[Development of diagnosis-related groups in different surgical disciplines]. / Entwicklung der Fallpauschalenvergütung in verschiedenen chirurgischen Fachgebieten.

BACKGROUND: Since the introduction of Diagnosis-Re-lat-ed Groups (DRGs) in Germany, the variables of remuneration have continuously changed. Subjectively, reimbursement by DRG has a negative connotation among all specialities. We analysed the development of reimbursement and length of stay in different surgical specialties. MATERIAL AND METHODS: By grouping the top-10-diagnoses and therapies in hand surgery, trauma surgery, general surgery as well as cardiothoracic and vascular surgery between 2004 and 2010, DRGs were obtained, compared and the data deduced. RESULTS: While the lower threshold of length of stay remained almost the same, mean value and upper threshold became shorter in most of the top-10-diagnoses. During the observation period, total reimbursement increased by 30 % in hand surgery, 20 % in general surgery and 17 % in cardiothoracic and vascular surgery, while in trauma surgery it decreased by 1 %. This corresponds to mean annual growth rates of 4.47 %, 3.08 %, 2.68 % and - 0.15 %, respectively. No correlation was found between the 4 disciplines and macro-economic parameters. CONCLUSION: Reductions of mean and upper thresholds of length of stay are present in all surgical disciplines. Total reimbursements developed partially in a contradictory manner. Negative growth involves the danger that hospital investments cannot be realised, especially in the presence of high personnel costs.

Severe posttraumatic radiocarpal cartilage damage: first report of autologous chondrocyte implantation.

STUDY DESIGN: Case report. CLINICAL QUESTION: Traumatic articular cartilage defects predispose to secondary osteoarthritis accompanied by impairment or complete loss of function in the corresponding joint. On this account, the timely and correct diagnosis as well as the selection of an appropriate therapy for reconstruction of articular cartilage defects is important. METHODS: A 22-year-old healthy male patient with history of traumatic intra-articular distal radius fracture is presented with in the course detectable 4° cartilage damage in the fovea scaphoidea and into the fovea lunata. For the first time, autologous chondrocyte implantation by the use of an in situ polymerizable albumin-hyaluronic acid gel was performed to restore the articular cartilage. RESULTS: The assessment 6 months after autologous chondrocyte implantation using the standard DASH questionnaire for upper extremity pointed out an improvement in the patient outcome (DASH score pre-operative: 10.8 and 6 months post-operative: 7.5). The clinical examination also showed an improvement in the range of movement of the wrist without pain. The radiological control investigation (MRI- examination) of the wrist 6 months after implantation also revealed a good integration of the implant. CONCLUSION: The case presented here demonstrates the first use of autologous chondrocyte implantation for cartilage reconstruction using an in situ polymerizable albumin-hyaluronic acid gel after traumatic cartilage lesion with 4° cartilage damage of the wrist in a 22-year-old non-smoking, active and healthy man. Initial results are promising in terms of mobility, pain and patient outcome. However, further clinical studies have to be performed with larger number of cases.

[Clinical functional assessment of various surgical hand arthrodesis techniques]. / Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden.

BACKGROUND: Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis. MATERIALS AND METHODS: Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n = 43, STT fusion n = 30 and midcarpal arthrodesis n = 25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n = 21, STT fusion n = 17 and midcarpal arthrodesis n = 10). RESULTS: Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist. CONCLUSION: Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.

[Comparison between the Austrian and German DRG systems in hand surgery]. / Vergleich der Handchirurgie im österreichischen und deutschen Fallpauschalensystem.

BACKGROUND: Diagnosis-Related Groups (DRG) are a patient classification system grouping related types of patients treated to the resources they consumed. In this analysis, we compared the Austrian and the German DRG systems. METHOD: The 15 most common hand surgical diagnoses and their corresponding operative treatment were transferred into the Austrian system. Thus, the length of stay and the reimbursement of both countries could be obtained and compared. RESULTS: The mean values and the median values of the upper and lower thresholds of length of stay as well as the average length of stay were all lower in Austria compared to Germany. Reimbursement in Germany was higher in 13 of 19 cases. Total proceeds amounted to 1.67 million in the German and 1.70 million in the Austrian health care system. Considering the purchasing power applying consumer prize parities, the difference of reimbursement between the countries rose to 130,000 which equals a difference of almost 8%. CONCLUSION: Reimbursement of the top 15 diagnoses in hand surgery in Austria is 8% higher than in Germany. Except for one case, mean values as well as upper and lower thresholds of length of stay are considerably shorter in Austria. Comparison of international data to refine a national compensation system is advocated.

The secretion pattern of perivascular fat cells is different from that of subcutaneous and visceral fat cells.

AIMS/HYPOTHESIS: We have previously found that the mass of perivascular adipose tissue (PVAT) correlates negatively with insulin sensitivity and post-ischaemic increase in blood flow. To understand how PVAT communicates with vascular vessels, interactions between perivascular, subcutaneous and visceral fat cells with endothelial cells (ECs) were examined with regard to inflammatory, metabolic and angiogenic proteins. To test for possible in vivo relevance of these findings, circulating levels of the predominant secretion product, hepatocyte growth factor (HGF), was measured in individuals carefully phenotyped for fat distribution patterns. METHODS: Mono- and co-cultures of human primary fat cells with ECs were performed. mRNA expression and protein production were studied using Luminex, cytokine array, RealTime Ready and ELISA systems. Effects of HGF on vascular cells were determined by WST assays. In patients, HGF levels were measured by ELISA, and the mass of different fat compartments was determined by whole-body MRI. RESULTS: In contrast with other fat cell types, PVAT cells released higher amounts of angiogenic factors, e.g. HGF, acidic fibroblast growth factor, thrombospondin-1, serpin-E1, monocyte chemotactic protein-1 and insulin-like growth factor-binding protein -3. Cocultures showed different expression profiles from monocultures, and mature adipocytes differed from pre-adipocytes. HGF was preferentially released by PVAT cells and stimulated EC growth and smooth muscle cell cytokine release. Finally, in 95 patients, only PVAT, not visceral or subcutaneous mass, correlated independently with serum HGF levels (p = 0.03; r = 0.225). CONCLUSIONS: Perivascular (pre-)adipocytes differ substantially from other fat cells with regard to mRNA expression and protein production of angiogenic factors. This may contribute to fat tissue growth and atherosclerotic plaque complications. Higher levels of angiogenic factors, such as HGF, in patients with increased perivascular fat mass may have pathological relevance.

[100 years after Kienböck's description: review of the etiology of Kienböck's disease from a historical perspective]. / 100 Jahre nach Kienböck: Literaturübersicht über die Ursachenforschung der Mondbeinnekrosen.

Kienböck's disease (KD) leads to collapse of the lunate bone with severe consequences for the wrist function which for some patients may result in occupational invalidity. The many synonyms of KD (aseptic necrosis or avascular necrosis) insinuate that the true etiopathology remains poorly understood. This reviews aims at exploring the level of evidence which brought forward the different hypotheses on the origin of KD. The widespread theories about the origin were formed about 100 years ago but a specific therapy is still not within reach. Although the cause of the disease remains essentially unknown it is officially recognized as an occupational disease in Germany. Empirical attempts to explain the etiopathology are based on compression of the lunate, impaired vascularity through vibration exposition, fracture and dislocation of the lunate from the radiolunate fossa. The level of evidence urges a cautious interpretation of currently discussed hypotheses on the etiology of KD.

[Treatment algorithm for scaphoid nonunion : retrospective case-control study of 208 patients]. / Behandlungsalgorithmus der Kahnbeinpseudarthrose : Eine retrospektive radiologische Fall-Kontroll-Studie von 208 Patienten.

INTRODUCTION: We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. MATERIALS AND METHODS: Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. RESULTS: Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). CONCLUSION: Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.

[Comparison of hand surgery in the German and Italian DRG systems]. / Vergleich der Handchirurgie im deutschen und italienischen DRG-System.

Diagnosis-related groups (DRGs) are a patient classification system grouping related types of patients treated to the resources they consumed. In this analysis we compared the Italian and the German DRG systems regarding hand surgery with an emphasis on reimbursement of clinical cases. The 15 most common hand surgical diagnoses and their corresponding operative treatment in our clinic in 2009 were processed using a DRG grouper. The underlying data were transferred to the Italian system. Thus, the length of stay and the reimbursement of both countries could be obtained and compared. The latter was adjusted and corrected by the purchasing power of each country. The mean of the upper threshold of length of stay was 10 days in the German as well as the Italian system whereas the median was 2 times higher in Italy (6 vs. 12 days). Fifteen out of 19 cases showed higher reimbursement in Germany. The case mix index (CMI) of 0.917 in Germany represents a mean payment of 2,676 € per case. In Italy the hypothetical CMI of 0.635 resulted in a mean reimbursement of 1,853 € per case. The biggest difference in remuneration could be found for replantation of multiple fingers. For this service the German health-care system pays 12,320 € more than the Italian. Total proceeds of the top 15 diagnoses applying the number of cases treated in our clinic revealed 1.7 million € in the German and 1.2 million € in the Italian DRG system. Considering the purchasing power utilizing consumer prize parities, the difference of reimbursement between the countries decreased to 300,000 €. There is no mean length of stay per DRG in Italy, only the upper threshold of length of stay is determined. In most cases the latter is higher in Italy compared to Germany. The consumption of resources for finger replantation is not adequately represented in the Italian DRG system compared to finger amputation. Reimbursement of inpatient care is influenced by multiple factors not being subject to the free market economy. For this reason only descriptive comparison is feasible.

[Primary treatment of complicated flexor tendon injuries of the hand]. / Primärversorgung komplizierter Beugesehnenverletzungen an der Hand.

Complicated flexor tendon injuries are classified into lacerations, avulsions, ruptures, and defects. They are often a challenge for hand surgeons and frequently they present unsatisfactory functional results postoperatively. Lacerations and avulsions are usually treated by pull-out sutures and suture anchors. In ruptures, the causality should be sought. Tendon-linking, transposition and tenodesis/arthrodesis are the domain of rheumatoid arthritis. The primary transplantation of tendons is rarely indicated, ideally in non-contaminated flexor tendon defects in zones III-V with an uninjured surrounding soft tissue situation. Postoperative rehabilitation programs are very the same as in normal flexor tendon injuries.

[Limited portal carpal tunnel release. An alternative to classic open release?]. / Die minimal-invasive Karpaltunnelspaltung. Eine Alternative zur klassischen offenen Spaltung?

The aim of this study was to determine the significance of limited portal carpal tunnel release compared to the classic open approach. We present a retrospective comparative clinical trial including 161 patients (105 open release and 56 limited portal release). Special interest was directed towards postoperative functionality, disorders and quality of life. Significant advantages could be demonstrated for the limited portal carpal tunnel release: rapid ability to return to work as well as to routine tasks of daily living and high patient satisfaction. In the hands of trained surgeons, limited portal carpal tunnel release represents a rewarding alternative to the classic open release.

Concepts and developments in peripheral nerve surgery.

Nerve injuries may result in sensory and motor deficits when not treated appropriately. Especially the surgical management of nerve defects still represents a challenge for the surgeon. In these cases the grafting of autologous nerves represents the only reasonable approach. Due to the side effects associated with this method (sacrifice of donor nerves, neuroma formation in the harvesting area, limited availability of donor nerves, etc.), numerous alternatives were proposed in order to avoid the transplantation of autologous tissue. This review provides a general view on the state of the art of how to supply gaping injuries in the peripheral nerve. Furthermore new approaches emphasizing tubulization techniques for the reconstruction of lost nerve tissue are described with a special focus on various materials with their advantages and disadvantages.

Manual stimulation of forearm muscles does not improve recovery of motor function after injury to a mixed peripheral nerve.

Transection and re-anastomosis of the purely motor facial nerve leads to poor functional recovery. However, we have recently shown in rat that manual stimulation (MS) of denervated vibrissal muscles reduces the number of polyinnervated motor endplates and promotes full recovery of whisking. Here, we examined whether MS of denervated rat forearm muscles would also improve recovery following transection and suture of the mixed (sensory and motor) median nerve (median-median anastomosis, MMA). Following MMA of the right median nerve, animals received no postoperative treatment, daily MS of the forearm muscles or handling only. An almost identical level of functional recovery, measured by the force of grip in grams, was reached in all animals by the sixth postoperative week and maintained till 3 months following surgery regardless of the postoperative treatment. Also, we found no differences among the groups in the degree of axonal sprouting, the extent of motor endplate polyinnervation and in the soma size of regenerated motoneurons. Taken together, we show that while MS is beneficial following motor nerve injury, combined strategies will be required for functional recovery following mixed nerve injury.

[Combined flexor tendon and nerve injury of the hand]. / Kombinierte Beugesehnen- und Nervenverletzungen der Hand.

Any restoration of hand function following tendon and nerve injury has to include the repair or replacement of the hand's ability to perform a great many tasks. It is hard at first to appreciate fully the loss that occurs with flexor tendon injury. Also sensibility can be compromised from tendon injury without direct injury to the nerve, as object recognition in the absence of vision requires finger movement. When peripheral nerve injury is combined with flexor tendon injury, sensibility is directly impaired. There is a loss in the sense of finger or thumb position, pain temperature and touch or pressure recognition, in addition to the tendon injury. However, the outcome after operative treatment of these"minor" injuries of the hand is horrible. Therefore, we try to summarize practical consequences for the repair of combined flexor tendon and nerve injuries which will improve operative outcome. These guidelines are based on current scientific knowledge and our own experience.

[Recurrence rates of venous leg ulcers and the special importance of its surgical treatment]. / Rezidivraten des venösen ulkus unter chirurgischer therapie.

BACKGROUND: Venous insufficiency may lead to recurrent leg ulcers. The reason for this observation remains still unclear. In this study we tried to underline the influence of surgical treatment on recurrence rate of venous leg ulcers. PATIENTS AND METHODS: In this study 69 patients were treated in a special wound care centre. Before treatment the angiological status was evaluated using phlebography or duplex scan. Afterwards, patients were scored according to the "Venous Clinical Severity Score" of the American Venous Forum. During the observation period compression therapy was performed and wounds were treated with moist dressings. Necroses were removed by radical debridement and large ulcers were covered by mesh graft tissue transfer. When indicated incompetent veins were treated surgically. RESULTS: The follow-up revealed an overall recurrence rate of 21 % after 30 months. Ulcers treated by radical wound debridement or mesh graft tissue transfer demonstrated a significant lower recurrence rate (p = 0.02 and p = 0.03). According to duplex sonography a correlation was evident among severity of venous insufficiency, the "clinical scoring" (p = 0.04), and the recurrence rate (p = 0.023). After surgical intervention by venous stripping, the insufficiency was improved but the recurrence rate was comparable to that of patients treated without venous surgery (p = 0.44). CONCLUSION: Surgical treatment of venous leg ulcers in modern wound care centres can reduce its recurrence rates. Herein this study a correlation among venous insufficiency evidenced by duplex scan and recurrence rate for leg ulcers could be demonstrated.

Experiences with Osteoligamentoplasty According to Weiss for the Treatment of Scapholunate Dissociation.

BACKGROUND: In post-traumatic, dynamic, or static scapholunate (SL) instability, an SL ligament reconstruction is advisable to avoid long-term complications. However, a sufficient primary reconstruction is best achieved in acute injuries. For chronic SL dissociation, there is still no satisfying standard surgical technique. In this context, we evaluated the clinical outcome of Weiss's osteoligamentoplasty as a treatment option. METHODS: Over a three-year period, 16 patients with chronic and symptomatic SL dissociation Grade-II and III, without the signs of osteoarthrosis were, surgically treated using a bone-retinaculum-bone autograft from the distal radius. All patients underwent prior wrist arthroscopy. The clinical outcome was measured using the Mayo-Wrist, Krimmer, and DASH score. In addition, radiological measurements were also performed. RESULTS: The postoperative clinical outcome successfully increased the Mayo-Wrist score: 32 to 64 points, Krimmer score: 30 to 53 points and DASH score: 41 to 30 points. The radiological follow-up demonstrated no evidence of an SL gap or significant loss of reposition in the SL angle in 13 of the 16 cases. Till date, two patients had to be revised to an arthrodesis. CONCLUSIONS: The autogenous osteoligamentary span from the distal radius improves a chronic SL dissociation and, therefore, presents a suitable option to anatomically reconstruct the SL ligament. It leads to a proper realignment of the carpus and could help to prevent arthritic changes of the wrist. Nevertheless, in patients with postoperative high occupational physical strain, the procedure should be performed with reservations. As long as there is no satisfying standard surgical treatment, Weiss's osteoligamentoplasty is a convincing technique.

Patient-rated long-term results after complete denervation of the wrist.

The aim of this study was to examine the long-term results after the denervation of the wrist. Between 1977 and 2001, we treated 375 patients in our clinic. The mean age was 43.5 years; 81% were male and 19% female. The long-term results were assessed by a questionnaire assessing pain on a visual analog scale and patient satisfaction and by the DASH questionnaire. After a mean follow-up of 12.23 years, we found an overall pain reduction of 52.1%. In 67.7% of the patients, we found a relief of pain: of these, 44% are free of pain until today and 56% were temporarily asymptomatic. Patients with a painful osteoarthritic condition without dynamic instability and good range of motion are ideal candidates to benefit from the denervation. The complete denervation of the wrist is an effective treatment option in patients with painful wrist conditions to reduce pain and improve the overall function.

Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees.

BACKGROUND: Hyperexcitability of N-methyl-d-aspartate acid (NMDA) receptors may play an important role in the development of phantom limb pain (PLP). AIM OF THE STUDY: To investigate whether early treatment with the NMDA antagonist memantine attenuates phantom pain memory formation in traumatic amputees. METHODS: In a randomized, double-blind, controlled trial 19 patients with acute traumatic amputation of the upper extremity were investigated. All patients received postoperative analgesia by continuous brachial plexus anesthesia (ropivacaine 0.375% 5 ml/h) for at least 7 days. In addition, the patients received either memantine (20-30 mg daily, n=10) or placebo (n=9) for 4 weeks. RESULTS: Memantine treatment reduced the number of requested ropivacacine bolus injections during the first week and resulted in a significant decrease of PLP prevalence and intensity at 4 weeks and 6 months follow up, but not at 12 months follow up. CONCLUSIONS: We conclude that memantine can reduce intensity of phantom limb pain and might also prevent the development of PLP. However, despite the very early begin of treatment; no long-term effect on established PLP was evident.

Comparative neuro tissue engineering using different nerve guide implants.

At the moment autologous nerve grafting remains the only reasonable technique for reconstruction of peripheral nerve defects. Unfortunately, this technique has a lot of complications and disadvantages. These problems are related to the autologous nerve that is harvested for this procedure. Donor site morbidity with loss of sensitivity, painful neuroma formation and of course the restricted availability of autologous nerves stimulates the idea for alternative techniques on that field. In this paper we describe our experience with different graft materials for reconstruction of a 2 cm nerve gap in a median nerve model in rats. After implantation of various materials (biological/synthetic) the main experiments were conducted with a synthetic, biodegradable nerve conduit seeded with autologous Schwann cells. With this material we were able to reconstruct successfully a 2 cm gap in the rat median nerve. Regeneration with this material was found to be equally to an autologous nerve graft.

[Arrosion of flexor tendons after palmar plate osteosynthesis of the distal radius: three case reports]. / Arrosion der Beugesehnen nach palmarer Plattenosteosynthese des distalen Radius: Drei Fallberichte.

Indication of palmar plate osteosynthesis of the distal radius has steadily broadened over recent years. The reason for this has been the introduction of angle stable implants. In addition, advantages were attributed to the palmar plate over the dorsal plate position on the distal radius through the covering of the M. pronator quadratus as a means of preventing the occurrence of arrosion of the tendon. Over a period of 12 months we treated 3 patients with varying degrees of flexor tendon rupture after palmar plate osteosynthesis, indicating that the incidence of flexor tendon arrosion occurring through palmar plate osteosynthesis is possibly greater than previously assumed.