Current status of the management of isolated syndesmotic injuries in Germany.

INTRODUCTION: Although non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany. MATERIALS AND METHODS: An online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS. RESULTS: Each question of the questionnaire was on average answered by 431 ± 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior-posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices. CONCLUSIONS: While arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany.

[Analysis of risk factors for dropping out of residency in orthopedics and trauma surgery]. / Risikofaktorenanalyse zu den Gründen des Ausscheidens aus der fachärztlichen Weiterbildung im Fach Orthopädie und Unfallchirurgie.

BACKGROUND: Currently, there are no data available on dropouts from residency programs and changes of clinic in orthopedics and trauma surgery (O&T). The aim of the study is to identify personal and structural risk factors leading to dropout or switching of postgraduate training in O&T in order to present solution strategies. METHODS: A nationwide anonymous online survey was conducted among residents in O&T in summer 2020. Official mail addresses were identified via the Traumanetzwerk© of the DGU and the German Hospital Federation (n = 2090). A questionnaire (51 questions) was administered using SurveyMonkey (San Mateo, CA, USA). All residents who worked in O&T for at least 1 month in the 6 years prior to the start of the survey (from 07/2014) were eligible to participate. A binary logistic regression was calculated to identify the risk factors. The significance level was p = 0.05. RESULTS: Of the 221 respondents, 37% switched hospital and 5% dropped out altogether. The regression revealed 3 significant risk factors for switching hospitals. Living in a partnership (p = 0.029, RR: 2.823) and less than 2 days of shadowing before the start of residency (p = 0.002, RR: 2.4) increased the risk of switching. Operating room (OR) allocation of residents according to the training plan/status (p = 0.028, RR: 0.48) reduces the risk of switching. Significant risk factors for leaving postgraduate training could not be determined (insufficient number of cases, n = 11). DISCUSSION: Switching the hospital and residency dropouts in O&T are a relevant problem (42%). Gender has no significant influence. Tools such as longer job shadowing, as well as OR allocation according to the training plan/status can minimize the risk of switching.

Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

PURPOSE: Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent. METHODS: Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU®) between 2009 and 2016. Coagulopathy was defined by a Quick's value < 70% (INR (international normalized ratio) > 1.4) and/or thrombocytes ≤ 100 k upon emergency room admission. Children were grouped according to age in 4 different groups (A: 1-5, B: 6-10, C: 11-15 and D: 16-17 years). Prevalence of coagulopathy was assessed. Demographics, injury severity, haemostatic management including transfusions and mortality were described. RESULTS: 5351 primary admitted children ≤ 17 years with an abbreviated injury scale (AIS) ≥ 3 and complete datasets were included. The prevalence of coagulopathy was 13.7% (733/5351). The majority of the children sustained blunt trauma (more than 90% independent of age group) and a combination of traumatic brain injury (TBI) and any other trauma in more than 60% (A, C, D) and in 53.8% in group B. Coagulopathy occurred the most among the youngest (A: 18.2%), followed by all other age groups with approximately 13%. Overall mortality was the highest in the youngest (A: 40.9%) and among the youngest patients with traumatic brain injury (A: 71.4% and B: 47.1%). Transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFPs) occurred almost in a 2:1 ratio (or less) across all age subgroups. CONCLUSION: Traumatic haemorrhage in association with coagulopathy and severe shock is a major challenge in paediatric trauma across all age groups.

"Quod licet Chefarzt  ": The Impact of Perceived Hierarchy on Working Atmosphere and Quality of Work in Orthopaedic and Trauma Surgery. Results of a Survey Among 799 Orthopaedic and Trauma Surgeons in Germany. / "Quod licet Chefarzt  ": Der Einfluss der empfundenen Hierarchie auf Arbeitsklima und Arbeitsqualität in O und U. Ergebnisse einer Umfrage unter 799 Orthopäden und Unfallchirurgen in Deutschland.

INTRODUCTION: Surgical departments are discredited as guardians of traditional structures of hierarchy. Hierarchy and working climate have a large share in human factor, being made responsible for 70% of avoidable errors in medicine. Aim of this study was the assessment of these topics amongst physicians in the field of orthopedics and traumatology. MATERIAL AND METHODS: A questionnaire of 10 questions was digitally handed to DGOU members. 799 questionnaires were answered. RESULTS: We found significant differences in the assessment of hierarchy and working atmosphere amongst the physician groups. Working atmosphere was perceived as not appreciative by registrars only. All groups were in favor of a hierarchy rather close to, but nut absolutely on equal terms. All groups attach high influence of working atmosphere on quality of daily work. DISCUSSION: Literature shows that hierarchic differentiation can increase performance of a team, while rigid hierarchy structures can lead to mistakes. Although hierarchy in orthopedics and traumatology seems to be less pronounced than assumed, hierarchy has great influence on daily work. CONCLUSION: In order to achieve a safety oriented medical environment, it will be of great importance to define hierarchy structures in clinics and to utilize them efficiently as a part of safety culture.

Traumatic tracheobronchial injuries: incidence and outcome of 136.389 patients derived from the DGU traumaregister.

To describe the incidence, therapy and outcome of traumatic tracheobronchial injuries (TTBI) in trauma patients with multiple injuries derived from the DGU TraumaRegister. We analyzed the data on all patients listed on the TraumaRegister DGU (TR-DGU) in Germany between 2002 and 2015 aged 16 years or older and with an Injury Severity Score (ISS) of ≥ 9. We analyzed the data on 136,389 trauma patients, 561 of whom had suffered tracheobronchial injuries (0.4%). The majority were male (73.4%) and had a mean age of 43.7 years. In total, 84.0% of all TTBI injuries occurred secondary to blunt trauma, caused mainly by accidents (71.2%). TTBI was accompanied by several concomitant thoracic injuries such as pneumo- (41.2%) and hemothorax (23.2%), lacerations (7.8%) and contusions (32.3%) of the lung, as well as multiple rib fractures (29.6%). The severity of injury was classified via the abbreviated injury scale (AIS): 39.3% with AIS = 3, 51.3% with AIS = 4 and 60% with AIS = 5 patients underwent surgical interventions. The mortality of patients with tracheobronchial injuries was higher: 24.6%, versus 13.7% in all patients (control group). This high percentage reflects their generally severe injury burden through concomitant injuries. The incidence of TTBI in this large cohort of trauma patients is very low. However, its high mortality rate emphasizes its importance. Mortality was associated with higher ISS and AIS scores. Higher rates of concomitant injuries were therefore associated with a higher mortality rate. TTBI injuries revealed a higher rate of progression to surgical management, with 35% undergoing surgery within the first 24 h. This excessive mortality rate demonstrates a high overall injury burden in patients with TTBI and high mortality of associated injuries. A surgical intervention's impact on mortality cannot be assessed in this study, as it would need to be investigated in a case-matched study.

Microparticles profiling in trauma patients: high level of microparticles induce activation of platelets in vitro.

PURPOSE: Trauma-induced coagulopathy (TIC) is recognised as an own clinical entity which includes all components of haemostasis following rapidly tissue injury, hypoperfusion and shock. Microparticles (MP) are known to be released in large quantities from different cell types after trauma. The present study aimed to perform a phenotypic MP profiling after major trauma and to elucidate potential procoagulative function of MP under simulated conditions of lethal triad. METHODS: For MP isolation, 20 trauma patients (median ISS 24) were included. To produce a Standard MP Phenotype Profile after trauma, samples were pooled, extracted and concentrated by using an ultracentrifuge protocol. Specific cell surface markers were measured by flow cytometry. Our Standard MP Phenotype Profile was subsequently added in high and low concentration to an in vitro lethal triad assay, simulating coagulopathy via induced hypothermia, dilution and acidosis. A comprehensive analysis of coagulation function was performed. RESULTS: Within our Standard MP Phenotype Profile, PDMP (56%) were found as predominant phenotype followed by EDMP (33%) and MDMP (11%). EDMP characterized by CD144, CD62E and Annexin were determined most frequently but also EDMP expressing CD62P. In addition, tissue factor (TF) was expressed on all MP entities (EDMP 63%, PDMP 30%, MDMP 7%). Within our lethal triad simulation assay, the addition of low and high concentrated MP did not cause any significant alteration in standard coagulation assays, coagulation initiation, clot kinetics or stability. Addition of high concentrated MP increased platelet function and P-selectin expression significantly. CONCLUSION: Our data confirm the assumption that there is a characteristic MP phenotype pattern in trauma, which may alter haemostatic capacity at least in part mediated via augmenting in primary haemostasis resulting in an improved contribution of platelets to clot formation. There are indications that expression of selectins on MP surface is involved in this activation process, but this pathway needs to be investigated in more detail.

Why bother: usefulness and effect of young surgeon committees in surgical societies.

Work-time constraints during surgical residency along with managing a private life usually take up the majority of the time of young surgeons. For many, work with a surgical society seems like something neither generally promising nor personally worthwhile, thus raising the question, why bother? This article sets out to show examples of the effects that surgical societies and young surgeon committees can have on surgery and residency training. Additionally, we highlight the personal side of being active on a committee. Our aim is to raise interest in participating in societal work by showing the rewarding general effects as well as personal benefits. While this article is based primarily on experiences made in Germany, we believe that aspects can be transferred to other medical systems.

The acceptance of CIRS among orthopedic and trauma surgeons in Germany-Significant gap between positive perception and actual implementation in daily routine.

PURPOSE: Medical errors are the third leading cause of death in the United States after malignant tumors and cardiovascular disease. Handling of errors becomes more and more eclectic due to the implementation of incident reporting systems and the use of checklists. Since 2015, any German hospital would have a critical incident reporting system (CIRS). The aim of this study is to discover the nationwide utilization and attitude toward CIRS of orthopedic and trauma surgeons. METHODS: Between April 10, 2015 and May 22, 2015, a web-based questionnaire, which was designed by an expert team consisting of orthopedic and trauma surgeons, aeronautic human factors specialists, and psychologists (Lufthansa Aviation Training), was sent to all members of the German Society for Orthopedic and Trauma Surgery. The survey consisted of three questions regarding CIRS and its use in German hospitals. RESULTS: A total of 669 orthopedic and trauma surgeons working in German hospitals completed the questionnaire. All participants rated CIRS as useful, although 71.3% of participants did not report a critical incident in the last 12 months. In that time period, only 13.4% of participating residents reported at least one incident, but 44.7% of chief physicians reported one incident within the same period. CONCLUSION: The present study demonstrates that even though CIRS as a tool is positively appreciated by orthopedic and trauma surgeons working in German hospitals, many do not know about its existence at their own hospital. This can be a reason for the low number of critical incidents reported.

Trauma-induced coagulopathy upon emergency room arrival: still a significant problem despite increased awareness and management?

PURPOSE: Over the last decade, the pivotal role of trauma-induced coagulopathy has been described and principal drivers have been identified. We hypothesized that the increased knowledge on coagulopathy of trauma would translate into a more cautious treatment, and therefore, into a reduced overall incidence rate of coagulopathy upon ER admission. PATIENTS AND METHODS: Between 2002 and 2013, 61,212 trauma patients derived from the TraumaRegister DGU® had a full record of coagulation parameters and were assessed for the presence of coagulopathy. Coagulopathy was defined by a Quick's value < 70% and/or platelet counts < 100,000/µl upon ER admission. For each year, the incidence of coagulopathy, the amount of pre-hospital administered i.v.-fluids and transfusion requirements were assessed. RESULTS: Coagulopathy upon ER admission was present in 24.5% of all trauma patients. Within the years 2002-2013, the annual incidence of coagulopathy decreased from 35 to 20%. Even in most severely injured patients (ISS > 50), the incidence of coagulopathy was reduced by 7%. Regardless of the injury severity, the amount of pre-hospital i.v.-fluids declined during the observed period by 51%. Simultaneously, morbidity and mortality of severely injured patients were on the decrease. CONCLUSION: During the 12 years observed, a substantial decline of coagulopathy has been observed. This was paralleled by a significant decrease of i.v.-fluids administered in the pre-hospital treatment. The reduced presence of coagulopathy translated into decreased transfusion requirements and mortality. Nevertheless, especially in the most severely injured patients, posttraumatic coagulopathy remains a frequent and life-threatening syndrome.

[Safety Culture in Orthopaedic Surgery and Trauma Surgery - Where Are We Today?] / Sicherheitskultur in Orthopädie und Unfallchirurgie ­ wo stehen wir heute?

INTRODUCTION: The development of a new safety culture in orthopaedics and trauma surgery needs to be based on the knowledge of the status quo. The objective of this research was therefore to perform a survey of orthopaedic and trauma surgeons to achieve a subjective assessment of the frequency and causes of "insecurities" or errors in daily practice. METHODS: Based on current literature, an online questionnaire was created by a team of experts (26 questions total) and was sent via e-mail to all active members of a medical society (DGOU) in April 2015. This was followed by two reminder e-mails. The survey was completed in May 2015. The results were transmitted electronically, anonymously and voluntarily into a database and evaluated by univariate analyses. RESULTS: 799 active members took part in the survey. 65% of the interviewed people stated that they noticed mistakes in their own clinical work environment at least once a week. The main reasons for these mistakes were "time pressure", "lack of communication", "lack of staff" and "stress". Technical mistakes or lack of knowledge were not of primary importance. CONCLUSIONS: The survey indicated that errors in orthopaedics and trauma surgery are observed regularly. "Human factors" were regarded as a major cause. In order to develop a new safety culture in orthopaedics and trauma surgery, new approaches must focus on the human factor.

[Young doctors wanted - but how many? : Current data on the number of aspiring specialist doctors in orthopedics and trauma surgery in Germany]. / Wie viel Nachwuchs braucht das Land? : Eine aktuelle Datenerhebung zur Anzahl der Ärzte in Weiterbildung in Orthopädie und Unfallchirurgie.

There is an ongoing discussion about demographic change, a possible lack of young doctors and its impact on the healthcare system in Germany. Up to now, no valid data has been available on the exact numbers of residents in orthopedics and trauma surgery. Therefore, the aim of this study was to determine the actual number of residents in Germany in 2013/2014. We generated a database with all eligible providers of postgraduate training in orthopedics and trauma surgery in Germany. All of these were asked to fill out a questionnaire about the number of trainees, their gender and year of training. We achieved an 80% response rate (1509 questionnaires). Within these institutions, 4310 residents are trained. For Germany, this means an estimated number of about 5300 residents in the year 2013/2014. Ninety percent of postgraduate training is performed within a hospital and one-third of the residents are female. Looking at the expected number of doctors who will retire within the next five years, there seems to be enough young doctors to fill the gap. However, by 2040, an increased demand for othopedic and trauma surgeons is experted. Thus, we recommend centrally analyzing and coordinating the demand of residents in orthopedics and trauma surgery in Germany.

Level of Evidence Analysis for the Latest German National Guideline on Treatment of Patients with Severe and Multiple Injuries and ATLS.

PURPOSE: Advanced Trauma Life Support (ATLS®) is one of the world's best-known training programs for medical providers. Revisions of the ATLS manual have been evidence based for a number of years. In 2011, a level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published in Germany. The scope of this study was the systematic comparison of the educational content of the ATLS concept and the interdisciplinary "S3 polytrauma guideline." METHODS: A total of 123 key recommendations of the guideline were compared with the content of the ATLS manual (9th edition). Depending on the level of agreement, the recommendations were classed in the following categories: (1) Agreement. (2) Minor variation. (3) Major variation. RESULTS: An overall 86% conformity was found between the key recommendations of the guideline and the ATLS® manual. The ATLS® primary survey (ABCDE) showed an 85% conformity. The degree of conformity for the individual priorities was as follows: A (Airway) 79%, B (Breathing) 79%, C (Circulation) 86%, D (Disability) 93%, E (Exposure) 100%. The ATLS® secondary survey showed a 94% conformity. The main differences were in the areas of anesthetic induction, fluid administration, and coagulation therapy. CONCLUSIONS: According to our comparison, the educational content and manual of the ATLS are largely compatible with a high level of evidence S3 guideline. However, subsequent editions of both the ATLS® and the S3 guideline should re-examine and reassess a number of aspects.

Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge.

BACKGROUND: Despite poor evidence and high costs, fibrinogen concentrate (FC) represents one of the most frequently used hemostatic agents in exsanguinating trauma. The aim was to assess whether the administration of FC in severely injured patients was associated with improved outcomes. METHODS: Patients documented in the Trauma Registry of the German Society for Trauma Surgery (primary admissions, Injury Severity Score [ISS] ≥16) who had received FC during initial care between emergency department (ED) arrival and intensive care unit admission (FC+) were matched with patients who had not received FC (FC-). RESULTS: The matched-pairs analysis yielded two comparable cohorts (n = 294 in each group) with a mean ISS of 37.6 ± 13.7 (FC+) and 37.1 ± 13.3 (FC-) (p = 0.73); the mean age was 40 ± 17 versus 40 ± 16 (p = 0.72), respectively. Patients were predominantly male (71.1% in both groups, p = 1.0). On emergency department arrival, hypotension (systolic blood pressure, ≤90 mm Hg) occurred in 51.4% (FC+) and 48.0% (FC-) (p = 0.41), and base excess was -7.4 ± 5.3 mmol/L for FC+ and was -7.5 ± 6.2 mmol/L for FC- (p = 0.96). Patients were administered 12.8 ± 14.3 (FC+) versus 11.3 ± 10.0 (FC-) packed red blood cell units (p = 0.20). Thromboembolism occurred in 6.8% (FC+) versus 3.4% (FC-) (p = 0.06), and multiple organ failure occurred in 61.2% versus 49.0% (p = 0.003), respectively. Whereas 6-hour mortality was 10.5% for FC+ versus 16.7% for FC- (p = 0.03), the mean time to death was 7.5 ± 14.6 days versus 4.7 ± 8.6 days (p = 0.006). The overall hospital mortality rate was 28.6% versus 25.5% (p = 0.40), respectively. CONCLUSION: This is the first study to investigate the effect of FC administration in bleeding trauma. In our large population of severely injured patients, the early use of FC was associated with a significantly lower 6-hour mortality and an increased time to death, but also an increased rate of multiple organ failure. A reduction of overall hospital mortality was not observed in patients receiving FC. LEVEL OF EVIDENCE: Therapeutic study, level IV.

NF-E2 overexpression delays erythroid maturation and increases erythrocyte production.

The transcription factor Nuclear Factor-Erythroid 2 (NF-E2) is overexpressed in the vast majority of patients with polycythaemia vera (PV). In murine models, NF-E2 overexpression increases proliferation and promotes cellular viability in the absence of erythropoietin (EPO). EPO-independent growth is a hallmark of PV. We therefore hypothesized that NF-E2 overexpression contributes to erythrocytosis, the pathognomonic feature of PV. Consequently, we investigated the effect of NF-E2 overexpression in healthy CD34+ cells. NF-E2 overexpression led to a delay in erythroid maturation, manifested by a belated appearance of glycophorin A-positive erythroid precursors. Maturation delay was similarly observed in primary PV patient erythroid cultures compared to healthy controls. Protracted maturation led to a significant increase in the accumulated number of erythroid cells both in PV cultures and in CD34+ cells overexpressing NF-E2. Similarly, NF-E2 overexpression altered erythroid colony formation, leading to an increase in erythroid burst-forming unit formation. These data indicate that NF-E2 overexpression delays the early phase of erythroid maturation, resulting in an expansion of erythroid progenitors, thereby increasing the number of erythrocytes derived from one CD34+ cell. These data propose a role for NF-E2 in mediating the erythrocytosis of PV.

Limited effects on JAK2 mutational status after pegylated interferon alpha-2b therapy in polycythemia vera and essential thrombocythemia.

Twenty-five patients with myeloproliferative diseases were treated with pegylated interferon alpha-2b. Prior to therapy, 15/25 patients had a JAK2(V617F) mutation. Eight JAK2-positive patients were on therapy in hematological complete remission at 24 months. Five of eight patients demonstrated a 1.2-3.6 fold reduction in the percentage of JAK2(V617F) cells.