Predictors of colonization with Staphylococcus species among patients scheduled for cardiac and orthopedic interventions at tertiary care hospitals in north-eastern Germany-a prevalence screening study.

As methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in humans are a global challenge. In Mecklenburg and Western Pomerania (Germany) 1,517 patients who underwent surgical interventions were systematically screened for MRSA and MSSA colonization on the day of hospital admission and discharge. Demographic data, risk factors and colonization status of the (i) nose, (ii) throat, (iii) groin, and (iv) thorax or site of surgical intervention were determined. Of the 1,433 patients who were included for further evaluation, 331 (23.1%) were colonized with MSSA, while only 17 (1.2%) were MRSA carriers on the day of hospital admission. A combination of nose, throat and groin swabs returned a detection rate of 98.3% for MSSA/MRSA. Trauma patients had lower prevalence of MRSA/MSSA (OR 0.524, 95% CI: 0.37-0.75; p < 0.001) than patients with intended orthopedic interventions. Males showed significantly higher nasal S. aureus carrier rates than females (odds ratio (OR) = 1.478; 95% CI: 1.14-1.92; p = 0.003). Nasal S. aureus colonization was less frequent among male smokers as compared to non-smokers (chi2 = 16.801; phi = 0.154; p < 0.001). Age, gender and smoking had a significant influence on S. aureus colonization. Combining at least three different swabbing sites should be considered for standard screening procedure to determine S. aureus colonization at patients scheduled for cardiac or orthopedic interventions at tertiary care hospitals.

The chemical and antioxidant stability of isolated low molecular weight phlorotannins.

Due to their high anti-oxidant activity, phlorotannins represent potential natural alternatives to synthetic preservatives currently used within the food industry. However, their successful integration into food products requires research into their chemical integrity, particularly when selecting appropriate storage conditions. Subsequently, this study aims to investigate the stability of low molecular weight phlorotannin fractions from Fucus vesiculosus (L.). Powder and aqueous fractions were stored under five different conditions for 10weeks. Phlorotannin stability was determined using Q-ToF-MS and UPLC-TQD-MS/MS and a DPPH assay. After 10weeks of storage, fractions suspended in an aqueous matrix underwent oxidation when exposed to continuous atmospheric oxygen and thermal degradation when exposed to a constant temperature of 50°C, resulting in decreases in radical scavenging activity (p<0.001). Phlorotannins remained stable under all other storage conditions. This study highlights phlorotannins as highly stable polymers, under certain storage conditions, with an excellent capacity for scavenging radicals.

[Intraoperative 3D imaging : Diagnostic accuracy and therapeutic benefits]. / Intraoperative 3­D-Bildgebung : Diagnostische Genauigkeit und therapeutischer Nutzen.

Intraoperative 3D imaging has a marked impact on the surgical treatment of articular fractures. In theory, insufficient reduction of fracture fragments and malpositioning of implants can be corrected in the same session so that unnecessary secondary imaging and revision surgery can be avoided. Current evidence on the accuracy of 3D scans, however, relies on heterogeneous preclinical data and must be interpreted with caution. Every fourth 3D scan seems to lead to a repositioning of fracture fragments or implants, despite unproven sensitivity and specificity. The interaction between diagnostic accuracy and therapeutic consequences needs exploration before any conclusions on the (additional) benefits of intraoperative 3D imaging can be drawn.

[Evidence-based trauma and orthopedic surgery : 20 years after Sackett]. / Evidenzbasierte Unfallchirurgie und Orthopädie : Zwanzig Jahre nach Sackett.

The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.

[Influence of registries on the quality of care]. / Einfluss von Registern auf die Versorgungsqualität.

Registries are a topic of lively debate amongst all stakeholders in healthcare, politics and economics. In general, registries are national or international (prospective) databases documenting the current state of diagnostic, therapeutic and long-term outcome variables of subjects with a distinct condition or health problem. The access to and handling of registry information is subject to strict legal, methodological and ethical principles and regulations before these data can be scientifically utilized and reentered into the routine daily practice. Because of the representativeness and reality of data, registries are widely regarded as the backbone of health systems and budgets.Currently there is only indirect evidence that registries influence outcomes and the quality of care. Recent statistical techniques may allow quasi-experimental modelling of observational information. In orthopedic and trauma surgery, current and upcoming registries should be wisely utilized to develop and evaluate innovations and to make informed decisions relevant to care.

Standardised effect sizes in clinical research: how to compare shoulder surgeons with hip surgeons.

The Bone & Joint Journal provides the latest evidence to guide the clinical practice of orthopaedic surgeons. The benefits of one intervention compared with another are presented using outcome measures; some may be specific to a limb or joint and some are more general health-related quality of life measures. Readers will be familiar with many of these outcome measures and will be able to judge the relative benefits of different interventions when measured using the same outcome tool; for example, different treatments for pain in the knee measured using a particular knee score. But, how should readers compare outcomes between different clinical areas using different outcome measures? This article explores the use of standardised effect sizes.

Acetabular fractures with marginal impaction: mid-term results.

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta's criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was 'anatomical' in 44 hips (73.3%) and 'imperfect' in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as 'excellent', 11 (18.3%) as 'good', one (1.7%) as 'fair' and 15 (25%) as 'poor'. A total of 11 further operations were required in 11 cases, of which six were total hip replacements. Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients.

Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial.

INTRODUCTION: Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Even though several prognostic factors for patellofemoral instability have been identified so far, the appropriate therapy for patients with patellar dislocation remains a controversial issue. The purpose of this study was to compare the outcome after conservative or operative treatment in patients after first-time patellar dislocation. PATIENTS AND METHODS: This randomized controlled clinical trial was designed multicentric including patients from six German orthopaedic and trauma departments. Twenty patients with a mean age of 24.6 years with first-time traumatic patella dislocation were included and randomized into either a conservative arm or an operative arm. Plain X-ray images of the knee joint (a.p. and lateral view and tangential view of both patellae) were performed in all cases prior to therapy to exclude osteochondral fragments requiring refixation. An MRI was recommended, but not compulsory. Patients were consulted after 6, 12, and 24 months with a questionnaire including the criteria of the Kujala score, recurrent dislocation, and satisfaction. RESULTS: The mean Kujala score of the conservative vs operative treatment group was 78.6 vs 80.3 after 6 months (p = 0.842), 79.9 vs 88.9 after 12 months (p = 0.165), and 81.3 vs 87.5 after 24 months (p = 0.339). Redislocation rate after 24 months was 37.5 % in the conservative group and 16.7 % in the operative group (p = 0.347). Due to the small number of patients that could be included, no significant difference between the groups could be detected. We see a tendency towards better results after operative treatment. CONCLUSION: Our multicentric prospective randomized controlled trial revealed no significant difference between conservative and operative treatment for patients after first-time traumatic patellar dislocation. However, a tendency towards a better Kujala score and lower redislocation rates for patients with operative treatment was observed. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A meta-analysis including other study's level I data is desirable for the future.

A new pathway to classification of complex hand injuries: a clinical pilot testing using a new method of assessment.

All existing classifications, which are based on the severity of hand injuries, are being referred to facets of variety of hand injuries in general. A clear picture of all consequences of hand injuries would be apparent, if any kind of injury mechanism and occurrence of an injury would be identified and academically captured. Predictions regarding return to the former occupation and rehabilitation time would be possible with further study; 102 patients with different hand injuries were engaged in a pilot project using a specifically designed assessment sheet to achieve this purpose in the framework of a retrospective clinical testing within 1 year. Data were summarized and demonstrated graphically. Each category showed a picture of prior localization of the injury and its morphology. All categories show specific injury patterns. The choice of categories reflects the mechanisms of injury emphasized in literature. Furthermore, the mean DASH equivalents of one category were compared to the mean Hand Injury Severity Scoring (HISS) scores in order to get an initial idea of information on the degree of severity. A first impression of the potential of this assessment sheet has been obtained with regard to the above. With further study, we could evaluate the assessment sheet and try to create a classification of the grade of severity as well as prognostic values like return to the former occupation and rehabilitation time.

[Identification of risk factors for subsequent legal claims in orthopedic and trauma surgery]. / Identifikation von Risikofaktoren anerkannter Vorwürfe von ärztlichen Behandlungsfehlern aus dem Fachgebiet Orthopädie und Unfallchirurgie.

In Germany, orthopedic and trauma surgery rank first in the number of alleged malpractice claims amongst all medical disciplines. Thus, the German Association of Trauma and Orthopedic Surgery, together with the Bavarian Chamber of Physicians, set out to identify potential predictors of approved malpractice claims to improve process quality. In a case-control study, 164 cases of approved malpractice claims were matched according to age and gender to 336 controls of rejected claims, based on the 2004 to 2006 dataset of the Bavarian Chamber of Physicians. Potential predictors of acceptance of an alleged incident were modeled by uni- and multivariate logistic regression analysis. The final model explained 71% of the probability of acceptance of an asserted claim. It contained three medical consequences (i.e. delayed healing, reoperation, and loss of motion), one specific entity (i.e. fracture) and one socio-demographic variable (i.e. professional driver) as independent predictors of acceptance. Insufficient or lacking explanation of the planned procedure to patients or relatives and / or lacking informed consent (odds ratio [OR] 2.33, 95% confidence interval [CI]1.23-4.43), as well as inappropriate, low-quality, or erroneously interpreted imaging (OR 1.90, 95% CI 1.06-3.41) independently contributed to the likelihood of acceptance of a legal claim. Strict adherence to the principles of surgical quality assurance in terms of transparent patient information and joint informed consent procedures, as well as intransigent radiological imaging are mandatory to foster surgeon-patients-relationships and to avoid later legal claims.

Factors determining quality of life and level of sporting activity after internal fixation of an isolated acetabular fracture.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

[Outcomes research: definitions, methods and challenges in trauma and orthopaedic surgery]. / Versorgungsforschung : Bedeutung, Methoden und Herausforderungen in der Unfallchirurgie.

BACKGROUND: Besides basic, illness- and patient-oriented research, outcomes research is regarded as the fourth pillar of modern health care systems. Outcomes research investigates both the desirable and adverse effects of medical and surgical interventions under day-to-day conditions. METHOD: Because of rigorous entry criteria and selection of eligible subjects, the efficacy of a certain treatment derived from clinical experiments (i.e. classic randomized trials) may not necessarily be transferred to common patient populations or clinical settings. Apart from efficacy, a valuable (thus reimbursable) diagnostic or therapeutic procedure must prove its effectiveness in clinical practice as well. Demanding study designs are necessary to model effectiveness and to separate the observed intervention-related effects from bias and confounding. RESULTS: Registries and pragmatic randomized trials may represent the most appropriate modalities to establish outcomes research in trauma and orthopaedic surgery. Good examples for interventions still needing proof of effectiveness are kyphoplasty and vertebroplasty, navigated surgery, damage control, interlocking implants and bone growth factors. Revealing over- and undersupply, generating negative lists (i.e. interventions of questionable or almost nil effectiveness) and integrating patients as co-therapists requires networking between hospitals and private practitioners. CONCLUSION: Also, since outcomes research is a societal need, its development and funding must be ensured by all providers and payers of health care services.

Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability.

PURPOSE: To analyse the functional and radiological outcomes of the Bristow-Latarjet procedure in patients with recurrent anterior glenohumeral instability. METHODS: Records of 29 patients were reviewed retrospectively. Date of first dislocation, injury mechanism, and number of recurring dislocations before and after surgery were recorded. The overall function and stability of the shoulder was evaluated. RESULTS: 24 (83%) of the glenohumeral instabilities were caused by trauma. The mean number of recurring dislocations was 8 (95% confidence interval [CI], 0-18); one patient had had 40 recurrences. No dislocation ensued postoperatively. The overall functional outcome was good, with a mean Rowe score of 90 points (95% CI, 78-100). Scores of 17 (59%) of the patients were excellent, 7 (24%) were good, 3 (10%) were fair, and 2 (7%) were poor. CONCLUSION: The Bristow-Latarjet procedure is a good surgical treatment for recurrent anterior-inferior instability of the glenohumeral joint.

Randomized clinical trial comparing bipolar coagulating and standard great saphenous stripping for symptomatic varicose veins.

BACKGROUND: Typical side-effects of saphenous stripping for symptomatic varicose veins include painful thigh haematomas, which a new bipolar coagulating electric vein stripper (EVS) may reduce. METHODS: In a randomized, single-blind trial at three vascular centres, 99 patients were assigned to EVS and 101 to conventional stripping. The primary outcome was postoperative pain at rest and following physical exercise (climbing stairs). Haematomas were quantified by ultrasonography. Further endpoints were duration of postoperative compression, sick leave and quality of life (measured by the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ) and Short Form 36 (SF-36). RESULTS: Mean resting visual analogue scale for pain 24 h after surgery was 1.6 in the EVS group and 3.3 in the conventional stripping group (mean difference 1.7, 95 per cent confidence interval (c.i.) 1.4 to 1.9, P < 0.001). Mean ratings following exercise were 3.3 and 5.5 (mean difference 2.3, 95 per cent c.i. 2.0 to 2.6, P < 0.001) respectively. No patient in the EVS group had a measurable thigh haematoma, compared with 74 patients after conventional stripping (P < 0.001). The EVS significantly decreased the length of compression therapy and sick leave, and produced superior CIVIQ and SF-36 ratings. CONCLUSION: The EVS was safe and effective in avoiding painful haematomas following varicose vein surgery.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]. / Frakturen der oberen Extremität beim geriatrischen Patienten - Harmlose Monoverletzung oder Ende der Selbstständigkeit? Eine prospektive Studie zum Outcome nach distaler Radius- und proximaler Humerusfraktur bei über 65-jährigen.

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

[Surgical management of abdominal injury]. / Operative Therapie abdomineller Verletzungen.

PURPOSE: Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury. METHODS: Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine. RESULTS: Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this. DISCUSSION: Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

Biweekly pegylated liposomal doxorubicin in patients with relapsed ovarian cancer: results of a multicenter phase-II trial.

BACKGROUND: The obvious benefit of pegylated liposomal doxorubicin (PLD) for tumour control in recurrent ovarian cancer is frequently offset by severe palmar-plantar erythrodysesthesia (PPE). There is evidence that dose reduction from 50 to 40 mg/m(2) reduces the incidence of PPE without compromising cytotoxic activity. We set out to investigate whether biweekly application further improves the therapeutic index of PLD. PATIENTS AND METHODS: Patients with recurrent ovarian cancer after surgery and adjuvant chemotherapy with platinum and taxane compounds were eligible to participate in this multi-institutional phase II study. PLD was administered at a dose of 20 mg/m(2) every two weeks. Eligible patients had ECOG performance status of < or =2, and sufficient organ function. We employed an optimized two-stage design to test the hypothesis that biweekly application of PLD reduces the frequency of grade III and IV PPE from 25% to 10%. Response and survival were addressed descriptively. RESULTS: Between October 2001 and February 2004, 64 patients with median age of 59 (range 38-81) years were recruited onto this trial. We evaluated 553 (median 7, range 1-25) courses of PLD treatment. Most patients were in their third or fourth line of chemotherapy. PPE was noted in 30 patients (47.6%), but only three participants progressed to grade 3 severity (4.7%, 95% confidence interval 1.0-13.1%). Partial response, stable disease, and tumour progression were observed in 5, 13, and 24 patients, respectively. Median overall and progression-free survival were 18.2 (range, 1.4-34.0) and 4.3 (range 0.5-22.3) months. CONCLUSIONS: Biweekly PLD may reduce the incidence of PPE while retaining efficacy in relapsed ovarian cancer. Our data support the need for a randomized trial to strengthen these assumptions.

[The clinical use of the ISO-C(3D) imaging system in calcaneus fracture surgery]. / Die klinische Wertigkeit des ISO-C(3D) bei der Osteosynthese des Fersenbeins.

We compared in a prospective study including 82 patients treated with ORIF of an intraarticular calcaneus fracture the quality of fluoroscopy, intraoperatively Iso-C(3D) and postoperative CT-scans. Therefore the posterior facet of the calcaneus (PFOC) was divided into three sectors. Joint steps and fracture gaps were detected by two independent investigators and statistically analysed. Another focus was to evaluate if the findings due to intraoperatively Iso-C(3D) assessment performed by the surgeon were correct and subsequently influenced the surgical procedure. There were no statistically differences between the Iso-C(3D)- and CT findings concerning joint steps or fracture gaps in PFOC sectors I-III. With fluoroscopy an assessment of the PFOC sectors I and II was not possible. In six cases (7.3%), intraoperative reduction was redone after performing an Iso-C(3D) scan. In ten cases, 12 malpositioned screws were replaced (12.2%/14.6%). These results suggest that intraoperative 3D Iso-C(3D) imaging provides a high diagnostic reliability. By careful assessment of the images the surgeons receive information which could lead to a change of the operative strategy.