Injury Classification Research Articles

Performing Advanced Trauma Life Support (ATLS) across Borders: Midterm Follow-Up of the Aeromedical Evacuation after Civilian Bus Accident at Madeira.

On 17 April 2019, a coach with tourists from Germany crashed in Madeira, requiring repatriation by the German Air Force. The Advanced Trauma Life Support (ATLS) concept was the central component of patient care. Data in Madeira were collected through a structured interview. The analysis of the Aeromedical Evacuation was based on intensive care transport records. In Germany, all available medical data sheets were reviewed for data collection. Quality of life (HRQoL) was evaluated by the 12-item Short Form Health Survey (SF-12). Twenty-eight prehospital patients were transported to the Level III Trauma Center in Funchal (Madeira). Five operative procedures were performed. Fifteen patients were eligible for Aeromedical Evacuation (AE). In the second hospital phase in Germany, in total 82 radiological images and 9 operations were performed. Hospital stay lasted 11 days (median, IQR 10-18). Median follow-up (14 of 15 patients) was 16 months (IQR 16-21). Eighty percent (8 out of 10) showed an increased risk for post-traumatic stress disorder (PTSD). Six key findings were identified in this study: divergent injury classification, impact of AE mission on health status, lack of communication, need of PTSD prophylaxis, patient identification, and media coverage. Those findings may improve AE missions in the future, e.g., when required after armed conflicts.

Cellular senescence implication in mustard keratopathy

Mustard agents are vesicants that were used in warfare multiple times. They are potent alkylating agents that activate cellular pathways of apoptosis, increase oxidative stress, and induce inflammation. Eyes are particularly susceptible to mustard exposure with a wide range of ocular surface damage. Three main categories of mustard-related eye injuries are acute, chronic, and delayed-onset manifestations. Mustard keratopathy (MK) is a known complication characterized by corneal opacification, ulceration, thinning, and neovascularization that can lead to severe vision loss and discomfort. Recently, a few reports demonstrated the role of senescence induction as a new pathological mechanism in mustard-related injuries that could affect wound healing. We ran the first murine model of delayed-onset MK and nitrogen mustard-induced senescence, evaluating the pathological signs of senescence in the cornea using beta-galactosidase staining. Our results suggest that nitrogen mustard exposure causes senescence in the corneal cells, which could be the underlying mechanism for chronic and late-onset ocular surface damage. We also found a significant correlation between the percentage of positive beta-galactosidase staining and the degree of fibrosis in the cornea. This provides valuable insight into the possible role of anti-senescence drugs in the near future for accelerating corneal healing and restricting fibrosis in patients with mustard keratopathy.

Poster 257: Decreased time between injury and surgery and increased injury severity predict motion loss after multi-ligament knee injury, but are only part of the picture

Objectives: Postoperative motion loss is the most common complication following multiple ligament knee injuries (MLKIs). MLKIs are often associated with concomitant musculoskeletal and neurovascular injuries and complex surgical treatment; however, factors that increase the risk of postoperative motion loss remain largely unknown. The purpose of this study was to identify predictors of motion loss following MLKI. We hypothesized that injury classification (Knee Dislocation [KD] grade), and shorter time between injury and surgery would be independent predictors of postoperative motion loss. Methods: This was a multicenter retrospective review of 773 MLKIs that occurred between 2011 and 2015. MLKI was defined as a complete tear of two or more ligaments where at least 1 ligament was repaired or constructed. Individuals with a MLKI defined as a complete tear (grade III tear) of two or more ligaments that underwent surgical repair or reconstruction of at least one ligament were included. Cases with loss of motion were identified from review of follow-up documentation or the need for subsequent manipulation under anesthesia and/or lysis of adhesions. A multivariable logistic regression with forward variable entry (p<0.05) was performed to determine if any of the following variables were predictive of motion loss after MLKI: biological sex, KD grade, number of days between injury and surgery, graft type, use of external fixation, if staged procedures were performed, and associated vascular, nerve or tendon injury. Results: Of the 773 patients identified in the multicenter review, 562 (72.7%) had complete data for inclusion in the current analyses with 65 (11.6%) having postoperative motion loss (Table 1). Of the 562 patients (76.0% male, age=30.7±12.9 y, BMI=29±6.8 kg/m2), the median number of days between injury and surgery was 59 days (IQR=22-192 days). KD I injuries were the most common (59.6%) with 3.6% having KD II, 14.4% KD III-M, 13.9% KD III-L, 5.3% KD IV, and 3.2% KD V injuries. External fixation was used in 8.2% and 6.8% of the patients underwent staged procedures. Multiple graft combinations were used (all allograft = 37.5%, all autograft = 11.4%, combination = 48.9%, all repairs = 2.1%). Associated nerve injuries occurred in 19.8%, tendon injuries in 15.8%, and vascular injuries in 4.1%. Regression analysis identified decreased time between injury and surgery (OR=0.998, 95%CI[0.997-1.00]) and increased injury severity (KDIII OR=2.31, 95%CI[1.19-4.48], KDV OR=5.42, 95%CI[1.84-15.98]) as independent predictors of motion loss after MLKI (p < 0.001, Nagelkerke R2=0.08). Conclusions: While KD grade and time between injury and surgery are predictive of motion loss after MLKI, these variables only explain 8% of the variability in motion loss. This confirms that clinicians should be cognizant that decreased time between injury and surgery and more severe injuries may increase this risk of motion loss; however, postoperative factors not measured in this secondary analysis might more heavily impact motion loss after surgical treatment for MLKI. Future studies are necessary to identify other factors such as pre-operative ROM, the postoperative inflammatory state of the knee, utilization of physical therapy and/or psychosocial factors that might influence motion loss after MLKI reconstruction to better inform postoperative care. [Table: see text]

Paper 60: Effect of Mouthguard Type on Severity of Concussion During Game-Related College Football Competition. A 16-Season Prospective Study

Objectives: Prior studies have either claimed or disputed the role of mouthguard protection in reducing the incidence of concussion. Other than investigating a decrease in concussion rate, no long term studies have specifically compared the effect of type of mouthguard protection on the severity of concussion. The increasing incidence of head trauma in sport, the potential for long-term traumatic brain injury, and concerns of rising medical costs, dictate a focus on variables that may influence concussion severity in contact sports. Therefore, this study quantified the effect of mouthguard type on severity of concussion during game-related college football competition. Methods: 40 universities were evaluated over 16 competitive seasons (2006-2021) across all Football Bowl Subdivision (FBS) conferences. Mouthguard type was divided into two groups based on dentist- fitted and self-fitted (generic/boil and bite). Outcomes of interest included concussion severity (simple: 0-10 days time loss, complex: > 10 days time loss), injury category, player position, injury situation, injury mechanism, elective imaging, and playing surface. Data were subject to multivariate analyses of variance (MANOVA) and Wilks’ λ criteria using GLM procedures, and expressed as incidence rates (lR) per 10 game season. Results: Of the 2,332 games documented, 9,563 total injuries were reported, resulting in 708 (589 simple, 119 complex) concussion cases, consisting of 653 player-to-player contacts and 55 player-to- surface impacts. MANOVA indicated significant main effects of mouthguard type by concussion severity ( F1,705 = 3.587; P = .028), player position by team ( F2,705 = 3.551; P = .029), player position by skill position ( F8,699 = 2.373; P = .016), and injury mechanism ( F6,701 = 4.467; P < .001). Post hoc analyses indicated a significantly lower ( P = .023) incidence of complex concussions [1.3, (95% CI, 0.9-1.6) vs 2.1 (1.7-2.5)], with a significantly higher ( P = 0.014) occurrence of simple concussions [8.7, (95% CI, 8.4-9.1) vs 7.9 (7.5- 8.3)] while wearing dentist-fitted versus self-fitted mouthguards, respectively. Although significantly greater ( P <.05) incidences of concussion were documented across offensive teams [4.3, (95% CI, 3.8- 4.8) vs 3.3 (2.9-3.8)], quarterbacks [0.9, (95% CI, 0.6-1.2) vs 0.3 (0.2-0.6)], and players tackled above the waist [2.8, (95% CI, 2.4-3.3) vs 1.7 (1.4-2.1)] than observed across other teams and injury mechanisms while wearing dentist-fitted as compared to self-fitted mouthguards, respectively. The majority of these cases, however, were diagnosed as simple concussions. Of the 1,150 games (49.3%) played on a 3-layer artificial turf (≥9.0 lbs/ft2) infill system and 1,182 games (50.7%) played on natural grass, surface-related concussions on artificial turf (n = 26; 3.7% of total concussions; 21 simple, 5 complex concussions) and natural grass (n = 30; 4.2 % of total concussions; 23 simple, 7 complex concussions) were minimal and less severe on both surfaces than often perceived. Conclusions: The significantly lower incidence of complex concussions documented with dentist-fitted mouthguards during college football competition may reflect greater shock absorption and redistribution of energy during head impact due to more optimal fit and fabrication when compared to self-fitted mouth protection, translating to less severity of trauma and more expedient return to play. This longitudinal study directly compares and addresses type of mouthguards as they relate specifically to concussion severity. Although findings of this study may be generalizable only to this level of football competition, further research is warranted into lower levels of competition, e.g., high school, youth football, where the use of self-fitted mouthguards is prevalent.

Acute Cervical Spine Trauma: Imaging Assessment and Management

The intent of this article is to provide a comprehensive, educational overview of cervical spinal trauma, bringing together the mechanism of injury, imaging assessment, common injury patterns and classification systems, and acute management. Accompanying illustrations will act as powerful tools for comprehension. These concepts will be underpinned by frequent reference to neuroradiology and a grounding of cervical spinal anatomy. Although primarily aimed at the reporting radiologist, this article will serve as an important scholastic adjunct to other clinical specialties, including emergency physicians, trauma and orthopedic surgeons, and neurosurgeons.Learning Objective: To understand cervical spinal anatomy, describe the common mechanisms and patterns of cervical spinal injury, and identify injuries for which further imaging assessment is recommended

Management of late presented thoracolumbar spine fracture: Comparison of clinical and radiological outcome in anterior and posterior approach

Abstract Background: Between 5% and 10% of polytrauma patients suffer spinal fractures or dislocations. The vast majority of these injuries affect the motion segments between T11 and L2 at the thoracolumbar junction. A few thoracolumbar fractures may be treated conservatively by rigid orthosis and prompt mobilisation, but a large number of such injuries are better managed surgically. A variety of surgical approaches viz. Anterior, posterior or circumferential/combined are used to decompress and stabilise injured thoracolumbar spine. The ideal method is still a matter of some debate, and in most cases, the operative plan is influenced by both clinical and radiological conditions. The purpose of this study was to compare the results of anterior versus posterior decompression and reconstruction of the spine in late presentation (>3 weeks). Materials and Methods: A prospective and randomised study was conducted from September 2012 to August 2014. Thirty patients with thoracolumbar spinal fractures (D11–L2) were taken for the study as per inclusion/exclusion criteria. The patients were operated 3 weeks after the injury due to late presentation. All patients underwent decompression and fixation of the spine using various methods either by anterior approach or posterior approach (15 patients in each group). All patients had Thoracolumbar Injury Classification and Severity Score 5 or more with age belonging to the age group of 15–65 years. On admission, American Spinal Injury Association Impairment Score (ASIA score) was evaluated and Frankel grade was assigned to each patient. Operative time, intraoperative blood loss, intraoperative and postoperative complications were noted. Neurology was assessed again at the time of discharge after surgery and at follow-up at month and then at 3-month intervals. Radiological evaluation is done based on a kyphotic angle before surgery and at follow-up visits. Clinical outcome variables analysis was done using an Unpaired t test and Graph Pad software. Significance was set at the P < 0.05 level. Results: Of 30 patients, 15 belonged to each group. Group A (operated with an anterior approach) and group B (operated with a posterior approach) were comparable in terms of patient demographics, type of fracture, and follow-up duration. No patient suffered from neurological deterioration post-surgery. ASIA score improvement in group A is 66 points and in group B is 59 points. Frankel grade improvement is up to 1.3 in group A and 1.2 in group B. Cosmetic results were better in a posterior group with the shorter incision. Conclusion: With this comparative study, we find that the anterior approach is better in overall outcome if operated after 3 weeks of injury.

Neutrophil Gelatinase-Associated Lipocalin Cutoff Value Selection and Acute Kidney Injury Classification System Determine Phenotype Allocation and Associated Outcomes.

We explored the extent to which neutrophil gelatinase-associated lipocalin (NGAL) cutoff value selection and the acute kidney injury (AKI) classification system determine clinical AKI-phenotype allocation and associated outcomes. Cutoff values from ROC curves of data from two independent prospective cardiac surgery study cohorts (Magdeburg and Berlin, Germany) were used to predict Kidney Disease: Improving Global Outcome (KDIGO)- or Risk, Injury, Failure, Loss of kidney function, End-stage (RIFLE)-defined AKI. Statistical methodologies (maximum Youden index, lowest distance to [0, 1] in ROC space, sensitivity≍specificity) and cutoff values from two NGAL meta-analyses were evaluated. Associated risks of adverse outcomes (acute dialysis initiation and in-hospital mortality) were compared. NGAL cutoff concentrations calculated from ROC curves to predict AKI varied according to the statistical methodology and AKI classification system (10.6-159.1 and 16.85-149.3 ng/mL in the Magdeburg and Berlin cohorts, respectively). Proportions of attributed subclinical AKI ranged 2%-33.0% and 10.1%-33.1% in the Magdeburg and Berlin cohorts, respectively. The difference in calculated risk for adverse outcomes (fraction of odds ratios for AKI-phenotype group differences) varied considerably when changing the cutoff concentration within the RIFLE or KDIGO classification (up to 18.33- and 16.11-times risk difference, respectively) and was even greater when comparing cutoff methodologies between RIFLE and KDIGO classifications (up to 25.7-times risk difference). NGAL positivity adds prognostic information regardless of RIFLE or KDIGO classification or cutoff selection methodology. The risk of adverse events depends on the methodology of cutoff selection and AKI classification system.

Combined approach versus single Henry approach for fixation of die-punch distal radius fractures: a retrospective study

BackgroundDistal radius fracture (DRF) is one of the most common orthopaedic-related traumas. DRF patients with die-punch fractures have a higher risk of loss of reduction, poorer functional outcomes, and increased risk of complications even after open reduction and internal fixation (ORIF). According to the three-column theory, the lunate fossa is an important part of the intermediate column for load bearing. When the distal radius fracture involves the lunate fossa, adequate anatomical reduction can have an important impact on the prognosis of wrist function. Herein, we used the combined volar and dorsal approach, and the dorsal approach was used to assist in bone grafting or dorsal plate fixation in reducing fractures. We compare the combined approach versus the Henry approach for the fixation of die-punch distal radius fractures.MethodsWe reviewed patients who were admitted for surgery for die-punch fractures from January 2016 to June 2021. The patients were followed-up after surgery to measure and evaluate their Gartland–Werley wrist score, wrist range of motion (ROM), and follow-up imaging data.ResultsThere were 21 patients in the volar locking plate (VLP) group and 10 patients in the combined approach group. The majority of fractures in the VLP and combined approach groups were AO B and C fractures, respectively. The cause of injury and AO fracture classification showed significant differences between the two groups, and there was no difference in age or sex between the two groups. There was no significant difference in ROM between the two groups, but the VLP group presented a better Gartland–Werley score and volar tilt angle, and the combined group presented better maintenance in radial height and articular congruity.ConclusionsReduction through the combined palmar and dorsal approach supplemented by bone grafting or dorsal plate fixation is an effective method for the treatment of die-punch distal radius fractures, which provides a new option for the treatment of die-punch fractures.

Arthroscopy-Assisted Scapholunate Reconstruction With Internal Brace Augmentation

Various surgical techniques exist to repair or reconstruct complete scapholunate (SL) interosseous ligament tears, including capsulodesis, static or dynamic tenodesis, ligament reconstruction with tendon graft, bone-retinaculum-bone reconstruction, and the reduction and association of the scaphoid and lunate (RASL) procedure. The choice of surgical technique depends on arthroscopic assessment using the Geissler classification and European Wrist Arthroscopy Society staging of SL injury. This article describes arthroscopy-assisted extracapsular SL reconstruction using free tendon graft and internal brace augmentation for the treatment of unrepairable complete SL interosseous ligament tears.

Using guided credible history interviews to establish special education eligibility for students with traumatic brain injury.

In Oregon in 2019, only 261 students were eligible for special education under the traumatic brain injury (TBI) category. Many students with TBIs are not treated by a medical provider, so the requirement for a medical statement could prevent eligible youth from receiving special education services. This study investigated barriers to using a medical statement to establish special education eligibility for TBI, support for using a guided credible history interview (GCHI), and training needs around GCHI. Among participants, 84% reported difficulty obtaining a medical statement for TBI eligibility determination, and 87% favored the GCHI as an alternative, though they reported a need for training in TBI and GCHI. The results support the use of GCHI to establish special education eligibility for TBI and informed Oregon's addition of GCHI to TBI special education eligibility determination.

Colorado Needle Assisted Cross-Leg Flap

Lower limb injuries are most commonly due to road traffic accidents which cause lower limb defects.The management of lower limb fractures is guided by the Gustilo-Anderson classification of injuries. Simple leg defects are covered by localflap and complex defects by free flap. Complex defects of the lower limbs which were unfit for free flap require management by conventional cross leg flap. Colorado needle allows meticulous dissection of flaps due to the sharp tip and increases the efficiency in raising the flaps.

Concomitant vascular and bile duct injury in cholecystectomy

Aim . To evaluate the immediate and long-term outcomes in surgical treatment of concomitant vascular and bile duct injuries. Materials and methods. 157 patients with cicatricial strictures of the bile ducts were observed from 2012 to 2021. According to the Strasberg-Bismuth classification of bile ducts injuries, type E1-2 was detected in 22 patients, type E3 – in 77, and E4 – in 56 patients. 141 patients underwent cholecystectomy and five of them (4%) were detected with concomitant vascular and bile duct injury. Results . Hemihepatectomy with bile duct reconstruction was performed in two cases; three patients underwent bile duct reconstruction only. One patient died in the early postoperative period, three patients continue treatment. In one case, treatment was successfully completed. Conclusion . Concomitant vascular and bile duct injury is a rare and severe complication of cholecystectomy. Success of treatment depends on the level and character of the vessels and bile duct damage, and treatment strategy.

#5569 ASSOCIATION OF URINARY CCL14 WITH PLASMA PROTEIN BIOMARKERS IN CRITICALLY ILL SEPSIS PATIENTS WITH PERSISTENT ACUTE KIDNEY INJURY

Abstract Background and Aims The urinary concentration of CC chemokine ligand 14 (CCL14) – a chemoattractant for T-cells and monocytes – has recently been identified as a strong predictor of persistence of severe acute kidney injury (AKI). The mechanisms by which CCL14 mediates persistent severe AKI are not yet completely understood. With sepsis being the most frequent cause of AKI, we wanted to externally validate whether urinary CCL14 concentration can differentiate sepsis patients with and without persistence of AKI, and its association with plasma protein biomarkers reflective of three pathophysiological pathways. Method Patients admitted with sepsis to the intensive care unit (ICU) were categorized according to the evolution of AKI (no-AKI, transient-AKI, and persistent-AKI, defined as lasting > 48h), and matched to a 1:1:1 ratio. AKI was assessed prospectively and daily, using the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification. Transient- and persistent-AKI patients had at least injury or failure (severe) RIFLE stages. Urine samples collected at ICU admission were analyzed for CCL14 level; in the same patient cohort we measured 9 plasma biomarkers reflective of systemic inflammation and cytokine responses, endothelial cell activation, and loss of endothelial barrier function. We applied a recently proposed cutoff of 1.3 ng/mL for high CCL14 for the identification of patients at high risk for persistent severe AKI. Results of 211 sepsis patients enrolled, 72 patients did not have AKI, 71 had transient AKI and 68 had persistent AKI. Majority of patients with high CCL14 had a persistent AKI (23 out of 31; 74.2%). CCL14 showed good discrimination between persistent-AKI and no-AKI (Area Under the ROC Curve [AUC], 0.82, 95%CI 0.75-0.89), and moderate discrimination between persistent-AKI and transient-AKI (AUC 0.71, 95%CI 0.55-0.87). High CCL14 was associated with higher disease severity as measured by APACHE-IV score, and source of infection being the urinary tract, and skin. The plasma protein analysis revealed that high urinary CCL14 was associated with more prominent systemic (anti-)inflammatory and cytokine responses, and signs of disrupted endothelial barrier function (shown by elevated interleukin [IL]-8 and IL-10, and decreased angiopoietin-1 [P = .005; P = .004; P = .009, respectively]). Within the persistent-AKI group, baseline characteristics (age, chronic comorbidities, and disease severity) did not differ between CCL14 groups, and high CCL14 was only associated with decreased angiopoietin-1 (P = .003). Conclusion External validation of urinary CCL14 showed good discrimination in critically ill sepsis patients between persistent AKI and no-AKI, and moderate discriminative ability to separate transient-AKI. High urinary CCL14 identifies persistent-AKI sepsis patients with more profound dysregulation of inflammatory pathways coupled with loss of endothelial barrier function. This could guide future therapeutic strategies targeting subgroups within the AKI population.

#2572 CLINICAL CHARACTERISTICS OF ACUTE KIDNEY INJURY IN PATIENTS WITH GLUFOSINATE POISONING

Abstract Background and Aims Glufosinate-containing herbicide is widely used in agriculture. According to previous reports, glufosinate poisoning causes various complications, but there are few reports of nephrotoxicity. In this study, we investigated the incidence and clinical characteristics of acute kidney injury (AKI) in patients with glufosinate poisoning. Method This study performed between 2008 and 2021 included 76 patients categorized into the AKI and the non-AKI groups. The incidence, clinical characteristics, and severity of AKI were compared between the AKI (n=54) and the non-AKI (n=22) groups, based on the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease classification. Results The incidence of AKI was 71.1%, of which 40.9%, 26.3%, and 3.9% patients were classified into the Risk, Injury, and Failure categories, respectively. Patients in the AKI group were older (62.6±14.2 years vs. 54.9±16.2 years, P=0.045) and poorer renal function (73.9±25.2 mL/min/1.73 m² vs. 94.5±35.5 mL/min/1.73 m², P=0.006) on admission. The length of hospitalization was longer (17.2±17.2 days vs. 7.6±7.6 days, P=0.014) in AKI group, and the mean amount of glufosinate ingested was higher in AKI group than that in non-AKI group (250±172 mL vs. 152±121 mL, P=0.032). In addition, the serum bicarbonate level was lower in AKI group than in non-AKI group (19.9±4.7 vs. 23.0±3.3, P=0.006). Notably, intensive care unit admissions (81.5% vs. 40.9%, P=0.001) and mechanical ventilator support (68.5% vs. 22.7%, P<0.001) were more frequently required in the AKI group. Multivariate logistic regression analysis showed that serum bicarbonate concentration on admission remained significant predictors of AKI in patient with glufosinate poisoning. Conclusion Serum bicarbonate is helpful to predict the development of patients with glufosinate poisoning.

#6695 THE ROLE OF A DEEP LEARING MODEL FOR EVALUATING HISTOPATHOLOGY OF ACUTE RENAL TUBULAR INJURY

Abstract Background and Aims Acute tubular injury is the most common intrinsic cause in acute kidney injury. Histopathological diagnosis may help distinguish between different types of acute kidney injury and aid in treatment. Currently, there have not been any studies that uses deep learning model for assisting histopathological diagnosis in acute kidney injury. The aim of our study is histopathological classification and segmentation identified four structures of acute renal tubular injury based on deep learning models. Method We used injury classification model to evaluate the degree of renal injury (grade 0, grade 1 and grade 2) and segmentation model (glomerulus, healthy tubules, tubules with cast, and necrotic tubules) specifically to classify the tubular specific injury after cisplatin treatment. We trained a classification model using ResNet-18 to classify the grade of acute tubular injury and a segmentation model using DeepLabV3 with ResNet-50 backbone for four structures of the mouse PAS-stained histopathology of acute renal tubular injury. Results The classification algorithm achieved area under the receiver operating characteristics curve of 0.98, 0.77, and 0.80 for grade 0, grade 1, and grade 2, respectively. In segmentation model for four structures, the highest Intersection over Union and the Dice coefficient were obtained for the segmentation of “glomerulus” class, followed by the “healthy tubules”, “tubules with cast”, and “necrotic tubules” classes. The overall performance of the segmentation algorithm for all classes in the test set is Intersection over Union 0.7256, Dice coefficient 0.8185. Conclusion The predictive model by deep learning could identify the histopathological structures and classify the grade of renal tubular injury, and may contribute to a more effective evaluation of renal pathology.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of Interosseous Suture and Endobutton Across Age Groups.

Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in theelectronic health record. Univariate analysis, including chi-square and independent t-tests, was used.Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.

Global Validation of the AO Spine Upper Cervical Injury Classification: Erratum.

Global Validation of the AO Spine Upper Cervical Injury Classification: Erratum.

The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study

BackgroundRobotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients. MethodsAll patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels. ResultsForty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach. ConclusionsThis initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance.

Computed tomography findings of hepatobiliary systems in patients with immune checkpoint inhibitor-induced liver injury.

The incidence of immune checkpoint inhibitor (ICI)-induced liver injury has increased recently; however, its imaging characteristics remain unclear. This study aimed to characterize the computed tomography (CT) findings of ICI-induced liver injury. This was a single-center retrospective study of patients with ICI-induced liver injury who underwent CT between January 2020 and December 2021. Two board-certified radiologists independently evaluated the CT findings of the patients before the start of ICI therapy (pre-CT)and at the onset of ICI-induced liver injury (post-CT) to determine the presence or absence of imaging findings suggestive of hepatitis and cholangitis. ICI-induced liver injury was classified into three categories based on the CT findings: hepatitis alone, cholangitis alone, and overlapped (cholangitis plus hepatitis). A total of 19 patients were included in this study. Bile duct dilatation, bile duct wall thickening, non-edematous gallbladder wall thickening, hepatomegaly, periportal edema, and gallbladder wall edema were observed in the post-CT images of 12 (63.2%), 9 (60%), 11 (57.9%), 8 (42.1%), 6 (31.6%), and 2 (10.5%) patients, respectively. Wall thickening in the perihilar, distal, intrapancreatic bile duct and the cystic duct were observed in 53.3%, 60%, 46.7%, and 26.7% of the study population, respectively. Regarding the classification of ICI-induced liver injury, cholangitis alone was most common (36.8%), followed by overlapped (26.3%) and hepatitis alone (26.3%). Patients with ICI-induced liver injury demonstrated a higher incidence of biliary abnormalities than hepatic abnormalities on CT images; nonetheless, future studies with larger sample sizes are needed to validate these findings.

Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor

An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.