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Background: Severe injuries caused by accidents, like traumatic brain injury (TBI) or thoracic trauma (TT) continue to be the leading cause of death in younger people with relevant socio-economic impact. Fast and targeted diagnostics is essential for further therapy decisions and prognosis. The following study investigates NSE as a potential biomarker for lung injury after blunt TT., Methods: This is a retrospective analysis of prospectively collected data in a level-1 trauma center from 2014 to 2020. Serum levels of Neuron-specific Enolase (NSE) and Interleukins (IL-6, IL-10) in injured patients (n = 41) with isolated TT (AISthorax ≥ 3) compared to isolated TBI (AIShead ≥ 3) were assessed from day 0 to 5 after trauma. The extend of lung injury was quantified by Hounsfield scale in CT scans., Results: 30 patients with TT (ISSmed = 20, age 50y ± 17, 83,3% male) and 11 patients with TBI (ISSmed = 25, age 54y ± 17,27,3% male) were included. After TT, NSE concentration increased initially after trauma with a peak value on the day of admission (8.51 ± 3.68 ng/ml) compared to healthy controls (4.51 ± 1.504 ng/ml, p < 0.001). Isolated thoracic trauma and TBI lead to equally strong NSE release ad the day of admission. There is a significant linear relationship (r = 0.636, p = 0.035) between serum NSE levels and severity of pulmonary contusion at the time of admission and after 24 hours., Conclusion: A significant NSE release after isolated thoracic trauma peaks on the day of admission. The extent of lung contusion volume (defined as alveolar parenchymal density) correlates with NSE serum concentration. Thus, NSE has predictive value for the extent of pulmonary contusion. However, according to these data, NSE seems to have no diagnostic value as a TBI biomarker in concomitant TT., Competing Interests: Conflict of Interest: Anna C. Rix, P. Störmann, J.-T. Vollrath, J-A. Hörauf, K. Eichler, I. Marzi and C. R. Schindler declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 by the Shock Society.)

Purpose: The aim of this retrospective study was to identify independent prognostic factors for developing a postoperative delirium (POD) in patients suffering from a proximal femoral neck fracture and treated by implantation of a hemiprosthesis., Methods: A retrospective study, including patients with hip hemiarthroplasty due to a femoral neck fracture between 2011 and 2020 was performed. Demographic data, preexisting conditions, intra-/postoperative complications, mobilization and laboratory results were extracted from the patients' charts. The different parameters were analyzed comparing patients with and without POD., Results: 412 patients, mean age of 81 ± 9.58 years were included, 66.5% (n = 274) were female, 18.2% (n = 75) of them developed a POD. Significantly higher incidence of POD was associated with older age (p < 0.001), lower level of haemoglobin (p < 0.001), higher post-surgery interleukin 6 (IL 6) level (p = 0.008), higher postoperative level of leukocytes (p = 0.01). Patients with POD received more units of packed red blood cells (PRBC) (p = 0.007). Patients with no mobility limitations pre-operatively developed POD less frequently (p = 0.01), whereas suffering from pneumonia (p = 0.03) or limited mobility postoperatively increased the risk of POD (p < 0.001)., Conclusion: This study could help to identify patients with a risk for developing POD after a hemiarthroplasty in femoral neck fractures. As a consequence, frequent controls of Hb, IL 6 and leucocytes levels to avoid anemia and infections, as well as the well surgical treatment to guarantee a good postoperative outcome., (© 2024. The Author(s).)

Methods: Due to demographic change, the number of polytraumatized geriatric patients (> 64 years) is expected to further increase in the coming years. In addition to the particularities of the accident and the associated injury patterns, prolonged inpatient stays are regularly observed in this group. The aim of the evaluation is to identify further factors that cause prolonged inpatient stays. A study of the data from the TraumaRegister DGU® from 2016-2020 was performed. Inclusion criteria were an age of over 64 years, intensive care treatment in the GAS-region, and an Injury Severity Score (ISS) of at least 16 points. All patients who were above the 80th percentile for the average length of stay or average intensive care stay of the study population were defined as so-called long-stay patients. This resulted in a prolonged inpatient stay of > 25 days and an intensive care stay of > 13 days. Among other, the influence of the cause of the accident, injury patterns according to body regions, the occurrence of complications, and the influence of numerous clinical parameters were examined., Results: A total of 23,026 patients with a mean age of 76.6 years and a mean ISS of 24 points were included. Mean ICU length of stay was 11 ± 12.9 days (regular length of stay: 3.9 ± 3.1d vs. prolonged length of stay: 12.8 ± 5.7d) and mean inpatient stay was 22.5 ± 18.9 days (regular length of stay: 20.7 ± 15d vs. 35.7 ± 22.3d). A total of n = 6,447 patients met the criteria for a prolonged length of stay. Among these, patients had one more diagnosis on average (4.6 vs. 5.8 diagnoses) and had a higher ISS (21.8 ± 6 pts. vs. 26.9 ± 9.5 pts.) Independent risk factors for prolonged length of stay were intubation duration greater than 6 days (30-fold increased risk), occurrence of sepsis (4x), attempted suicide (3x), presence of extremity injury (2.3x), occurrence of a thromboembolic event (2.7x), and administration of red blood cell concentrates in the resuscitation room (1.9x)., Conclusions: The present analysis identified numerous independent risk factors for significantly prolonged hospitalization of the geriatric polytraumatized patient, which should be given increased attention during treatment. In particular, the need for a smooth transition to psychiatric follow-up treatment or patient-adapted rehabilitative care for geriatric patients with prolonged immobility after extremity injuries is emphasized by these results., (© 2024. The Author(s).)

Background: The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures., Methods: This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach., Results: A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2)., Conclusion: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room., Level of Evidence: Delphi-Consensus/Systematic Review; Level IV., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Background: Frontotemporal lobar degeneration with ubiquitin-positive inclusions (FTLD-TDP), amyotrophic lateral sclerosis (ALS) and limbic-predominant age-related TDP-43 encephalopathy (LATE) are associated with deposition of cytoplasmic inclusions of TAR DNA-binding protein 43 (TDP-43) in neurons. One complexity of this process lies in the ability of TDP-43 to form liquid-phase membraneless organelles in cells. Previous work has shown that the recombinant, purified, prion-like domain (PrLD) forms liquid droplets in vitro, but the behaviour of the complementary fragment is uncertain., Methods: We have purified such a construct without the PrLD (PrLD-less TDP-43) and have induced its phase separation using a solution-jump method and an array of biophysical techniques to study the morphology, state of matter and structure of the TDP-43 assemblies., Results: The fluorescent TMR-labelled protein construct, imaged using confocal fluorescence, formed rapidly (< 1 min) round, homogeneous and 0.5-1.0 µm wide assemblies which then coalesced into larger, yet round, species. When labelled with AlexaFluor488, they initially exhibited fluorescence recovery after photobleaching (FRAP), showing a liquid behaviour distinct from full-length TDP-43 and similar to PrLD. The protein molecules did not undergo major structural changes, as determined with circular dichroism and intrinsic fluorescence spectroscopies. This process had a pH and salt dependence distinct from those of full-length TDP-43 and its PrLD, which can be rationalized on the grounds of electrostatic forces., Conclusions: Similarly to PrLD, PrLD-less TDP-43 forms liquid droplets in vitro through liquid-liquid phase separation (LLPS), unlike the full-length protein that rather undergoes liquid-solid phase separation (LSPS). These results offer a rationale of the complex electrostatic forces governing phase separation of full-length TDP-43 and its fragments. On the one hand, PrLD-less TDP-43 has a low pI and oppositively charged domains, and LLPS is inhibited by salts, which attenuate inter-domain electrostatic attractions. On the other hand, PrLD is positively charged due to a high isoionic point (pI) and LLPS is therefore promoted by salts and pH increases as they both reduce electrostatic repulsions. By contrast, full-length TDP-43 undergoes LSPS most favourably at its pI, with positive and negative salt dependences at lower and higher pH, respectively, depending on whether repulsive or attractive forces dominate, respectively., (© 2024. The Author(s).)

A macrophage shift from the M1 to the M2 phenotype is relevant for promoting tissue repair and regeneration. In a previous in vivo study, we found that direct current (DC) electrical stimulation (EStim) increased the proportion of M2 macrophages in healing tissues and directed the balance of the injury response away from healing/scarring towards regeneration. These observations led us to hypothesize that DC EStim regulates macrophage polarization towards an M2 phenotype. THP-1-derived M0, M1 (IFN-γ and LPS), and M2 (IL-4 and IL-13) macrophages were exposed (or not: control group) to 100 mV/mm of DC EStim, 1 h/day for three days. Macrophage polarization was assessed through gene and surface marker expressions and cytokine secretion profiles. Following DC EStim treatment, M0 cells exhibited an upregulation of M2 marker genes IL10, CD163, and PPARG. In M1 cells, DC EStim upregulated the gene expressions of M2 markers IL10, TGM2, and CD206 and downregulated M1 marker gene CD86. EStim treatment also reduced the surface expression of CD86 and secretion of pro-inflammatory cytokines IL-1β and IL-6. Our results suggest that DC EStim differentially exerts pro-M2 effects depending on the macrophage phenotype: it upregulates typical M2 genes in M0 and M1 cells while inhibiting M1 marker CD86 at the nuclear and protein levels and the secretion of pro-inflammatory interleukins in M1 cells. Conversely, M2 cells appear to be less responsive to the EStim treatment employed in this study.

The field of regenerative medicine is increasingly in need of effective and biocompatible materials for tissue engineering. Human acellular dermal matrix (hADM)-derived collagen matrices stand out as a particularly promising candidate. Their ability to preserve structural integrity, coupled with exceptional biocompatibility, positions them as a viable choice for tissue replacement. However, their clinical application has been largely confined to serving as scaffolds. This study aims to expand the horizon of clinical uses for collagen sheets by exploring the diverse cutting-edge clinical demands. This review illustrates the clinical utilizations of collagen sheets beyond traditional roles, such as covering skin defects or acting solely as scaffolds. In particular, the potential of Epiflex ® , a commercially available and immediately clinically usable allogeneic membrane, will be evaluated. Collagen sheets have demonstrated efficacy in bone reconstruction, where they can substitute the induced Masquelet membrane in a single-stage procedure, proving to be clinically effective and safe. The application of these membranes allow the reconstruction of substantial tissue defects, without requiring extensive plastic reconstructive surgery. Additionally, they are found to be apt for addressing osteochondritis dissecans lesions and for ligament reconstruction in the carpus. The compelling clinical examples showcased in this study affirm that the applications of human ADM extend significantly beyond its initial use for skin defect treatments. hADM has proven to be highly successful and well-tolerated in managing various etiologies of bone and soft tissue defects, enhancing patient care outcomes. In particular, the application from the shelf reduces the need for additional surgery or donor site defects.

Background: Extracellular particles (EPs), particularly extracellular vesicles, play a crucial role in regulating various pathological mechanisms, including immune dysregulations post-trauma. Their distinctive expression of cell-specific markers and regulatory cargo such as cytokines or micro-ribonucleic acid suggests their potential as early biomarkers for organ-specific damage and for identifying patients at risk for complications and mortality. Given the critical need for reliable and easily assessable makers to identify at-risk patients and guide therapeutic decisions, we evaluated the early diagnostic value of circulating EPs regarding outcomes in severely injured multiple-trauma patients., Methods: Plasma samples were collected from 133 severely injured trauma patients (Injury Severity Score (ISS) ≥16) immediately upon arrival at the emergency department (ED). Patients were categorized into survivors and non-survivors. Injury characteristics and outcomes related to sepsis, pneumonia, or early (<1 day after admission) and late mortality were assessed. Circulating EPs, cytokine profiles, and blood counts of platelets and leukocytes were determined. Receiver operating characteristic analyses were conducted., Results: Despite no significant differences in injury pattern or severity, non-survivors exhibited significantly elevated counts of circulating EPs compared to survivors. The optimal cut-off for EPs <200 nm indicating non-survivors was 17380/µl plasma, with a sensitivity of 77% and a specificity of 61% in predicting in-hospital mortality. Later non-survivors received significantly higher numbers of units of packed red blood cells [8.54 ± 5.45 vs. 1.29 ± 0.36 units], had higher serum lactate [38.00 ± 7.51 vs. 26.98 ± 1.58 mg/dL], significantly lower platelet counts [181.30 ± 18.06 vs. 213.60 ± 5.85 *10³/µL] and lower heart rates [74.50 ± 4.93 vs. 90.18 ± 2.06 beats/minute] upon arrival at the ED compared to survivors., Conclusion: Our results demonstrate the high diagnostic potential of elevated concentrations of circulating EPs <200 nm for identifying patients at risk of mortality after severe trauma. This parameter shows comparable sensitivity to established clinical predictors. Early evaluation of EPs concentration could complement assessment markers in guiding early therapeutic decisions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Becker, Franz, Eguchi, Wagner, Sturm, Rinderknecht, Kobayashi, Iwasa, Weber, Marzi and Relja.)

Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIS head (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.

Introduction: Fixation of major fractures plays a pivotal role in the surgical treatment of polytrauma patients. In addition to ongoing discussions regarding the optimal timing in level I trauma centers, it appears that the respective trauma systems impact the implementation of both, damage control and safe definitive surgery strategies. This study aimed to assess current standards of polytrauma treatment in a Europe-wide survey., Methods: A survey, developed by members of the polytrauma section of ESTES, was sent online via SurveyMonkey ® , between July and November 2020, to 450 members of ESTES (European Society of Trauma and Emergency Surgery). Participation was voluntary and anonymity was granted. The questionnaire consisted of demographic data and included questions about the definition of "polytrauma" and the local standards for the timing of fracture fixation., Results: In total, questionnaires of 87 participants (19.3% response rate) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years, and on average, 17 multiple-injured patients were treated monthly. Most of the participants stated that a polytrauma patient is defined by ISS ≥ 16 (44.16%), followed by the "Berlin Definition" (25.97%). Systolic blood pressure < 90 mmHg, tachycardia or vasopressor administration (86.84%), pH deviation, base excess shift (48.68%), and lactate > 4 mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three most often stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytrauma patients. Normal coagulation (79.69%), missing administration of vasopressors (62.50%), and missing clinical signs of "SIRS" (67.19%) were stated as criteria for safe definite secondary surgery., Conclusion: Different definitions of polytrauma are used in the clinical setting. Indication for and the extent of secondary (definitive) surgery are mainly dependent on the polytrauma patient`s physiology. The «Window of Opportunity» plays a less important role in decision making., (© 2022. The Author(s).)

Background: Two-tier trauma team activation (TTA)-protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15)., Methods: We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15., Results: During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67-0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001)., Conclusions: The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage., Level of Evidence: Level IV, retrospective cohort study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures., Methods: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023., Results: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared., Conclusions: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes., (© 2024. The Author(s).)

Background: Benefit of implant removal in spine surgery remains unclear. While there is mostly consensus about necessity of implant removal in posterior-only stabilized patients, the effect of this measure in cases with combined anterior-posterior stabilization is undetermined. With this work we present a retrospective analysis of 87 patients with traumatic thoracolumbar vertebral fractures concerning quality of life (QOL), loss of correction (LOC) and range of motion (ROM). The effect of implant removal on the outcome 18-74 months after surgery was analyzed to determine how implant removal affects radiologic, functional and quality-of life-related parameters., Patients and Methods: 87 patients suffering from a traumatic vertebral body fracture (T11 - L2) were included. Quality of life was determined using four different scoring systems (SF 36, VAS, Oswestry, LBOS). Clinical examination included range of motion. Radiologic findings were correlated with QOL., Results: Patients with removal of the internal fixator had a trend towards better range of motion than patients with posterior instrumentation left in place. Radiologic findings showed no correlation to QOL. Implant removal led to better values in Oswestry and SF-36. 69% of patients after removal reported a reduction of their symptoms.All patients with persistence of severe pain after implant removal belonged to subgroup II.2 (anterior monosegmental fusion with bone graft)., Conclusion: Removal of the internal fixator can lead to a reduction of symptoms. Patient selection is crucial for successful indication. Radiologic findings do not correlate with QOL., (© 2024 The Authors.)

In the last few years, several studies have emphasized the existence of injury-specific EV "barcodes" that could have significant importance for the precise diagnosis of different organ injuries in polytrauma patients. To expand the research potential of the NTF (network trauma research) biobank of polytraumatized patients, the NTF research group decided to further establish a biobank for EVs. However, until now, the protocols for the isolation, characterization, and storage of EVs for biobank purposes have not been conceptualized. Plasma and serum samples from healthy volunteers (n = 10) were used. Three EV isolation methods of high relevance for the work with patients' samples (ultracentrifugation, size exclusion chromatography, and immune magnetic bead-based isolation) were compared. EVs were quantified using nanoparticle tracking analysis, EV proteins, and miRNAs. The effects of different isolation solutions; the long storage of samples (up to 3 years); and the sensibility of EVs to serial freezing-thawing cycles and different storage conditions (RT, 4/-20/-80 °C, dry ice) were evaluated. The SEC isolation method was considered the most suitable for EV biobanking. We did not find any difference in the quantity of EVs between serum and plasma-EVs. The importance of particle-free PBS as an isolation solution was confirmed. Plasma that has been frozen for a long time can also be used as a source of EVs. Serial freezing-thawing cycles were found to affect the mean size of EVs but not their amount. The storage of EV samples for 5 days on dry ice significantly reduced the EV protein concentration.

Background: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature., Methods: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society., Results: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training., Conclusions: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts., (© 2024. The Author(s).)

Sepsis as a severe systemic inflammation leads oftentimes to organ dysfunction and subsequently to death. In polytrauma patients, septic complications represent with 45% the predominant cause of late death and are responsible for extremely high costs in the healthcare system. Therefore, clinicians have to detect as early as possible the begin of sepsis to improve the patient's outcome. One new promising diagnostic tool to diagnose septic complications in polytraumatized patients are exosomes. Plasma samples from polytraumatized patients (Injury Severity Score (ISS) ≥16) which developed sepsis (n = 10) and without sepsis (n = 10), were collected at emergency room (ER), 24h and 5 days after trauma. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with plasma EVs from healthy controls (n = 10). Moreover, exosomal cytokine concentrations were measured via high-sensitive ELISA and were correlated with systemic concentrations. For miRNA cargo analysis, we analysed the miRNAs miR-1298-5p, miR-1262, miR-125b-5p, miR-92a-3p, miR-93-5p, miR-155-5p and miR-21-5p and compared their exosomal concentrations by means of RT-qPCR. CD62p + exosomes were significantly increased in septic polytrauma-patients (p ≤ 0.05), while CD40+exosomes, as well as CD49e + exosomes were diminished (p ≤ 0.05). Furthermore, we observed that the exosomal IL-6 concentration reflects the systemic IL-6 concentration (r 2  = 0.63) and did not significantly alter between patients with and without sepsis. The exosomal IL-10 concentration seemed to be constant in all patients and healthy controls. We observed that a decrease of miR-21-5p in exosomes was associated with the development of sepsis (p ≤ 0.05), while exosomal miR-93-5p, miR-155-5p and miR-92a-3p were not specifically altered in septic patients. Taken together, the present study in polytraumatized patients demonstrated that the development of sepsis is associated with an increase of CD62p + exosomes. Furthermore, the exosomal cargo was changed in septic patients: miR-21-5p was diminished., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The goal of this study was to identify changes in extracellular vesicles (EV) surface proteins specific to traumatic brain injury (TBI), which could be used as a diagnostic and prognostic tool in polytrauma patients., Summary Background Data: Known serum TBI-specific biomarkers (S100B, NSE, and GFAP), which can predict the severity and outcome of isolated TBI, lose their predictive value in the presence of additional extracranial injuries. Extracellular vesicles (EVs) are released from cells in response to various stimuli and carry specific cargo/surface molecules that could be used for tracking injury-responding cells., Methods: EVs were isolated using size exclusion chromatography (SEC) from the plasma of two groups of patients (with isolated TBI, ISS≥16, AIShead≥4, n=10; and polytraumatized patients without TBI ISS≥16, AIShead=0, n=10) collected in the emergency room and 48 h after trauma. EVs' surface epitope expression was investigated using a neurospecific multiplex flow cytometry assay and compared with healthy controls (n=10). Three enrichments of EV epitopes found to be specific to TBI were validated by western blot., Results: The expression of 10 EV epitopes differed significantly among the patient and control groups, and five of these epitopes (CD13, CD196, MOG, CD133, and MBP) were TBI-specific. The increased expression of CD196, CD13, and MOG-positive EVs was validated by western blot., Conclusion: Our data showed that TBI is characterized by a significant increase of CD13, CD196, MOG, CD133, and MBP-positive EVs in patients' plasma. A high level of MOG-positive EVs negatively correlated with the Glasgow Coma Scale score at admission and could be an indicator of poor neurological status., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Schindler, Hörauf, Weber, Schaible, Marzi, Henrich and Leppik.)

Purpose: Soft tissue infections can be severe and life-threatening. Their treatment consists currently in radical surgical wound debridement and combined systemic antimicrobial therapy. Different side effects are possible. Local antibiotic therapy represents a new approach to reduce side effects and improve healing. The aim of this study is to assess the effectiveness of the local sprayed use of antibiotics with fibrin sealing compared with negative pressure wound therapy as an established treatment of soft-tissue infections., Methods: In this retrospective study, patients with soft tissue infections who underwent surgical treatment were analysed. One group consists of patients, who received local fibrin-antibiotic spray (FAS) (n = 62). Patients treated by vacuum-assisted wound therapy (VAWT) as the established treatment were the control group (n = 57). Main outcomes were differences in the success of healing, the duration until healing and the number of needed operations., Results: Clinical healing could be achieved for 55 patients (98.21%) in the FAS group vs. 47 patients (92.16%) in the VAWT group (p = 0.19). Time to require this was 10.65 ± 10.38 days in the FAS group and 22.85 ± 14.02 days in the VAWT group (p < 0.001). In the FAS group, patients underwent an average of 1.44 ± 0.72 vs.3.46 ± 1.66 operations in the VAWT group (p < 0.001)., Conclusion: Compared to vacuum-assisted wound therapy in soft tissue infections, local fibrin-antibiotic spray shows faster clinical healing and less needed operations. Leading to shorter hospital stays and more satisfied patients. The combination of sprayed fibrin and antibiotics can be seen as a promising and effective method., (© 2024. The Author(s).)

Background: Polytrauma is one of the leading mortality factors in younger patients, and in particular, the presence of cardiac damage correlates with a poor prognosis. Currently, troponin T is the gold standard, although troponin is limited as a biomarker. Therefore, there is a need for new biomarkers of cardiac damage early after trauma. Methods: Polytraumatized patients (ISS ≥ 16) were divided into two groups: those with cardiac damage (troponin T > 50 pg/mL, n = 37) and those without cardiac damage (troponin T < 12 pg/mL, n = 32) on admission to the hospital. Patients' plasma was collected in the emergency room 24 h after trauma, and plasma from healthy volunteers (n = 10) was sampled. The plasma was analyzed for the expression of HFABP, GDF-15 and uPAR proteins, as well as miR-21, miR-29, miR-34, miR-122, miR-125b, miR-133, miR-194, miR-204, and miR-155. Results were correlated with patients' outcomes. Results: HFABP, uPAR, and GDF-15 were increased in polytraumatized patients with cardiac damage ( p < 0.001) with a need for catecholamines. HFABP was increased in non-survivors. Analysis of systemic miRNA concentrations showed a significant increase in miR-133 ( p < 0.01) and miR-21 ( p < 0.05) in patients with cardiac damage. Conclusion: All tested plasma proteins, miR-133, and miR-21 were found to reflect the cardiac damage in polytrauma patients. GDF-15 and HFABP were shown to strongly correlate with patients' outcomes.

Objective: This study aimed to evaluate the effectiveness of a 3D-printed hands-on radius fracture model for teaching courses. The model was designed to enhance understanding and knowledge of radius fractures among medical students during their clinical training., Methods: The 3D models of radius fractures were generated using CT scans and computer-aided design software. The models were then 3D printed using Fused-Filament-Fabrication (FFF) technology. A total of 170 undergraduate medical students participated in the study and were divided into three groups. Each group was assigned one of three learning aids: conventional X-ray, CT data, or a 3D-printed model. After learning about the fractures, students completed a questionnaire to assess their understanding of fracture mechanisms, ability to assign fractures to the AO classification, knowledge of surgical procedures, and perception of the teaching method as well as the influence of such courses on their interest in the specialty of trauma surgery. Additionally, students were tested on their ability to allocate postoperative X-ray images to the correct preoperative image or model and to classify them to the AO classification., Results: The 3D models were well received by the students, who rated them as at least equal or better than traditional methods such as X-ray and CT scans. Students felt that the 3D models improved their understanding of fracture mechanisms and their ability to explain surgical procedures. The results of the allocation test showed that the combination of the 3D model and X-ray yielded the highest accuracy in classifying fractures according to the AO classification system, although the results were not statistically significant., Conclusion: The 3D-printed hands-on radius fracture model proved to be an effective teaching tool for enhancing students' understanding of fracture anatomy. The combination of 3D models with the traditional imaging methods improved students' ability to classify fractures and allocate postoperative images correctly., (© 2023. The Author(s).)

Proximal humerus fractures are common in an aging population. The standard operative treatment is open reduction internal fixation (ORIF) using an angular stable plate. However, this procedure has complications such as a relatively high rate of secondary dislocation, humeral head necrosis or nonunion caused by delayed bony consolidation. Autologous bone marrow mononuclear cells (BMC) combined with a β-TCP scaffold could support bone healing and is considered clinically safe. This multicentric, randomized, open phase IIa clinical trial (Clinical Trials. Gov Identifier: NCT02803177, Eudra CT No: 2015-001820-51) evaluated whether autologous BMC with β-TCP in addition to ORIF reduces the incidence of secondary dislocations in patients with proximal humerus fracture. Ninty-four patients equally divided between verum group (BMC+β-TCP) and control group (ß-TCP only) were targeted and calculated. At the time of planned interim evaluation, ie, enrolment of 56 patients, no statistical difference in secondary dislocations or complications was demonstrated in either group after an observation period of 12 weeks. Radiographic bone healing and DASH score to determine shoulder function were comparable between both groups. Bone marrow harvest and BMC transplantation did not result in any severe adverse events. Therefore, the study was terminated after the interim analysis, as no other result could be expected. From the study results, it can be concluded that the application of autologous BMC is well tolerated, and bone healing can be achieved. Augmentation of bone defects with β-TCP could be shown to be feasible and might be considered in other clinical situations., (© The Author(s) 2023. Published by Oxford University Press.)

Purpose: Earlier research has identified several potentially predictive features including biomarkers associated with trauma, which can be used to assess the risk for harmful outcomes of polytraumatized patients. These features encompass various aspects such as the nature and severity of the injury, accompanying health conditions, immune and inflammatory markers, and blood parameters linked to organ functioning, however their applicability is limited. Numerous indicators relevant to the patients` outcome are routinely gathered in the intensive care unit (ICU) and recorded in electronic medical records, rendering them suitable predictors for risk assessment of polytraumatized patients., Methods: 317 polytraumatized patients were included, and the influence of 29 clinical and biological features on the complication patterns for systemic inflammatory response syndrome (SIRS), pneumonia and sepsis were analyzed with a machine learning workflow including clustering, classification and explainability using SHapley Additive exPlanations (SHAP) values. The predictive ability of the analyzed features within three days after admission to the hospital were compared based on patient-specific outcomes using receiver-operating characteristics., Results: A correlation and clustering analysis revealed that distinct patterns of injury and biomarker patterns were observed for the major complication classes. A k-means clustering suggested four different clusters based on the major complications SIRS, pneumonia and sepsis as well as a patient subgroup that developed no complications. For classification of the outcome groups with no complications, pneumonia and sepsis based on boosting ensemble classification, 90% were correctly classified as low-risk group (no complications). For the high-risk groups associated with development of pneumonia and sepsis, 80% of the patients were correctly identified. The explainability analysis with SHAP values identified the top-ranking features that had the largest impact on the development of adverse outcome patterns. For both investigated risk scenarios (infectious complications and long ICU stay) the most important features are SOFA score, Glasgow Coma Scale, lactate, GGT and hemoglobin blood concentration., Conclusion: The machine learning-based identification of prognostic feature patterns in patients with traumatic injuries may improve tailoring personalized treatment modalities to mitigate the adverse outcomes in high-risk patient clusters., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Fachet, Mushunuri, Bergmann, Marzi, Hoeschen and Relja.)

Active travel can contribute to multiple health benefits in youth. Previous research has identified several factors influencing travel behavior. This study investigates how adolescents process these factors during their decision-making process on travel mode choice. Semi-structured interviews were conducted with 13 adolescents (11-14 years) and analysed using deductive-inductive thematic analysis. Four themes were generated from which the decision-making process on mode choice was conceptualized according to adolescents. The step-by-step process in which travel mode options were gradually reduced, was dependent on the context (Theme 1), the perceived availability of travel mode choice options, which was influenced by factors beyond the individual's perceived control (Theme 2), and on adolescents' pros/cons assessment to identify the most convenient option. Adolescents' habitually used travel mode influenced the decision at several stages throughout the process (Theme 4). To promote healthy travel behaviors, interventions should consider contextual circumstances, balance between enabling autonomous choices and promoting advantages of active travel modes, address individual travel modes and include practices that foster conscious processing of decision-making., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: To assess physical activity (PA) there is a need of objective, valid and reliable measurement methods like accelerometers. Before these devices can be used for research, they need to be calibrated and validated for specific age groups as the locomotion differs between children and adults, for instance. Therefore, the aim of the present study was the calibration and validation of the Move4 accelerometer for children aged 8-13 years., Methods: 53 normal weighted children (52% boys, 48%girls) aged 8-13 years (mean age = 10.69 ± 1.46, mean BMI = 17.93 kg/m - 2 , 60th percentile), wore the Move4 sensor at four different body positions (thigh, hip, wrist and the Move4ecg including heart rate measurement at the chest). They completed nine activities that considered the four activity levels (sedentary behavior (SB), light PA (LPA), moderate PA (MPA) and vigorous PA (VPA)) within a test-retest design. Intensity values were determined using the mean amplitude deviation (MAD) as well as the movement acceleration intensity (MAI) metrics. Determination of activities and energy expenditure was validated using heart rate. After that, cut-off points were determined in Matlab by using the Classification and Regression Trees (CART) method. The agreement for the cut-off points between T1 and T2 was analyzed., Results: MAD and MAI accelerometer values were lowest when children were lying on the floor and highest when running or doing jumping jacks. The mean correlation coefficient between acceleration values and heart rate was 0.595 (p = 0.01) for MAD metric and 0.611 (p = 0.01) for MAI metric, indicating strong correlations. Further, the MAD cut-off points for SB-LPA are 52.9 mg (hip), 62.4 mg (thigh), 86.4 mg (wrist) and 45.9 mg (chest), for LPA-MPA they are 173.3 mg (hip), 260.7 mg (thigh), 194.4 mg (wrist) and 155.7 mg (chest) and for MPA-VPA the cut-off points are 543.6 mg (hip), 674.5 mg (thigh), 623.4 mg (wrist) and 545.5 mg (chest). Test-retest comparison indicated good values (mean differences = 9.8%)., Conclusion: This is the first study investigating cut-off points for children for four different sensor positions using raw accelerometer metrics (MAD/MAI). Sensitivity and specificity revealed good values for all positions. Nevertheless, depending on the sensor position, metric values differ according to the different involvement of the body in various activities. Thus, the sensor position should be carefully chosen depending on the research question of the study., (© 2023. The Author(s).)

Introduction: Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital., Methods: All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint., Results: Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups., Conclusion: Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted., Level of Evidence: Level IV, meta-analysis., (© 2023. The Author(s).)

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: There are numerous operative procedures to treat osteoarthritic changes or a significant instability of the distal radioulnar joint (DRUJ). The key problem of most methods is the destabilization of the forearm leading to secondary painful impingement between the radius and ulna, as well as a significant limitation of forearm rotation. The Aptis-Prosthesis designed by Scheker represents a complete substitute for the DRUJ. It is mostly used after the failure of various treatment options to solve the primary problems (arthritis, instability). We have used this type of prosthesis mostly after multiple operative treatments for more than 25 years., Methods: In the following retrospective study, we analyzed the data of patients that received an Aptis-prosthesis between 2016 and 2021. We have implanted this prosthesis in 13 cases (11 female, 2 male). Routinely, we document the clinical outcome concerning range of motion (ROM), grip strength, and pain according to numeric rate scaling (NRS) after more than 12 months (month 12-24). In addition, complications, osseous changes, and the rate of loosening of the prosthesis were registered. Furthermore, DASH-Score and patients ' satisfaction were evaluated. Also-as with other implants-follow-up x-rays were performed., Results: Removal or significant revision of any of the prostheses was not needed. The ROM was 68.1° ± 19.7° for pronation and 72.3° ± 20.9° for supination, grip strength amounted to 27.7 kg ± 11.0 kg equaling 83% of the contralateral side. NRS was 0 at rest and 1.2 (0-2) under weight-bearing. A lysis margin of the radial tap was noted in the radiological examination in 2 patients but without any signs of loosening. The DASH-Score added up to 31.8 ± 13.8 (13-55). All patients were satisfied or very satisfied having this implant., Conclusion: The semiconstrained Aptis-prosthesis is a safe and efficient treatment option after failed DRUJ surgeries. It is striking that of the 20 implanted prostheses no significant revision or explantations were necessary over a period of 25 years., (© 2023. The Author(s).)

Introduction: While there are several approaches to collect basic information on physical activity (PA) promotion policies, some governments require more in-depth overviews on the situation in their country. In Germany, the Federal Ministry of Health expressed its interest in collecting detailed data on target group specific PA promotion, as relevant competences are distributed across a wide range of political levels and sectors. This study describes the development of a policy brief on physical activity promotion for children and adolescents in Germany. In particular, it addresses two major gaps in the current literature by systematically assessing good practice examples and "routine practices," i.e., PA promotion activities already taking place on large scale and regular basis., Materials and Methods: Based on relevant national and international guidelines, the TARGET:PA tool was co-produced by researchers and ministry officials. It includes (1) PA recommendations, (2) national prevalence rates, (3) recommendations for PA promotion, and data on national (4) routine practices, (5) good practice projects and (6) policies. Data were collected for children and adolescents in Germany using desk research, semi-structured interviews and secondary data analysis., Results: A policy brief and scientific background document were developed. Results showed that 46% of the 4-5-year-olds fulfil WHO recommendations but only 15% of the 11-17-year-olds, and that girls are less active than boys. Currently, in Germany no valid data are available on the PA behaviour of children under the age of three. An overview of routine practices for PA promotion for children and adolescents was compiled, and experts were asked to critically assess their effectiveness, reach and durability. Overall, 339 target group specific projects for PA promotion were found, with 22 classified as examples of good practice. National PA policies for children and adolescents were identified across different sectors and settings., Conclusion: The study provides a comprehensive overview of the current status of PA promotion for children and adolescents in Germany. The co-production of the policy brief was a strength of the study, as it allowed researchers to take the needs of ministry officials into account, and as it supported the immediate uptake of results in the policymaking process. Future studies should test the applicability of the TARGET:PA tool to different target groups and countries., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Messing, Gelius, Abu-Omar, Marzi, Beck, Geidl, Grüne, Tcymbal, Reimers and Pfeifer.)

Objective: The present study aims to understand the familial decision-making process on transport mode choice in adolescents with a focus on the parental perspective within this process., Background: Active travel contributes to adolescents' overall physical activity and its positive health effects. Based on the social-learning theory, especially parents are assigned a central role for adolescents' travel behavior. The aim of the present study was to examine how parents are involved in the decision-making process on transport mode choice in adolescents., Method: The study is part of the cross-sectional mixed-methods ARRIVE study which includes semi-structured interviews with mothers ( n  = 12) and fathers ( n  = 7) of 11- to 14-year-old German adolescents. The interviews focused on travel behavior in adolescents and the decision-making process on transport mode choice from the parental perspective. All interviews were analyzed inductively using Thematic Analysis., Results: Our study revealed that parents do not primarily decide for or against active travel in adolescents, but are mostly involved in the decision-making process, especially in case of a deviation from the main transport mode. Different forms of parental involvement in the decision-making process were identified. Some parents acted as main decision makers which is the highest form of involvement while others gave their children complete freedom of choose a transport mode for themselves. These parents accepted their child's choice fully which shows a low involvement in the decision-making process., Conclusion: The results provide a deeper understanding of the familial decision-making process on travel behavior in adolescents. The results indicate an occasionally parental involvement in the decision-making process on the mainly used transport mode by adolescents, and that mothers and fathers are always involved when deviating from the main mode., Implications: Further research should investigate changes in travel behavior from childhood to young adulthood to understand long-term travel decisions in families. Due to the findings that parents are often involved in the decision-making process on transport mode choice and that they mainly reported safety concerns as barriers to their children's active travel, further research should focus especially on the social and physical environment of adolescents., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Tristram, Reimers, Renninger, Beck, Demetriou and Marzi.)

Background: Dupuytren's disease often leads to an increasing limitation in finger extension in affected patients. As the incidence rises with age, the number of cases is expected to rise in the future due to the demographic change. Therefore, an easy and patient-oriented treatment is required. In the following study, we investigated the short and medium-term results after percutaneous needle fasciotomy (PNF)., Patients and Methods: Overall, 65 fingers of 40 patients were treated with PNF. We evaluated the total passive deficit of extension (TPED), the passive deficit of extension of the joints (PED), the Buck-Gramcko score, rate of recurrence, DASH score and patient satisfaction. The average age of the patients was 65,9 years. Most of the patients (82%) were male., Results: Directly after the PNF, extension in the treated fingers improved significantly (TPED before PNF 74,6°±41,1 SD to 32,8°±29,0 SD after the procedure). By the time of the follow-up examination (30,2±13,9 SD months), TPED had increased again (52,7°±40,2 SD). The rate of recurrence was 29,7%, and a higher Tubiana stage before the procedure correlated significantly with a higher recurrence rate. Nevertheless, patients demonstrated a very high level of satisfaction with the procedure and almost all patients would choose to undergo PNF again., Conclusion: Although it is associated with a relatively high recurrence rate, PNF represents an effective and patient-oriented treatment of Dupuytren's contracture., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Abstract: Background: Pneumonia is a frequent complication after polytrauma. This study aims to evaluate the ability of different serum markers to identify patients at risk of developing pneumonia after polytrauma. Methods: A retrospective analysis of prospectively collected data in polytraumatized patients with concomitant thoracic trauma (Injury Severity Score ≥16, Abbreviated Injury Scale Thorax ≥ 3) was performed. The study cohort was divided into patients with and without pneumonia during the clinical course. Serum levels of lung epithelial (CYFRA 21-1), endothelial (Ang-2), and inflammatory (PTX-3, sRAGE, IL-6, IL-10) markers were measured upon arrival in the trauma room and on days 2 and 5. Results: A total of 73 patients and 16 healthy controls were included in this study. Of these, 20 patients (27.4%) developed pneumonia. Polytraumatized patients showed significantly increased CYFRA 21-1 levels with a distinct peak after admission compared with healthy controls. Serum PTX-3 significantly increased on day 2 in polytraumatized patients compared with healthy controls. Injury Severity Score and demographic parameters were comparable between both groups (pneumonia vs. no pneumonia). No statistically significant difference could be observed for serum levels of CYFRA 21-1, Ang-2, PTX-3, sRAGE, IL-6, and IL-10 between the groups (pneumonia vs. no pneumonia) on all days. Logistic regression revealed a combination of IL-6, IL-10, sRAGE, and PTX-3 to be eventually helpful to identify patients at risk of developing pneumonia and our newly developed score was significantly higher on day 0 in patients developing pneumonia ( P < 0.05). Conclusion: The investigated serum markers alone are not helpful to identify polytraumatized patients at risk of developing pneumonia, while a combination of IL-6, IL-10, PTX-3, and sRAGE might be., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by the Shock Society.)

(1) Background: Bone healing is a complex process that can not be replicated in its entirety in vitro. Research on bone healing still requires the animal model. The critical size femur defect (CSFD) in rats is a well-established model for fractures in humans that exceed the self-healing potential. New therapeutic approaches can be tested here in vivo. Histological, biomechanical, and radiological parameters are usually collected and interpreted. However, it is not yet clear to what extent they correlate with each other and how necessary it is to record all parameters. (2) Methods: The basis for this study was data from three animal model studies evaluating bone healing. The µCT and histological (Movat pentachrome, osteocalcin) datasets/images were reevaluated and correlation analyses were then performed. Two image processing procedures were compared in the analysis of the image data. (3) Results: There was a significant correlation between the histologically determined bone fraction (Movat pentachrome staining) and bending stiffness. Bone fraction determined by osteocalcin showed no prognostic value. (4) Conclusions: The evaluation of the image datasets using ImageJ is sufficient and simpler than the combination of both programs. Determination of the bone fraction using Movat pentachrome staining allows conclusions to be drawn about the biomechanics of the bone. A standardized procedure with the ImageJ software is recommended for determining the bone proportion.

Electrical stimulation (EStim), whether used alone or in combination with bone tissue engineering (BTE) approaches, has been shown to promote bone healing. In our previous in vitro studies, mesenchymal stem cells (MSCs) were exposed to EStim and a sustained, long-lasting increase in osteogenic activity was observed. Based on these findings, we hypothesized that pretreating MSC with EStim, in 2D or 3D cultures, before using them to treat large bone defects would improve BTE treatments. Critical size femur defects were created in 120 Sprague-Dawley rats and treated with scaffold granules seeded with MSCs that were pre-exposed or not (control group) to EStim 1 h/day for 7 days in 2D (MSCs alone) or 3D culture (MSCs + scaffolds). Bone healing was assessed at 1, 4, and 8 weeks post-surgery. In all groups, the percentage of new bone increased, while fibrous tissue and CD68+ cell count decreased over time. However, these and other healing features, like mineral density, bending stiffness, the amount of new bone and cartilage, and the gene expression of osteogenic markers, did not significantly differ between groups. Based on these findings, it appears that the bone healing environment could counteract the long-term, pro-osteogenic effects of EStim seen in our in vitro studies. Thus, EStim seems to be more effective when administered directly and continuously at the defect site during bone healing, as indicated by our previous studies.

Background: Hemorrhagic shock (HS) is responsible for approximately 2 million deaths per year worldwide and is caused in 80% by polytrauma. These patients need a precise and quick diagnostic, which should be based on a combination of laboratory markers and radiological data. Extracellular vesicles (EVs) were described as potential new markers and mediators in trauma. The aim of the present study was to analyze, whether the surface epitopes of plasma-EVs reflect HS in polytraumatized patients and whether cell-specific EV subpopulations are useful diagnostic tools., Material and Methods: Plasma samples from polytraumatized patients (ISS ≥16) with HS (n=10) and without (n=15), were collected at emergency room (ER) and 24h after trauma. Plasma-EVs were isolated via size exclusion chromatography and EV-concentrations were detected by Coomassie Plus (Bradford) Assay. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with healthy controls (n=10). To investigate the diagnostic and prognostic potential of EVs subpopulations, results were correlated with clinical outcome parameters documented in the electronical patients' record., Results: We observed a significant reduction of the total amount of plasma EVs in polytrauma patients with HS, as compared to polytrauma patients without HS and healthy controls. We found significant reduction of CD42a+ and CD41b+ (platelet-derived) EVs in all polytrauma patients, as well as a reduction of CD29+ EVs compared to healthy volunteers (*p<0.05). CD44+ and CD31+ EVs were specifically altered in patients with HS (*p<0.05). Both EV populations showed a moderate correlation (r² = 0.42) with the transfusion of erythrocyte concentrate, were associated with non-survival and the need for catecholamines (*p<0.05)., Conclusion: Our data reveal that polytrauma patients with a hemorrhagic shock are characterized by a reduction of CD44+ and CD31+ plasma-EVs. Both EV populations showed a moderate correlation with the need of erythrocyte transfusion, were associated with non-survival and the need for catecholamines., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Weber, Sturm, Henrich, Marzi and Leppik.)

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide., (© 2023. The Author(s).)

Objective: Traumatic hip dislocations are very rare in childhood and adolescence. The aim of this multi-centre study is to analyse the current epidemiology and injury morphology of a large number of traumatic hip dislocations in children. This can provide a better understanding of childhood hip dislocations and contribute to the development of a therapeutic approach in order to prevent long-term impacts., Methodology: This retrospective, anonymised multi-centre study included patients, aged up to 17 years, with acute traumatic hip dislocations and open growth plates. The patients came from 16 German hospitals. Exclusion criteria included insufficient data, a positive history of hip dysplasia, or an association with syndromal, neurological or connective tissue diseases predisposing to hip dislocation. An analysis was carried out on the patients' anthropometric data and scans (X-ray, MRI, CT), which were collected between 1979 and 2021. Gender, age at the time of dislocation, associated fractures, mechanism of injury, initial treatment including time between dislocation and reduction, method of reduction, treatment algorithm following reduction and all documented complications and concomitant injuries were evaluated., Results: Seventy-six patients met the inclusion criteria. There were two age peaks at 4-8 years and 11-15 years. There was an increased incidence of girls in the under-eight age group, who had mild trauma, and in the group of over-eights there were more boys, who had moderate and severe trauma. Dorsal dislocation occurred in 89.9% of cases. Mono-injuries dominated across all age groups. Concomitant injuries rarely occurred before the age of eight; however, they increased with increasing ossification of the acetabulum and appeared as avulsion injuries in 32% of 11-15-year-olds. Of the 76 patients, 4 underwent a spontaneous, 67 a closed and 5 a primary open reduction. A reduction was performed within 6 h on 84% of the children; however, in around 10% of cases a reduction was not performed until after 24 h. Concomitant injuries needing intervention were identified in 34 children following reduction. Complications included nerve irritation in the form of sensitivity disorders (n = 6) as well as avascular necrosis (AVN) of the femoral head in 15.8% of the patients (n = 12)., Conclusions: Traumatic hip dislocations are rare in childhood and adolescence and have high complication rates. The most severe complication, femoral head necrosis, occurred in 16% of cases. Minor injuries, especially in younger children, are enough to cause a dislocation. Posterior dislocation was more frequent and primarily occurred as a mono-injury; however, concomitant injuries must be considered with increasing age. Children continue to experience delayed reductions. The length of time until reduction, age and the severity of the concomitant injury play a role in the development of femoral head necrosis; however, this topic requires additional investigation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy., (© 2023. The Author(s).)

Trauma remains a leading cause of morbidity and mortality. Polytraumatized patients need a precise, early diagnosis to avoid complications such as multiorgan failure or sepsis. Inflammatory cytokines, commonly used for diagnosis, have a short half-life, which limits their efficacy as a diagnostic or prognostic marker. In this study, we hypothesized that cytokines in exosomes could have a longer half-life, and therefore could be used as diagnostic and prognostic markers in polytrauma patients. Plasma samples from polytraumatized patients (ISS ≥ 16, n = 18) were collected in the emergency room (ER) 1, 2, 3 and 5 days after trauma. Plasma-exosomes were isolated via size exclusion chromatography from polytraumatized patients and healthy volunteers ( n = 10). The systemic and exosomal concentrations of interleukin (IL)-6, IL-10, IL-1β and TNF were measured using high-sensitive ELISAs. To investigate the diagnostic and prognostic potential of exosomal cytokines, data were correlated with clinical outcome parameters (injury severity, ventilation time, time in ICU and survival) documented in the patients' electronic records. Despite the use of high-sensitive ELISAs, IL-1β and TNF alpha were not detected in exosomes. IL-6 and IL-10 were detectable in polytraumatized patient exosomes at all time points. A decrease over time of both systemic and exosomal IL-6 concentrations was observed. Furthermore, exosomal and systemic IL-6 concentrations moderately correlated (r = 0.63). Exosomal IL-6 in the ER moderately correlated with the Injury Severity Score (ISS) (mean 35.5 ± 11.5) (r = 0.45) and was associated with non-survival in polytrauma patients ( p < 0.05). In contrast to IL-6, no correlation between systemic and exosomal IL-10 concentrations was found. Exosomal IL-10 concentrations remained unchanged throughout the observation time, whereas systemic IL-10 concentrations peaked in the ER and were significantly reduced after 24 h. Data from this study support our hypothesis that some cytokines (IL-10), but not all (IL-6), are detectable in exosomes significantly longer than they are in plasma. This might indicate that they are protected from degradation. Although we did not find a correlation between IL-10 exosomal concentration and patient outcome, our data confirm that exosomal cytokines are of interest as potential diagnostic and prognostic markers in polytrauma patients, and require further detailed research.

Acetabular fractures are challenging fractures and finding the best supportive treatment is complex. Many operative treatment options exist - one of them is the plate osteosynthesis via the modified Stoppa approach gaining popularity over the last decades. The purpose of this study is to give an overview of this surgical techniques and its main complications. Patients ≥ 18 years between the years 2016 and 2022 with acetabular fractures in our department received a surgical intervention with plate fixation via the modified Stoppa approach. All protocols and documents during a patient's hospital stay were analyzed to find relevant perioperative complications concerning this operative technique. Between 01/2016 und 12/2022 75 patients with acetabular fractures were treated surgically in the author's institution with a plate osteosynthesis via the modified Stoppa approach. In 26.7 % (n = 20) of all cases, patients were confronted with one or more perioperative complications typical for this operation. Intraoperative venous bleedings were the main complication with 10.6 % (n = 8). Postoperative functional impairment of the obturator nerve and deep vein thrombosis occurred with 2.7 % (n = 2) and 9.3 % (n = 7). This retrospective study shows that plate fixation via the Stoppa approach is a good treatment option because of the excellent intraoperative overview of the fracture, but has its pitfalls and complications. Especially severe vascular bleedings must be taken into account and its management well known., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries., Methods: From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months., Results: For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home., Conclusion: Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany., (© 2023. The Author(s).)

Because of their low incidence, studies about carpal fractures are rare. The aim of the present study was to analyze epidemiology and treatment of fractured carpal bones. We retrospectively analyzed data of 178 patients admitted to our emergency room with carpal fractures over 6 years. More males than woman were injured. In 91%, a CT scan was performed. The most commonly affected bone was the triquetrum followed by the scaphoid. Almost all triquetral fractures were treated conservatively as opposed to perilunate dislocations that were all operated on. Half of all patients with scaphoid fractures were operated. Young men had the highest risk to sustain a carpal fracture. The triquetrum and the scaphoid are most frequently affected. Usually a CT scan is needed. Treatment of scaphoid and perilunate luxation fractures is rather operative whereas the other fractures mostly allow conservative casting. Nevertheless, correct indication for treatment is important to avoid sequelae., (© 2023. The Author(s).)

Background: Many patients with minor injuries hastily present in the emergency department and tie up resources and personnel there., Objective: To establish the cost-revenue relationship of outpatient care of minor injuries in the traumatology emergency department., Material and Methods: The calculation was based on the uniformly billed emergency flat rates of the uniform assessment standard (EBM). Using the current collective bargaining agreements for physicians and nurses, per minute costs were calculated. The time required for treatment was determined on the basis of 100 reference patients with minor injuries. The case cost calculation with the respective resources was carried out with the operational controlling of the University Hospital Frankfurt., Results: A total of 4088 patients with minor injuries who presented in 2019 were included. Most common reasons for presentation were contusions of the lower (31.9%; n = 1303) and upper extremities (16.6%; n = 677). A time expenditure of 166.7 min per day for the medical staff and 213.8 min per day for nursing staff was calculated. A total revenue of 29,384.31 € and total costs of 69,591.22 € were calculated. Thus, a revenue deficit of -40,206.91 € can be calculated for the year 2019. This corresponds to a monetary deficit of 9.84 € per patient., Conclusion: There is a shortage of the medical resource "personnel" to satisfactorily and economically manage the nowadays high volume of self-presenting pedestrian patients with minor injuries. The current remuneration of the treatment of minor injuries by the uniform assessment scale is insufficient for the hospital sector., (© 2022. The Author(s).)

For acute and chronic soft tissue infections, radical surgical debridement is required and is considered the gold standard, along with its immediate systemic antibiotic therapy. Treatment with local antibiotics and/or antibiotic-containing materials is commonly used as an additional tool in clinical practice. Spraying with fibrin and antibiotics is a newer technique that has been studied for some antibiotics. However, for gentamicin, data are not yet available on absorption, optimal application, antibiotic fate at the site and transfer of antibiotic into the blood. In an animal study involving 29 Sprague Dawley rats, 116 back wounds were sprayed with gentamicin using either gentamicin alone or one of two possible spray combinations of gentamicin and fibrin. Simultaneous application of gentamicin and fibrin via a spray system to soft tissue wounds resulted in significant antibiotic concentration over a long period of time. The technique is easy and cost-effective. The systemic crossover was significantly minimized in our study, which may have led to fewer side effects in patients. These results could lead to an improvement in local antibiotic therapy.