Endotracheal intubation (ETI) with direct view laryngoscopy (DL) is the gold standard for airway management. Videolaryngoscopy (VL) can improve glottis visualization, thus facilitating ETI. The aim of this monocentric, randomized, prospective study on a physician staffed German air ambulance is to compare DL and VL for ETI in terms of number of attempts and time as well as visualization of the glottis in a prehospital setting in a physician-based rescue system in adult patients. A power analysis was performed à priori. We used consecutive on-scene randomization with a sealed envelope system for the DL and VL-group. Successful ETI with first pass success was significantly more frequent with VL than DL and three seconds faster. The percentage of glottis opening and the Cormack & Lehane classification were significantly better with VL than DL. Regarding improved first pass success in ETI with the VL, we would recommend the use of VL for prehospital airway management in physician-based rescue systems.

Purpose: Bipolar hemiarthroplasty has been shown to have a lower rate of dislocation than total hip arthroplasty. However, as the influencing risk factors for bipolar hemiarthroplasty dislocation remain unclear, we aimed to analyse patient and surgeon-specific influencing risk factors for bipolar hemiarthroplasty dislocation. Methods: We retrospectively analysed patients who were operated between 2012 and 2018 and had dislocated bipolar hemiarthroplasty and matched them to patients without a dislocated bipolar hemiarthroplasty, operated between 2018 and 2019. The study was limited to patients who received either a pre- or postoperative pelvic computed tomography. Besides demographic, morphologic, and physiologic data, we analysed duration of surgery; ASA score; Charlson Comorbidity Index; Almelo Hip Fracture Score; Parker Score; and acetabular morphology angles including acetabular anteversion angle, posterior acetabular sector angle, posterior wall angle, and acetabular roofing. Results: We included nine patients with a dislocated bipolar hemiarthroplasty and 30 with a non-dislocated bipolar hemiarthroplasty. Patient-specific factors prompting a higher risk for dislocated bipolar hemiarthroplasty were longer duration of surgery (min) (115 ± 50 vs. 80 ± 27, p = 0.01); dementia (56% vs. 13%, p < 0.01); smaller posterior acetabular sector angle (°) (96 ± 6 vs. 109 ± 10, p < 0.01); and smaller posterior wall angle (°) (67 ± 6 vs. 77 ± 10, p = 0.02). Conclusion: Dementia and insufficient posterior wall angle were associated with higher risk of dislocation in bipolar hemiarthroplasty

Purpose After intramedullary nailing of tibial shaft fractures using an infrapatellar/transtendinous approach, several patients suffer anterior knee pain. We suspect that the approach is associated with soft tissue scars and the development of a postoperative patella baja. The goal of the study is to investigate whether the development of patella baja is associated with worse subjective outcomes. Methods We retrospectively analyzed all patients in our orthopedic trauma department between 2011 and 2020 who underwent tibial fracture fixation via intramedullary nailing via an infrapatellar/transtendinous approach. Pre- and postoperative lateral knee x-rays were evaluated by measurement of the Insall-Salvati Index, and nail tip position. All patients were asked to answer the self-assessment Kujala questionnaire and Lysholm questionnaire. Results We included 78 patients (age: 44 ± 18 years) with a minimum follow-up of 12 months. Mean follow up was 59 ± 25 months. We included 50 male and 28 female patients. Patella baja detected by Insall-Salvati Index could be observed in 8 (10.3%) patients. Patients with patella baja showed significant worse function measured by the Kujala score 54 ± 18 vs. 80 ± 14 (p < 0.01). Likewise, Lysholm score did show significant differences between both groups (60 ± 24 vs. 86 ± 11; p < 0.01). Nail tip position was not associated with worse subjective function. Conclusions Patella baja in patients after tibial intramedullary nailing via an infrapatellar/transtendinous approach, is associated with worse subjective function and increased pain.

The diagnosis of periprosthetic infections (PJI) can be challenging in clinical practice because the clinical presentations of aseptic loosening and low-grade infections are similar. Semiquantitative evaluation of leukocyte esterase (LE) in synovial fluid using a urine strip test has already established itself as a diagnostic method over the past decade. The analysis of LE in synovial fluid leads to a high number of false-positive test results. In the present study, the value of a combined semiquantitative determination of glucose and LE in synovial fluid to improve the diagnosis of PJI was investigated. Over a 4-year period, 145 synovial samples were collected from patients who developed joint effusion after arthroplasty. LE and glucose test strips were considered as an index test for the diagnosis of PJI. A ++ or +++ LE and a negative glucose test strip reading were considered as positive test results. Modified diagnostic criteria for PJI as recommended by the Musculoskeletal Infection Society (MSIS) served as the reference test, except that intraoperative findings were excluded. Forty-six out of 145 samples were classified as septic complication according to the reference test. In regard to PJI, our data showed that combined use of LE and glucose strip test reading displayed a 98.0% specificity (95% confidence interval (CI): 95.2% to 100%), a 50% sensitivity (95% CI: 35.6% to 64.4%), a 92% positive predictive value (95% CI: 81.4% to 100.0%), and an 80.3% negative predictive value (95% CI: 73.2% to 87.4%). In contrast, the exclusive analysis of LE on the urine strip to diagnose PJI demonstrated a 90.9% specificity (95% CI: 85.2% to 96.6%), a 67.4% sensitivity (95% CI: 53.8% to 80.9%), a 77.5% positive predictive value (95% CI: 64.6% to 90.4%), and an 85.7% negative predictive value (5% CI: 79.0% to 92.4%). A combination of LE and glucose test pad reading is considered superior as a potential “rule-in” method for the diagnosis of PJI compared with LE test pad analysis alone. However, combined LE and glucose synovial fluid testing also demonstrated lower test sensitivity and thus diagnostic accuracy compared with LE analysis alone. Therefore, combined glucose and LE test pad analysis does not represent a sufficient diagnostic standard to exclude PJI with certainty.

Background: Postoperative delirium (POD) is a common complication in older patients. Multicomponent prevention reduces POD but requires substantial resources. The effect of single interventions derived from multicomponent programs remains elusive, but it is essential to assess their effect to identify which components are meaningful. This study investigates whether a single intervention from a multicomponent program may reduce the incidence of POD. Methods: This prospective, single-center before-and-after study evaluated older surgery patients at a university hospital’s geriatric trauma center between July 2020 and November 2021. Inclusion criteria were age ≥ 70 years and a proximal femoral fracture. A control cohort (CC) left their dentures, vision, and hearing aids on the ward throughout surgery, while an intervention cohort (IC) used them until anesthesia induction and received them back when they regained consciousness. Therefore, IC obtained a transport case for hygienic storage and perioperative device management. The time of sensory aid removal was measured to ensure proper implementation. Outcomes were the incidence of POD (assessed via the 3-min Diagnostic Confusion Assessment Method at admission and twice daily for three days postoperatively), patient satisfaction, and recovery (evaluated via Quality of Recovery-9), length of hospital stay, postoperative monitoring time, Barthel-index, and 30-day mortality. Results: 248 patients were screened for eligibility. Following a dropout rate of n = 166, the cohorts were: CC n = 40 and IC n = 42. Both cohorts had similar baseline and treatment characteristics. The intervention significantly reduced the median time of sensory aid removal (CC 12h 14min, IC 12min, p < 0.001), and the incidence of POD overall (CC 65.0%, IC 40.5%, p = 0.026). The length of hospital stay and long-term recovery outcomes remained insignificant. However, postoperative monitoring time correlated with time of sensory aid removal (r_s = 0.518, p < 0.001, n = 62), and median quality of recovery improved on average (CC 12.75, IC 15.62, p < 0.001). Conclusion: Reduced perioperative sensory impairment may reduce the incidence of POD, decrease postoperative monitoring time, and be associated with a better postoperative recovery. Therefore, multimodal preventative efforts should include reducing sensory aid removal. Trial registration: German Clinical Trial Register (DRKS-ID DRKS00022085); 07/07/2020

While improvements in pre-hospital and in-hospital care allow more multiple trauma patients to advance to intensive care, the incidence of posttraumatic multiple organ dysfunction syndrome (MODS) is on the rise. Herein, the influence of a selective IL-6 trans-signaling inhibition on posttraumatic cytokine levels was investigated as an approach to prevent MODS caused by a dysbalanced posttraumatic immune reaction. Therefore, the artificial IL-6 trans-signaling inhibitor sgp130Fc was deployed in a murine multiple trauma model (femoral fracture plus bilateral chest trauma). The traumatized mice were treated with sgp130Fc (FP) and compared to untreated mice (WT) and IL-6 receptor knockout mice (RKO), which received the same traumas. The overall trauma mortality was 4.4%. Microscopic pulmonary changes were apparent after multiple trauma and after isolated bilateral chest trauma. Elevated IL-6, MCP-3 and RANTES plasma levels were measured after trauma, indicating a successful induction of a systemic inflammatory reaction. Significantly reduced IL-6 and RANTES plasma levels were visible in RKO compared to WT. Only a little effect was visible in FP compared to WT. Comparable cytokine levels in WT and FP indicate neither a protective nor an adverse effect of sgp130Fc on the cytokine release after femoral fracture and bilateral chest trauma.