with postsurgical bleeding and wound healing disorders (WHD). Results: A total of 255 patients were included in the diagnostic cohort, of whom 84% were diagnosed with clinically relevant FXIII deficiency and 77% received FXIII supplementation. Median FXIII activity in patients with a clinically relevant deficiency was 42.5%, compared to 74.0% in those without. Most patients with FXIII activity levels below 60% were considered to have a clinically relevant deficiency. The treatment cohort comprised 96 postsurgical bleeding cases and 78 WHD cases. Median FXIII activity levels were similarly reduced in both cohorts (44.0% vs 48.0%). Conventional coagulation tests remained mainly within reference ranges for most patients, highlighting the diagnostic gap. Persistent infection was the leading comorbidity, affecting 33% of patients in both cohorts. Conclusion: In this real-world setting, FXIII supplementation was most frequently initiated at FXIII activity levels below 60%-70%. These findings suggest using this range as a clinical reference point for therapeutic intervention, while bearing in mind the exploratory nature of the data. Routine FXIII testing should be considered in patients with unexplained bleeding or impaired wound healing, particularly perioperatively, after major trauma, or with persistent infections.

Introduction: The anatomy of the distal tibiofibular joint (DTFJ) has been demonstrated to influence the radiological outcome of reduction with syndesmotic screw fixation in the course of ankle fracture treatment. The objective of this study was to describe the anatomy of the DTFJ and to analyze the effect of incisura anatomy on syndesmotic stabilization with suture button systems (SBS), also in the context of their flexible nature of fixation. Materials and Methods: Forty-four (21 females, 23 males) consecutive postoperative bilateral computed tomography scans after stabilization of the DTFJ by SBS in the course of operative treatment of unstable ankle fractures were retrospectively analyzed. The anatomy of the DTFJ was evaluated by examining the following parameters: depth of the tibial incisura (DI), rotation of the incisura (ROI), Nault talar dome angle (NTDA), Leporjärvi clear space (LCS), anterior tibiofibular distance (antTFD), and fibula engagement (FE). The side-to-side (Δ) of LCS, NTDA, and antTFD, which analyzed the reduction result, were correlated with DI, FE, ROI, and NTDA, as well as the transverse offset (TO), reflecting the flexible nature of fixation. Results: Patients with slight overtightening (ΔLCS > −1 mm) showed a fibula that protruded less into the incisura on the native side (smaller FE) compared to symmetrical reduced patients and to patients with slight diastasis (p < 0.05). There was no relationship between the parameters describing the anatomy of the incisura and parameters assessing the parameter of the “flexible nature of fixation” (rs < 0.300). Regarding the anatomical parameters, it was observed that there were inter-individual differences of more than 4 mm (p > 0.05). Conclusions: The considerable inter-individual anatomical variability of the DTFJ was confirmed. The morphological configuration of the incisura has no impact on the immediate radiological reduction result after SBS stabilization of the DTFG, as determined by CT. The extent of the flexible nature of fixation is also not affected by the morphology of the incisura. Stabilization of the DTFJ can be performed regardless of the anatomical configuration.

Objective: In patients with leg injuries, typical symptoms of thrombosis such as painful swelling may be misinterpreted as a consequence of the trauma. This has the potential to result in an unexpected embolism, especially during the perioperative period. This study investigates the incidence of unapparent preoperative deep-vein thrombosis (DVT) in patients with traumatic intraarticular tibial plateau fracture (TPF). A comprehensive analysis was conducted to identify possible risk factors, with particular attention paid to fracture severity and soft tissue injury. Methods: This retrospective single-centre study evaluated patient data from November 2021 to November 2024. It included 72 patients with traumatic intraarticular TPF who underwent surgery and received a preoperative compression ultrasonography screening. Results: The incidence of preoperative DVT was 23.6% (n = 17). Among these, 5.6% (n = 4) exhibited proximal thrombosis, while 18.1% (n = 13) demonstrated distal thrombosis. The fibular veins were predominantly affected (12/17). Patients with DVT suffered high-energy traumata, dislocations, compartment syndromes, and complex fractures (AO/OTA type C3: 82.4% vs. 52.7%) more often than patients without DVT and were more often immobilised with an external fixator. In 47.1% of DVT cases (n = 8), surgery could no longer be postponed, and an inferior vena cava filter was temporarily employed. The removal of the filter was successful in all cases, with no major complications encountered. Conclusions: This study reveals a high incidence (23.6%) of unapparent preoperative DVT in patients with traumatic intraarticular TPF despite prophylactic anticoagulation, particularly in those with severe fractures and soft tissue injuries. Systematic DVT screening and early anticoagulation are crucial to avoid potentially life-threatening complications.

Background: Fragility fractures of the pelvic ring (FFPs) represent a fast-growing entity in geriatric traumatology with increasing incidence worldwide. This study aimed to analyze the epidemiology, treatment concepts, and surgical strategies for FFPs based on data collected by the German Pelvic Multicenter Study Group documented in the German Pelvic Fracture Registry. It is the largest cohort study of its kind. Methods: This retrospective cohort study included patients aged 65 years or older after FFPs, as classified according to the Rommens and Hofmann classification. Data were collected from July 2018 onward and analyzed for demographics; fracture classifications; treatment modalities (operative vs. non-operative); and details of surgery, including timing and choice of implants. Patients after high-energy trauma were excluded. Statistical analyses included descriptive metrics and subgroup comparisons. Results: Among 1242 patients (84% female; median age 83.4 years), FFP Type II was the most common fracture type (50.8%), followed by Type IV (21.1%). Non-operative management was employed in 68.8% of cases, while 30.9% underwent surgery. Surgical intervention was more frequent in higher-grade FFPs (e.g., 72.1% in Type IV). The most common surgical technique for the posterior pelvic ring was percutaneous screw fixation (61.3%), with navigation used in 47.4% of cases. Conclusions: This study highlights the variability in treatment strategies for FFPs, with conservative management predominating in lower-grade fractures and surgical approaches increasingly utilized for more complex cases. The findings underscore the need for standardized, evidence-based guidelines and further research to optimize treatment and long-term outcomes for geriatric patients with FFPs.