[Differences in injury patterns in motorcycle accidents involving children and adolescents]

Hintergrund

Verkehrsunfälle und ihre Verletzungsfolgen stellen eine häufige traumatische Ursache für das Versterben und für das Auftreten von irreversiblen Schäden bei Kindern und Jugendlichen dar. Bei Motorradunfällen unterscheiden sich dabei Verletzungsmuster abhängig vom Patientenalter.

Ziel der Arbeit

Ziel dieser Studie ist es, die typischen Verletzungsmuster nach Motorradunfällen im Kindes- und Jugendalter vergleichend zu beschreiben, da diese einen ausschlaggebenden Einfluss auf die Prävention sowie die adäquate Behandlung der jeweiligen Patientengruppen bieten können.

Material und Methoden

In die Studie wurden innerhalb der Jahre 2002–2018 22.923 Patienten aus dem TraumaRegister der Deutschen Gesellschaft für Unfallchirurgie (DGU®) eingeschlossen. Die Auswertung erfolgte in 4 Altersgruppen: Gruppe 1 (4 bis 15 Jahre), Gruppe 2 (16 bis 17 Jahre), Gruppe 3 (18 bis 20 Jahre) sowie Gruppe 4 (21 bis 50 Jahre) als Kontrolle.

Ergebnisse

In Gruppe 2 stellten Extremitätenverletzungen das häufigste Verletzungsmuster dar und traten überwiegend im Bereich der unteren Extremität auf. Zudem ergab die Analyse, dass Gruppe 1 häufiger ein schweres Schädel-Hirn-Trauma erleidet, trotz initial schlechtem Zustand aber ein besseres Outcome aufweist. Thorakale, abdominelle sowie Wirbelsäulen- und Beckenverletzungen kommen bei den jüngeren Altersgruppen seltener vor. Insbesondere stellen Rippenfrakturen eine Rarität bei Kindern dar. In der Diagnostik werden Kinder im Vergleich zu Erwachsenen seltener einer Ganzkörper-CT-Diagnostik zugeführt.

Diskussion

Die Studie deckt altersabhängige Unterschiede in den Verletzungsmustern von Patienten auf, die als Beifahrer oder Fahrer eines Motorrades in einen Unfall involviert waren. Zudem konnten ebenso Unterschiede in der prä- und innerklinischen Versorgung herausgearbeitet werden.

Health care utilization and excess costs after pelvic fractures among older people in Germany

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment.

INTRODUCTION

We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture.

METHODS

In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures.

RESULTS

Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture.

CONCLUSION

Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

Die Spül-Saug-Drainage zur Therapie der septischen Tenosynovialitis der Fingerbeugesehnen

BACKGROUND/PURPOSE

Pyogenic flexor tenosynovitis within the flexor tendon sheath requires urgent treatment to avoid tendon necrosis and loss of the finger. Objective of this article is the treatment by revision and postoperative continuous irrigation via a closed irrigation system.

PATIENTS AND METHODS

From 1.1.2007 to 31.12.2016 54 patients with a pyogenic flexor tenosynovitis were treated by revision and closed continuous irrigation. Besides the evaluation of the patient´s records with respect to the involved fingers and hand, duration of hospitalisation, and required revision surgery, 33 patients (19 males, 14 females) with an average age of 51 (8-85) years were re-examined on average after 21 (4-38) months. Re-examination included measurements of the mobility of the involved fingers and thumbs, grip and pinch strength, pain using the numeric rating scale (BRS), and DASH score. The overall result was graded according to the grading system by Buck-Gramcko for flexor tendon reconstruction.

RESULTS

Hospital stay was 9 (3-26) days on average. In 11 patients revision surgery was required including 3 re-installations of the continuous irrigation system, 2 ray amputations, and 1 finger amputation at the level of the proximal interphalangeal joint. The re-examined patients averaged a grip strength of 84 (23-163) % of the unaffected side. On average pain at rest was 0,2 (0-4), pain at daily living activity 1,2 (0-8) on the NRS, the DASH score 16,8 (0-58) points. According to the rating system for flexor tendon function there were one poor, one fair, 5 good and 26 excellent results.

CONCLUSIONS

Continuous irrigation by a closed irrigation system for pyogenic flexor tenosynovitis is a successful procedure with a low amputation rate. The functional results are predominantly good and excellent.

[Extensor tendon injuries at the level of the proximal interphalangeal joint]

Closed and open injuries of the extensor mechanism at the proximal interphalangeal (PIP) joint can involve the central slip, the lateral slips or both. They are classified as zone III injuries. All open injuries on the dorsal side of the PIP joint should raise suspicion of an extensor tendon injury that is frequently overlooked. The operative strategy consists of wound revision with extensor tendon suture or refixation of the central slip. Acute closed central slip injuries are clinically diagnosed (Elson test) after ruling out bony injuries to the joint. Nondisplaced avulsions of the central slip insertion or lacerations can be treated nonoperatively by splinting. For displaced avulsions and complex injuries the treatment is surgical. In overlooked injuries a typical deformity (buttonhole/Boutonnière deformity) develops within 1-2 weeks that is characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint. In early cases, when passive extension is still complete (mobile buttonhole deformity) the central slip can be immediately reconstructed. In fixed deformities complete passive extension of the PIP joint has to be restored before surgery by hand therapeutic measures or PIP joint release. Depending on the pattern of the injury and the resulting defects, a number of reconstructive techniques have been established that are summarized in this article. The functional results can be limited by tendon adhesions, imbalance within the reconstructed extensor apparatus and stiff joints that can all restrict the range of motion. Therefore, active rehabilitation protocols are mandatory for optimal results.

[External fixator of the wrist-temporary fixation]

OBJECTIVE

a) Fixed-angle bridging of the wrist between radius diaphysis and metacarpus by percutaneous or minimally invasively inserted threaded pins and a frame (fixator) placed above the skin level (external); b) retention of fracture fragments by ligamentotaxis; c) temporary stabilization after bone loss at wrist and distal forearm.

INDICATIONS

a) Initial treatment of fractures near the wrist or soft tissue injuries in multiple trauma patients; b) fractures of the distal radius and the distal ulna; c) dislocation of the carpus; d) infections of the wrist; e) instability after resection in the wrist area; f) fractures with impending or manifest compartment syndrome; g) fractures with extensive loss of soft tissues and lacking coverage of implants.

CONTRAINDICATIONS

a) Pathological changes at the site of pin application, as long as no alternative site is possible: infections, fractures, osteoporosis, tumors; b) fractures that are closed and not reduceable; c) exclusively intra-articular distal radius fractures; d) lack of compliance by the patient.

SURGICAL TECHNIQUE

Insertion of two threaded pins into the radial shaft proximal to the radiocarpal joint and two pins into the second metacarpal bone. Assembly of the fixator frame in advance of the definitive reduction. Subsequently, final reduction and fixation in the desired position by tightening of the screws on the fixator frame.

POSTOPERATIVE MANAGEMENT

Pin care and changes of wound dressing every 2-3 days RESULTS: Reliable, low complication procedure for temporary fixation of the wrist for many indications.

Possible risk factors for acute and chronic deep periprosthetic joint infections in primary total knee arthroplasty. Do BMI, smoking, urinary tract infections, gender, and ASA classification have an impact?

Purpose

Aim of this retrospective study was to evaluate the impact of the patient related factors body mass index (BMI), urinary tract infection, current smoking, gender, and American Society of Anesthesiologists (ASA) classification on the incidence of acute and chronic deep periprosthetic joint infections (PJI) in total knee arthroplasty (TKA).

Methods

All patients undergoing revision surgery for a deep PJI of primary TKA between July 2012 and December 2016 were included in this study. All relevant data was collected from the medical records. Acute deep PJI was defined when PJI was diagnosed within the first 6 weeks after primary TKA, chronic PJI was defined when patients demonstrated PJI later than 6 weeks after primary TKA.

Results

A total of 57 patients was included in this study with 13 cases of acute PJI and 44 of chronic PJI. Overweight patients (BMI > 25 kg/m²) represent a significantly larger proportion in both PJI groups (p < 0.05). Current smokers had an significantly increased risk for acute and chronic PJI (p < 0.05). In the acute PJI group 46.2% patients had an postoperative urinary tract infection.

Conclusion

An elevated BMI (>25 kg/m²), current smoking and urinary tract infection are possible risk factors for acute and chronic deep PJI. After primary TKA screening for urinary tract infection is recommendable to prevent predominantly acute deep PJI.

[Scaphoid pseudarthrosis : Complex reconstruction using vascularized bone grafts]

The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.

[Arthroscopy of the distal radioulnar joint]

OBJECTIVE

The aim of the procedure is to visualize the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar side surface of the triangular fibrocartilage complex (TFCC).

INDICATIONS

Arthroscopy of the distal radioulnar joint is applied for the evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X‑rays and MRIs and arthroscopically assisted procedures.

SURGICAL TECHNIQUE

In vertical extension, two portals of the wrist are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. By insertion of a small joint arthroscope via these portals visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ and the proximal surface of the TFCC is accomplished.

CONCLUSIONS

Arthroscopy of the DRUJ is a rarely and not routinely performed procedure for the diagnosis and therapy of ulnar-sided wrist pain. It is technical demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon, as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases, this procedure offers important additional information about the distal radioulnar joint. The procedure is especially valuable for the detection of proximal TFCC injuries that are missed otherwise.

Primary cemented bipolar radial head prostheses for acute elbow injuries with comminuted radial head fractures: mid-term results of 37 patients

BACKGROUND

Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason's classification type III after primary arthroplasty using a cemented bipolar design.

MATERIALS AND METHODS

In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively.

RESULTS

DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases.

CONCLUSION

Primary cemented bipolar arthroplasty for type III fractures according to Mason's classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

[Distal radius fractures : Current treatment concepts and controversies]

Distal radius fractures represent the most frequent bone fractures in humans. Although the treatment was dominated for decades by conservative measures or closed surgical procedures, such as percutaneous wire osteosynthesis, a paradigm shift was instigated by the introduction and rapid dissemination of volar locking plate osteosynthesis (VLP). The novel procedure was soon proclaimed to be the gold standard and applied for practically all forms of fractures of the distal radius. In addition to clinical mishaps, e.g. failure to address dorsal edge fragments or the occurrence of extensor and flexor tendon irritation, the publication of various prospective randomized studies and meta-analyses led to a certain degree of disillusionment. In comparison to percutaneous wire osteosynthesis, no differences in the clinical result could be established for VLP 1 year postoperatively. It was therefore obvious that not all problems of the distal radius could be solved using the innovative instrument of volar locking plates. This article gives an overview on the current insights and reflects the current expert opinion on the present concepts for the treatment of distal radius fractures. This is illustrated by comprehensive case presentations.

[Reconstruction of the middle phalangeal base of the finger using an osteocartilaginous autograft from the hamate]

OBJECTIVE

Restoration of proximal interphalangeal joint stability with preservation of mobility by reconstruction of the middle phalanx base using an osteochondral graft from the carpometacarpal joint surface of the hamate.

INDICATIONS

Acute and older isolated destruction of the palmar middle phalanx base >25%.

CONTRAINDICATIONS

Destruction of the head of the proximal phalanx, advanced chondropathia of the head of the proximal phalanx, extensive soft tissue injury with loss of skin coverage at the proximal interphalangeal joint.

SURGICAL TECHNIQUE

The fractured middle phalangeal base is debrided and the defect is replaced by a size-matched autograft from the dorsal carpometacarpal hamate osteoarticular surface that is secured in place with miniscrews.

POSTOPERATIVE MANAGEMENT

Immobilization for 2 weeks in a below-elbow cast in intrinsic plus position. Subsequent immobilization by a splint including the distal and proximal interphalangeal joint.

RESULTS

Healing was achieved in 100% with restoration of joint congruity in 12 of 13 cases and slight subluxation in 1 case. Follow up was possible in 9 cases after 22 ± 16 (5-51) months. The average range of motion in the reconstructed joint achieved 0/9/73°, grip strength 82% of the unaffected side. Of the 9 patients, 5 developed a mild flexion contracture of the proximal interphalangeal joint. The DASH score achieved 4 ± 3 (0-8) points, pain at rest was 1 ± 2 (0-5), pain at exercise 2 ± 2 (0-5) on a visual analogue scale (0-10). All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by using an osteochondral graft from the hamate is a reliable procedure to restore stability and mobility of the joint.

[Treatment of necrosis of the lunate bone]

BACKGROUND

There still is no standard therapy that predictably results in healing of avascular necrosis of the lunate bone. Nevertheless, there exists a wide spectrum of operative treatment options for different stages.

OBJECTIVE

This article reviews the treatment options for necrosis of the lunate bone and proposes algorithms based on the age of the patient and condition of the lunate bone and the wrist.

METHODS

Surgical treatment options for necrosis of the lunate bone can be divided into relieving or revascularization procedures and salvage procedures.

RECOMMENDATIONS

For patients under 20 years old the treatment of choice is prolonged immobilization, in cases of non-response or progression, minimally invasive and relieving procedures are used. In adult patients with limited affection of the lunate bone the first therapeutic approach should also be immobilization. If in progressive disease or advanced stages only the lunate bone is compromised but reconstructable, restoration should be considered. In progressive collapse of a non-reconstructable lunate bone the therapeutic efforts shift to mobility-preserving procedures utilizing still functional articulations of the wrist. If all functional articulations are lost only classical salvage procedures are feasible.

CONCLUSION

According to the presented algorithms a stage-dependent therapy of necrosis of the lunate bone is possible. It should not be ignored that there are still no scientific and evidence-based arguments for some of these treatment options. This is also true for maximally invasive procedures, where superiority to more simple procedures have not been proven. Therefore, their application should be restricted and based on an individual decision.

[Suture techniques and material in surgery of flexor tendons]

Adhesions and scar formation between flexor tendons and the surrounding tissue are only contemporarily avoidable by movement of flexor tendons. Concepts with active follow-up protocols are more favorable than passive mobilization. The main risks of flexor tendon repair are rupture of the tendon suture, insidious gap formation and resistance to tendon gliding within the tendon sheath. Currently, there is no consensus with respect to the optimal suture technique or suture material. Nevertheless, there are some principles worth paying attention to, such as using stronger suture material, blocking stitches, suture techniques with four or more strands as well as circular running sutures. A technically acceptable compromise, even for the less experienced, is currently the four-strand suture combined with a circular running suture. It maintains sufficient stability for active motion follow-up protocols without resistance.

The challenge of Monteggia-like lesions of the elbow

Aims

The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome.

Patients and Methods

A total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws.

Results

Good results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis.

Conclusion

Monteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18.

[Treatment of recurrent Dupuytren's disease]

BACKGROUND

The tendency of recurrence or progression is a frequent problem in Dupuytren's disease. The management of recurrence is adapted to the individual situation and the patient's needs. In mild cases a non-operative approach is recommended. Revision surgery is reserved for disabling situations with acceptable circulation and sensation in absence of dystrophy. It is complicated by a combined formation of scar tissue and new cords. This increases the risk of soft tissue loss and injuries to the neurovascular bundles, which impair sensation and circulation and may result in loss of the finger.

TECHNIQUE

The strategy consists of preoperative planning of the soft tissue reconstruction, meticulous preparation of the neurovascular bundles, arthrolyses and skin closure by Z‑plasty or transposition flaps. The corrective arthrodesis of the proximal interphalangeal joint may be an alternative to improve function without the risks of revision surgery. In cases of severe impaired circulation, sensation or dystrophy of the finger, amputation or ray resection may be indicated.

Documenting success stories of management of phosphorus emissions at catchment scale: an example from the pilot river Odense, Denmark

Documentation of the effects of different mitigation measures adopted at different scales to reduce phosphorus (P) loadings to surface waters is needed to help catchment managers select the best management practices. Water quality monitoring data from the outlets of two paired catchments (the river Odense catchment versus a neighbouring control catchment) on the island of Funen, Denmark, showed significantly different trends in annual flow-weighted P concentrations during the period 2000-2013. A significant downward trend in flow-weighted particulate P (PP) concentrations (0.051 mg P L^-1) and loss (0.155 kg P ha^-1) was detected for the river Odense catchment, whereas a similar trend did not emerge in the control catchment. The observed differences in PP reductions may be due to wetlands acting as P sinks since wetland restoration activities have been much more comprehensive in the river Odense catchment (1.8 ha wetlands km^-2) than in the control catchment (0.5 ha wetland km^-2). The excess downward trend in total P and PP in the river Odense catchment (5,600 kg P and 3,700 kg P) is corroborated by extrapolating the results from a mass-balance study and 10 years of in situ measurements of P storage (3,700 kg P and 15,000 kg P).

[Fractures of carpal bones]

Fractures of the carpal bones are uncommon. On standard radiographs fractures are often not recognized and a computed tomography (CT) scan is the diagnostic method of choice. The aim of treatment is to restore pain-free and full functioning of the hand. A distinction is made between stable and unstable carpal fractures. Stable non-displaced fractures can be treated conservatively. Unstable and displaced fractures have an increased risk of arthritis and non-union and should be stabilized by screws or k‑wires. If treated adequately, fractures of the carpal bones have a good prognosis. Unstable and dislocated fractures have an increased risk for non-union. The subsequent development of carpal collapse with arthrosis is a severe consequence of non-union, which has a heterogeneous prognosis.

[Correlation of Estimated and Factual Operation Time in Frequent Interventions in Traumatolgy]

BACKGROUND

The Surgical Safety Checklist (SSC) was introduced by the World Health Organization (WHO) in 2008 in order to analyse and reduce perioperative surgical morbidity. Preoperative estimation of the expected surgery time (EST) by the surgeon is an integral part of the SSC.

OBJECTIVE

The aim of the present study was to correlate EST and factual surgery time (FST), to identify factors influencing the correlation between the two parameters and to collect more information about planning surgical capacity.

MATERIAL AND METHODS

A retrospective analysis researched the EST and FST for plate osteosynthesis in distal radius fractures, intramedullary femur nailing or the implantation of duo head prosthesis in proximal femur fractures in our department between 06/2012 and 12/2013.

RESULTS

220 patients fulfilled the inclusion criteria and underwent further analysis (palmar plate osteosynthesis: n = 89, intramedullary femur nailing with joint involvement: n = 70, duo head prothesis: n = 61). Mean EST and FST exhibited no significant difference in any of the analysed surgical procedures. However, the correlation coefficients were comparatively low for individual surgical procedures (ρ = 0.60). The surgeon's experience had no influence on the correlation between EST and FST.

CONCLUSIONS

In this study, the FST for palmar plate osteosynthesis, proximal intramedullary femur nailing and implantation of duo head prosthesis agreed well with the national average. Unexpected intraoperative complications may cause above average FST. In this case, the surgical team and coordinator must identify rapid individual solutions.

[Direct Screw Osteosynthesis of a Bennett's Fracture by Radiopalmar Incision after Gedda and Moberg]

BACKGROUND

Bennett's fracture is a partial intra-articular fracture, with two main fragments of the first metacarpal bone. Treatment should aim to rebuild the articular surface and to achieve early mobilisation of the thumb saddle joint.

OBJECTIVE

To demonstrate the operation of direct screw osteosynthesis of a Bennet's fracture by a Gedda/Moberg radiopalmar incision in a video.

PATIENT

During distortion of the thumb, a 31-year old patient suffered a Bennets's fracture, which was operated by direct screw osteosynthesis.

CONCLUSION

Direct screw osteosynthesis is the method of choice to restore the articular surface and early mobilisation of the thumb saddle joint after Bennett's fracture.

Successful reduction of diffuse nitrogen emissions at catchment scale: example from the pilot River Odense, Denmark

Land-based total nitrogen (N) loadings to Danish coastal waters have been markedly reduced since 2000. This has been achieved by general measures reducing discharges from all point sources and N leaching from farmed land supplemented with more local and targeted mitigation measures such as restoration of wetlands to increase the catchment-specific N retention. In the catchment of River Odense, restoration of wetlands has been extensive. Thus, in the major gauged catchment (485 km(2)) eleven wetlands (860 ha) have been restored since 2000. A comparison of data on N concentrations and loss from a gauging station in the River Odense with data from a control catchment (772 km(2)), in which a significantly less intensive wetland restoration programme has been undertaken, showed an excess downward trend in N, amounting to 124 t N yr(-1), which can be ascribed to the intensive wetland restoration programme carried out in the River Odense catchment. In total, the N load in the River Odense has been reduced by 377 t N yr(-1) (39%) since 2000. The observed downward trend is supported by monitoring data from two wetlands restored in 2001 and 2004 in the River Odense catchment.

Leaching of dissolved phosphorus from tile-drained agricultural areas

We investigated leaching of dissolved phosphorus (P) from 45 tile-drains representing animal husbandry farms in all regions of Denmark. Leaching of P via tile-drains exhibits a high degree of spatial heterogeneity with a low concentration in the majority of tile-drains and few tile-drains (15% in our investigation) having high to very high concentration of dissolved P. The share of dissolved organic P (DOP) was high (up to 96%). Leaching of DOP has hitherto been a somewhat overlooked P loss pathway in Danish soils and the mechanisms of mobilization and transport of DOP needs more investigation. We found a high correlation between Olsen-P and water extractable P. Water extractable P is regarded as an indicator of risk of loss of dissolved P. Our findings indicate that Olsen-P, which is measured routinely in Danish agricultural soils, may be a useful proxy for the P leaching potential of soils. However, we found no straight-forward correlation between leaching potential of the top soil layer (expressed as either degree of P saturation, Olsen-P or water extractable P) and the measured concentration of dissolved P in the tile-drain. This underlines that not only the source of P but also the P loss pathway must be taken into account when evaluating the risk of P loss.

Uncommon carpal fractures

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.

Management algorithm for index through small finger carpometacarpal fracture dislocations

PURPOSE

Injuries to the carpometacarpal (CMC) joints are rare. The most common CMC fracture dislocations occur in the ring and small finger CMC joints. The aim of this study was to review the structured diagnostic procedure and different treatment options.

METHODS

We review the importance of early and correct diagnosis in CMC fracture dislocation, because it is needed to ensure pain-free hand function. Moreover, we contrast different therapeutic options, including non-operative and surgical therapy for CMC fracture dislocation.

RESULTS

If a clinical suspicion for a CMC dislocation based on patient examination or radiographic findings exists, then a thin slice CT should be considered. Non-operative treatment is rarely indicated. Surgical treatment may include closed or open reduction efforts. In the case of most fracture dislocations, open reduction is recommended. Fracture fixation may be accomplished with K-wires, mini plates or screws.

CONCLUSION

CMC fracture dislocations of the fourth and fifth CMC joints are uncommon and often overlooked. Primary goal of treatment is to restore normal function to the hand. Therefore, operative therapy might be the method of choice.

[Tenolysis of the flexor tendons in the hand]

BACKGROUND

Properly gliding flexor tendons is mandatory for the normal functioning of the finger and thumb. Any damage to tendons, tendon sheath or adjacent tissue can lead to the formation of adhesions that inhibit the normal gliding function. If adhesions limit the digital function and adequate hand therapy does not provide further progress, then surgical intervention should be considered.

AIM

The authors' strategy and treatment algorithm for flexor tenolysis are presented in the context of the current literature.

METHODS

There is no absolute indication for flexor tenolysis. The decision should be made in a motivated patient who has access to adequate postoperative hand therapy. It should be based on healed fractures and osteotomies, mature soft tissue coverage, intact tendons and gliding tissues, and a full range of passive flexion, and preferably extension of the affected joints. The principle of flexor tenolysis is the consequent resection of all adhesive tissue around the tendon inside and outside the tendon sheath, with preservation of as many pulley sections as possible. Therefore, extensive approaches are frequently necessary. Arthrolysis and the resolution of unfavorable scars, the resection of scarred lumbricals, and pulley reconstruction are additional procedures that are frequently performed.

RESULTS

In the literature, improvement in the range of motion is between 59 and 84 %. Good and excellent functional results are reported in 60-80 % of the cases. Nevertheless, in selected cases, functional deterioration occurs. Flexor tendon ruptures after tenolysis were observed in 0-8 % of the patients.

DISCUSSION

With regard to complications such as secondary tendon ruptures, loss of pulleys, and scar formation, flexor tenolysis is part of a reconstructive ladder that includes further procedures. In the case of failure or complications, salvage procedures such as arthrodesis, amputation, and ray resection or staged flexor tendon reconstruction including tendon grafting are recommended. After successful flexor tenolysis long-term hand therapy for at least 3-6 months is mandatory to maintain the intraoperative gain of function.

Hyperbaric oxygen therapy improves angiogenesis and bone formation in critical sized diaphyseal defects

Besides the use of autologous bone grafting several osteoconductive and osteoinductive methods have been reported to improve bone healing. However, persistent non-union occurs in a considerable number of cases and compromised angiogenesis is suspected to impede bone regeneration. Hyperbaric oxygen therapy (HBO) improves angiogenesis. This study evaluates the effects of HBO on bone defects treated with autologous bone grafting in a bone defect model in rabbits. Twenty-four New-Zealand White Rabbits were subjected to a unilateral critical sized diaphyseal radius bone defect and treated with autologous cancellous bone transplantation. The study groups were exposed to an additional HBO treatment regimen. Bone regeneration was evaluated radiologically and histologically at 3 and 6 weeks, angiogenesis was assessed by immunohistochemistry at three and six weeks. The additional administration of HBO resulted in a significantly increased new bone formation and angiogenesis compared to the sole treatment with autologous bone grafting. These results were apparent after three and six weeks of treatment. The addition of HBO therapy to autologous bone grafts leads to significantly improved bone regeneration. The increase in angiogenesis observed could play a crucial role for the results observed.

The effect of bone marrow concentrate and hyperbaric oxygen therapy on bone repair

Neoangiogenesis represents an essential part of bone regeneration. Therefore the improvement of neovascularization is the subject of various research approaches. In addition autologous mesenchymal stem cells concentrate in combination with bone substitute materials have been shown to support bone regeneration. In a rabbit model we examined the proposed synergistic effect of hyperbaric oxygen therapy (HBOT) and bone marrow concentrate (BMC) with porous calcium phosphate granules (CPG) on neoangiogenesis and osseous consolidation of a critical- size defect. The animal groups treated with HBOT showed a significantly higher microvessel density (MVD) by immunhistochemistry. Furthermore HBOT groups presented a significantly larger amount of new bone formation histomorphometrically as well as radiologically. We conclude that the increase in perfusion as a result of increased angiogenesis may play a key role in the effects of HBOT and consequently promotes bone healing.

Fracture-dislocations of the carpometacarpal joints of the ring and little finger

We report the functional and radiographic results of 16 patients with fracture-dislocations of the ring and little finger carpometacarpal joints and 23 cases with fracture-dislocations of only the little finger carpometacarpal joint treated between 2006 and 2012. The above two cohort populations of patients were treated with either open reduction and pin fixation or closed reduction and pin fixation. These patients were followed for a mean of 13 months (range 9 to 48). The DASH scores for patients with fracture-dislocations of the ring and little finger carpometacarpal joints were 6.0 and of the little finger carpometacarpal joint 7.2. We found no functional differences in term of DASH scores after treatment between patients with fracture-dislocations of only the little finger carpometacarpal joint and both the ring and little finger carpometacarpal joints.

The treatment of the acute Essex-Lopresti injury

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome. The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results. From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]

BACKGROUND

Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system.

METHODS

A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out.

RESULTS

The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system.

CONCLUSIONS

Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

[Injuries of the proximal interphalangeal joint]

BACKGROUND

Injuries of the proximal interphalangeal joint (PIP joint) are common. They are frequently underestimated by patients and initial treating physicians, leading to unfavorable outcomes. Basic treatment includes meticulous clinical and radiological diagnosis as well as anatomical and biomechanical knowledge of the PIP joint.

TREATMENT

In avulsions of the collateral ligaments and the palmar plate with or without involvement of bone, nonoperative treatment is preferred. Operative stabilization is reserved for large displaced bony fragments or complex instabilities. In central slip avulsion or rupture, osseous refixation, suture, or reconstruction is common and nonoperative treatment is limited to special situations like minimally displaced avulsions. In basal fractures of the middle phalanx, elimination of joint subluxation and restoration of joint stability are priority. If the fragments are too small for fixation with standard implants, therapeutic alternatives include refixation of the palmar plate, dynamic distraction fixation, percutaneous stuffing, or replacement by a hemihamate autograft. Early motion is initiated regardless of the treatment regime. Undertreatment leads to persistent swelling, instability, and limited range of motion, which are difficult to treat. Contributing factors are unnecessary immobilization, immobilization in more than 20° flexion or transfixation by K-wires. For residual limitations, nonoperative treatment with physiotherapists and splinting is first choice. Operative treatment is reserved for persistent flexion/extension contractures persisting for more than 6 months, as well as reconstructions in boutonniere and swan neck deformity and salvage procedures for destroyed joints.

[Early corrective osteotomy after secondary displaced distal radius fractures in children]

Secondary fracture displacement before osseous consolidation of distal radius fractures in children occasionally leads to restricted forearm rotation. So far, there is no consistent treatment recommendation to correct this complication. We report on 5 children with an age of 8-13 years (mean age 12.3 years, 4 boys, 1 girl) with secondary displaced distal radius fractures and high functional deficits in forearm rotation (mean ROM for pro-/supination 70-0-30°) after osseous consolidation. We performed corrective osteotomies of the distal radius using a palmar approach after a mean of 38 days. Stabilisation was achieved with a fixed-angle plate system. At the final follow-up examination (mean 9 months) the forearm rotation was normal. No complications were observed. We consider corrective osteotomies of the distal radius in children with deficits of forearm rotation to be a possible strategy. Early corrective osteotomies can lead to a predictable increase of function through reestablishing normal articulation.

[Complex fragmentation of the distal radial articular surface. Reconstruction with subchondral Kirschner wires and bone grafts]

BACKGROUND

Complex fragmentation of the distal radial articular surface often results in three major problems: some fragments are too small for stabilisation by standard plates or screws; in addition, substantial loss of articular surfaces and metaphyseal/subchondral bony defects frequently occur.

MATERIAL AND METHODS

To solve these problems the following strategy was developed: the fixation of small articular fragments was performed by small K-wires that were placed subchondrally and countersunk in the bone. In case of lost articular surfaces a silicone foil was inserted intra-articularly to induce a cartilage-like tissue. Bony defects were replaced by iliac crest bone grafts. Additional stability was achieved by dorsal and volar plate fixation or bridge plating.

RESULTS

An average of 53° of extension, 44° of flexion, 74° of pronation, and 66° of supination were achieved. The grip strength was an average of 61% of that in the contralateral limb. The average radiographic measurements were -5° of palmar inclination, 21° of ulnar inclination, and 0 mm of positive ulnar variance. A good or excellent functional result was achieved for five of seven wrists according to the rating system of Gartland and Werley. According to the modified Mayo Wrist Score four of five wrists achieved a good and one a fair result.The DASH Score averaged 19 (6-59) points.

CONCLUSIONS

The applied treatment resulted in stable, mobile wrists with reasonable alignment and nearly even articular surfaces. The functional results were similar to those reported by other authors for less complex distal radius fractures. This strategy seems to be a rational approach to the reconstruction of severely comminuted intra-articular fractures of the distal radius.

The early phase influence of bone marrow concentrate on metaphyseal bone healing

Bone marrow concentrate (BMC) contains high densities of progenitor cells. Therefore, in critical size defects BMC may have the potency to support bone healing. The aim of this study was to investigate the effect of BMC in combination with calcium phosphate granules (CPG) on bone defect healing in a metaphyseal long bone defect in mini-pigs. A metaphyseal critical-size bone defect at the proximal tibia of 24 mini-pigs was filled with CPG combined with BMC, CPG solely (control group) or with an autograft. Radiological and histomorphometrical evaluations after 6 weeks (42 days) showed significantly more bone formation in the BMC group in the central area of the defect zone and the cortical defect zone compared to the CPG group. At the same time the resorption rate of CPG increased significantly in the BMC group. Nevertheless, compared to the BMC group the autograft group showed a significantly higher new bone formation radiologically and histomorphometrically. In BMC the count of mononuclear cells was significantly higher compared to the bone marrow aspirate (3.5-fold). The mesenchymal progenitor cell characteristics of the cells in BMC were confirmed by flow cytometry. Cells from BMC created significantly larger colonies of alkaline phosphatase-positive colony forming units (CFU-ALP) (4.4-fold) compared to cells from bone marrow aspirate. Nevertheless, even in the BMC group complete osseous bridging was only detectable in isolated instances of the bone defects. Within the limitations of this study the BMC+CPG composite promotes bone regeneration in the early phase of bone healing significantly better than the isolated application of CPG. However, the addition of BMC does not lead to a solid fusion of the defect in the early phase of bone healing an still does not represent an equal alternative to autologous bone.

[Operative treatment of claw deformity by lassoplasty]

OBJECTIVES

The aim is correction of claw deformity of the fingers by intrinsic paralysis.

INDICATIONS

Indications are claw deformity of fingers caused by palsy or functional loss of the interosseus or lumbrical muscles as far as the function of the superficial and deep flexors of the finger is intact.

CONTRAINDICATIONS

Contraindications are loss or paralysis of finger flexors supplied by the median nerve, fixed extension or flexion contracture of the finger joints, osteoarthritis and other malfunctions of the finger joints, no active flexion and extension of the interphalangeal joints due to compromised tendon gliding. Relative: Upper ulnar nerve palsy with functional loss of the deep flexor of the small and ring finger and possibly of the middle finger.

SURGICAL TECHNIQUE

The operation technique involves detachment of the flexor digitorum superficialis IV tendon (FDS IV) distal to Camper's chiasm, division of the tendon into separate strips, interweaving of each tendon strip into the proximal part of the A2 pulley of the affected fingers. In cases of claw deformity of all fingers it may be advantageous to apply the superficial flexor tendon of the long finger in addition to the FDS IV tendon as otherwise the FDS IV tendon has to be divided into four strips resulting in relatively thin tendon strips. If the FDS III and IV tendons are applied, the two strips of the FDS IV tendon are used for lassoplasty of the small and ring fingers and the FDS III tendon for lassoplasty of the middle and index fingers.

POSTOPERATIVE MANAGEMENT

Postoperative management includes immobilization of the operated fingers by a dorsoulnar forearm plaster cast including the metacarpophalangeal joints which are flexed to 70°. After 2 weeks replacement of the cast by a thermoplastic splint for another 4 weeks. During the whole period exercises for the finger and thumb should be carried out.

RESULTS

From April 2003 to June 2012 a total of 17 patients, 8 female and 9 male were surgically treated for claw deformity. The dominant hand was affected in seven patients. The average age was 46 ± 15 (22-80) years, the average interval from onset of ulnar palsy to lassoplasty was 61 ± 91 (3-288) months. The final follow-up was performed after an average of 42 ± 32 (2-112) months. Claw deformity was resolved in 14 out of the 17 patients. The grip strength was on average 58 ± 28 % (11-96 %) of the unaffected hand, the mean disabilities of the arm, shoulder and hand (DASH) score was 32 ± 18 (5-68) points and the degree of patient satisfaction 7 ± 2 (0-10). According to own results and those in the literature lassoplasty can be recommended for the treatment of claw deformity.

[Giant cornu cutaneum - a grotesque manifestation of squamosus cell carcinoma in the palm]

Squamous cell carcinoma is the most common maligne primary tumour of the hand. It is almost always located on the dorsum of the hand, an occurrence in the palm is very rare. Usually these tumours are recognised early because of their clinical presentation and visible location. We report on a case in which the patient presented in our hospital only due to a massive mechanical impairment of his hand function through an oversized squamous cell carcinoma. On the basis of this case the therapeutic algorithm for large squamous cell carcinoma in the palm is illustrated and discussed.

[The malunited distal radius fracture - early or late correction?]

BACKGROUND/GOAL: Despite the fact that corrective osteotomy for malunited distal radius fractures is widely accepted, the optimal timing is still a matter of controversy. The presented study compares the clinical and radiological results of early vs. late corrective osteotomy at the distal radius to evaluate the influence of timing.

PATIENTS AND METHODS

We prospectively studied 34 consecutive patients with extraarticular malaligned fractures of the distal end of the radius who underwent corrective osteotomy. Early correction was performed in 14 patients (10 -women and 4 men with an average age of 48±18 years) at an average of 8±3 weeks (range, 3-13) after the injury, late correction in 20 patients (16 women and 4 men, average age of 54±19 years) at an average of 52±46 weeks (range, 24-229) -after the injury. The demographic data of the groups were statistically identical. Preoperatively and at the recent follow-up the range of motion of the wrist (ROM) and grip strength were recorded as well as pain at rest and activity (visual analogue scale), DASH score and radiological data. A conclusive evaluation was performed by the modified Mayo wrist score for the recent follow-up after 24±10 (6-44) (early correction) vs. 21±10 (8-56) (late correction) months.

RESULTS

All osteotomies healed uneventfully. Early corrections required significantly less bone-grafting. The comparison of the pre- and postoperative data in the early corrrection group showed an improvement of all parameters, that was significant in four parameters. The comparison of the pre- and postoperative data in the late correction group showed an improvement of all parameters, that was significant in 5 parameters. The comparison of the postoperative data revealed nearly identical results in both groups for all parameters including the modified Mayo wrist score.

CONCLUSION

The general improvement stresses the value of both, early and late reconstruction. Although no statistical difference was detectable early corrective osteotomy seems to be recommendable in early presenting patients, in order to avoid bone-grafting. In later presenting cases we recommend observation and return after 6 months in the case of persistent pain or disability. Nevertheless, the time choice of corrective osteotomy remains an individual decision in all patients.

[Interhospital transfer of severely injured patients in Germany. Evaluation of the DGU trauma register]

BACKGROUND

The TraumaNetzwerk(D) DGU was founded 3 years ago and since then the majority of trauma centers have been registered and organized into regional trauma network services (TNW). Within these networks assessment criteria for transferring patients to higher level hospitals are defined. The purpose of this study was to evaluate the incidence, causes, implications and quality of care for patients with major trauma who were transferred for definitive treatment before implementation of the TraumaNetzwerk(D) DGU in Germany.

PATIENT AND METHODS

The data of 19,035 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >9 and a blood pressure documented on admission were included into the study. Data were allocated according to patients where therapy was performed completely in the primary hospital of admission (group I; n=16,033; 84.2%) and patients transferred after primary care from one hospital to another centre for definitive care (group II; n=3,002; 15.8%). Comparative parameters were the pattern and severity of injury, physiological state on admission and clinical outcome.

RESULTS

Mean ISS and percentage of patients with an ISS ≥25 did not differ significantly between groups. Of the patients who were transferred to a higher level trauma centre (group II) 20.7% needed catecholamines on admission, 10.1% were in shock (blood pressure <90 mmHg) and 2.5% of the patients underwent resuscitation in the emergency department. Patients of group II had a considerably longer hospital stay (31.2±35.5 days) than patients of group I (24.8±27.1 days). Furthermore, treatment costs were significantly higher for group II (I: EUR 23,870; II: EUR 26,054).

CONCLUSIONS

A relevant percentage of patients transferred from one hospital to another were hemodynamically and clinically unstable. To what extent the quality of patient transfer and therefore major trauma care is improved by the implementation of regional trauma networks in Germany remains to be seen over the next years.

[Therapy of triangular fibrocartilage complex lesions]

The triangular fibrocartilage complex (TFCC) represents an important anatomical structure interposed between the ulnar carpus and the distal ulnar. Injuries and degenerative changes of the TFCC are of high clinical relevance and there are numerous treatment options available based on different concepts and which are being used to varying extents. The aim of this systematic review was to evaluate the effectiveness of different therapies for lesions of the TFCC. Studies on TFCC lesions were systematically reviewed, classified into evidence levels and selected according to predefined criteria. A total of 259 publications were identified as being potentially relevant and finally 35 studies could be included in the review. In addition, a survey was performed among German hand surgeons in order to identify commonly used procedures for TFCC lesions in Germany. The classification of Palmer is mostly used both in the literature and in Germany and therapeutic decisions are predominantly based on this classification. The systematic review revealed some common treatment strategies for traumatic and degenerative lesions. Generally, the level of evidence was poor for all identified publications. For this reason, evidence-based recommendations for the treatment of TFCC lesions could not be derived from the literature. There was broad consent between the results of the literature review and the survey.

[Hyperbaric oxygen in the treatment of hemorrhagic radiogenic cystitis after prostate cancer]

BACKGROUND

Postradiation hemorrhagic cystitis is a well known long-term complication of radiation therapy occurring in 3-6 % of patients. Hyperbaric oxygen (HBO) has been demonstrated to be an effective treatment for radiation-induced hemorrhagic cystitis not responding to conventional management. This article reviews experiences with HBO for radiogenic cystitis after prostate cancer.

METHODS

All patients treated for hemorrhagic cystitis with HBO between 2006 and 2012 were retrospectively reviewed. The HBO procedure was performed for 130 min/day at 1.4 atmospheres overpressure. Patient demographics, type of radiotherapy, onset and severity of hematuria and time between first hemorrhagic episode and beginning of HBO were evaluated. The effect of HBO was defined as complete or partial (lower RTOG/EORTC grade) resolution of hematuria.

RESULTS

A total of 10 patients with radiogenic cystitis and a median age of 76 years were treated with a median of 30 HBO treatment sessions. Patients received primary, adjuvant, salvage and high dose rate (HDR) radiotherapy (60-78 Gy). First episodes of hematuria occurred after a median of 41 months following completion of radiotherapy and HBO was performed 11 months after the first episode of hematuria. After a median 35-month follow-up 80% experienced complete resolution, one patient suffered a one-off new hematuria and in one patient a salvage cystectomy was necessary. No adverse effects were documented.

CONCLUSIONS

The experiences indicate that HBO is a safe and effective therapy option in treatment-resistant radiogenic cystitis but prospective clinical trials are needed for a better evaluation.

[Treatment strategy for carpometacarpal fracture dislocation]

Carpometacarpal (CMC) fracture dislocations of the 2nd through 5th ray are rare injuries whose extent is regularly underestimated in the initial radiographic evaluation of the hand. Obtaining a computed tomography scan is imperative due to the radiographic underrepresentation of the full bone and joint injury. Restoration of bone and joint anatomy of the affected region is of paramount import to prevent joint deterioration and loss of hand durability and dexterity. Early surgical intervention can lead to good functional results. Different operative treatment strategies exist with a common approach being Kirschner wire, screw or plate fixation after closed or open fracture reduction and joint relocation.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system]

BACKGROUND

Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised.

METHODS

A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done.

RESULTS

The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system.

CONCLUSION

The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.

[Quality of documentation and care for victims of violence for the example of a trauma surgery emergency department in a major city]

BACKGROUND

People who have become victims of violence have manifold problems. Besides medical diagnostics and therapy, it is necessary to recognise the situation in which these patients have become such victims, to document the consequences of this violence for use in court and to offer further assistance. Victims of violence often contact primarily a trauma ambulance. The optimisation of the medical treatment of the victims is a relevant traumatological topic, which so far has received only very scant attention. Therefore the aim of this study was to evaluate the necessity for an interdisciplinary combination of treatments for the targeted treatment of these victims.

MATERIAL AND METHODS

Using a standardised data card a retrospective data analysis of all out-patients and all in-patients of a trauma centre with regard to the existence of a violent context was carried out for the year 2004. All such cases were included and the data were evaluated descriptively according to age, gender, information about the act of violence, consequences thereof, type and scope of the diagnostic findings, as well as inducements for further measures. In this context we differentiated between "domestic violence" and "public violence".

RESULTS

The data of 7132 patients were evaluated. Altogether 347 victims of violence were identified (among them 109 victims of "public violence", 59 victims of domestic violence, and 179 cases that could not be allocated clearly). This results in a quota of 4.9% of all patients treated. The average age of the victims was 30.6 years. It was striking that in many cases the anamnesis and documentation were rather fragmentary.

CONCLUSION

A very high percentage of victims of violence could be found among the patients needing traumatological treatment. With regard to the fragmentary care there is an enormous need for medical training and interdisciplinary treatment of victims of violence.

Fixed-angle plates in patella fractures - a pilot cadaver study

Objective

Modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring are currently the fixation of choice for patellar fractures. Failure of fixation, migration of the wires, postoperative pain and resulting revision surgery, however, are not uncommon. After preliminary biomechanical testing of a new fixed-angle plate system especially designed for fixation of patella fractures the aim of this study was to evaluate the surgical and anatomical feasibility of implanting such a plate-device at the human patella.

Methods

In six fresh unfixed female cadavers without history of previous fractures around the knee (average age 88.8 years) a bilateral fixed-angle plate fixation of the patella was carried out after previous placement of a transverse central osteotomy. Operative time, intra-operative problems, degree of retropatellar arthritis (following Outerbridge), quality of reduction and existence of any intraarticular screw placement have been raised. In addition, lateral and anteroposterior radiographs of all specimens were made.

Results

Due to the high average age of 88.8 years no patella showed an unimpaired retropatellar articular surface and all were severely osteoporotic, which made a secure fixation of the reduction forceps during surgery difficult. The operation time averaged 49 minutes (range: 36-65). Although in postoperative X-rays the fracture gap between the fragments was still visible, the analysis of the retropatellar surface showed no residual articular step or dehiscence > 0.5 mm. Also in a total of 24 inserted screws not one intraarticular malposition was found. No intraoperative complications were noticed.

Conclusions

Osteosynthesis of a medial third patella fracture with a bilateral fixed-angle plate-device is surgically and anatomically feasible without difficulties. Further studies have to depict whether the bilateral fixed-angle plate-osteosynthesis of the patella displays advantages over the established operative procedures.

Flexor tendon repair using a new suture technique: a comparative in vitro biomechanical study

INTRODUCTION

The purpose of this experimental study was to evaluate the biomechanical characteristics of two new four-strand core suture techniques for flexor tendon repair.

MATERIALS AND METHODS

The two new suture techniques (Marburg 1, Marburg 2) are characterized by four longitudinal stitches which are anchored by a circular or semicircular suture. They were compared with three commonly used core suture techniques (modified Kessler, Tsuge, Bunnell). Fifty porcine flexor tendons were randomly assigned to one of the five core suture techniques. Outcome measures included ultimate tensile strength, maximum of lengthening, mode of failure and 1 mm gap formation force.

RESULTS

The highest ultimate tensile strength was found for the modified Kessler technique (115 N). Both new techniques showed an ultimate load exceeding 50 N (57 N for Marburg 1, 54 N for Marburg 2). The Marburg 1 technique showed the highest gap resistance of all tested suture techniques. The Bunnell and Tsuge core suture techniques produced the poorest mechanical performance.

CONCLUSION

From these experimental results, the new Marburg 1 core suture technique can be considered for flexor tendon repair in a clinical setting with the use of active motion protocols.