Outcome of older hip fracture patients on anticoagulation: a comparison of vitamin K-antagonists and Factor Xa inhibitors.

INTRODUCTION: Older hip fracture patients are still challenging in daily clinical practice. Due to the high prevalence of osteoporosis and atrial fibrillation in this age group, the number of fragility fracture patients under oral anticoagulation (OAC) increases. The outcome is still disappointing, short- and long-term mortality and morbidity is high. The impact of pre-existing OAC is not yet clear, especially regarding new OAC drugs like Factor Xa inhibitors (FXa). The purpose of our study was to compare the short-term outcome of older hip fracture patients, without OAC (controls), on Vitamin K antagonists (VKA) and on FXa. MATERIALS AND METHODS: The study is a retrospective case-control study including patients older than 70 years who sustained hip fractures caused by an inadequate trauma and treated at a level 1 trauma center from February 2017 to June 2018. Patient's information was taken from patient's charts. 102 cases were analysed, 61 controls, 41 on OAC (15 on VKA and 26 on FXa). As outcome parameter we defined mortality, perioperative complications, bleeding, need of blood supplements, delay of surgery, length of stay, and a combined outcome parameter (mortality, myocardial infarction, stroke, thromboembolic events, blood preservations, re-vision surgery, major bleeding and decline of hemoglobin). RESULTS: Eight patients died during hospital stay, in-hospital mortality was 7.8%. The highest mortality rate was found in patients on VKA (20%), compared to patients on FXa (3.8%) and controls (6.6%). However, mortality rate did not differ significantly within the groups. The combined endpoint was significantly more frequently seen in patients on OAC compared to controls (p = 0.006). No difference was observed between patients on VKA or FXa. Mean time to surgery and LOS was significantly longer in patients on OAC compared to controls. No significant differences were seen between VKA and FXa. CONCLUSIONS: In our study OAC was significantly associated with worse outcome compared to controls. Marginal differences were observed between patients on FXa or VKA. Further studies involving a higher number of patients are necessary to confirm our results. At that time, some our results have to interpreted carefully and need confirmation.

[Humeral shaft fractures]. / Humerusschaftfraktur.

There is still no gold standard for the treatment of humeral shaft fractures. This might be attributed to the fact that several commonly used treatment methods have shown good clinical results. A bimodal age distribution of humeral shaft fractures with frequency peaks between 20 and 30 years old and above 60 years old is reported. Decision making for conservative or operative treatment depends not only on the injury pattern but is also dependent on individual patient needs. Currently available operative techniques include antegrade and retrograde interlocking medullary nailing as well as the use of longer proximal humeral nails. Plate osteosynthesis can be performed as open reduction and internal fixation (ORIF) or as minimally invasive plate osteosynthesis (MIPO). There is currently insufficient evidence for a clear superiority of either of the methods. Radial nerve palsy is the most typical complication of humeral shaft fractures but an improved outcome is not achieved by an emergency revision of the nerve.

[Nationwide implementation of a hospital resource register for daily trauma care, mass casualties and disasters : Position paper of the German Trauma Society and the Federation of German Medical Directors of Emergency Medical Services]. / Bundesweite Einführung eines Krankenhauskatasters in den Klinikalltag und bei Großschadens- und Bedrohungslagen : Positionspapier der DGU und des BV-ÄLRD e. V.

The introduction of requirements for a minimum intake capacity of trauma patients by the German Trauma Society (DGU) into the so-called white book of treatment of seriously injured patients, is helpful for a sufficient preparation for threats and for dealing with mass casualties for trauma centers as well as for the emergency medical services (EMS). In the hospital information database provided by the Federation of German Medical Directors of Emergency Medical Services, more than 1300 hospitals are currently listed. This information supports the allocation of trauma patients from the field to the appropriate trauma center. Currently, without any coordination requirements, the current 626 trauma centers in Germany are able to immediately handle 6260 patients. This number could be doubled by activating the local hospital action plan, where a priority plan is set up. Additionally, the implementation of a nationwide flexible standardized communication structure between the dispatch center of the ambulance service and the hospitals, would improve daily care as well as the management of threats and mass casualties. It is the obligation of the local medical director of the EMS, to maintain and update the hospital database. Providing the information in the database with the hospital resources and the flexible standard communication structure, is appropriate to improve the daily collaboration and the preparation for mass casualties.

[Upper extremity fractures in the elderly]. / Frakturen der oberen Extremitäten im Alter.

Upper extremity fractures in the elderly are very frequent and second only to hip fractures in the group of fragility fractures. Their impact on mobility and functional decline seems to be underestimated especially when they occur in combination with lower extremity fractures. Fractures of the proximal humerus and the distal radius can often be treated conservatively; however, the indications for operative treatment must not be based on fracture morphology alone and due consideration should be given to all concomitant circumstances affecting functional aspects of patients. Operative treatment of proximal humeral fractures may aim either at preserving the humeral head or at prosthetic replacement. There is broad agreement that this decision should depend on the condition of the humeral head fragment (degree of damage, perfusion). Fixation of distal radial fractures is commonly performed with angular volar stable plates. The more complex the fracture, the more likely conservative treatment will fail.

[Spinal fractures]. / Wirbelsäulenfrakturen.

Osteoporotic spinal fractures are typical age-related fragility fractures. Their impact on the quality of life is often underestimated; therefore, anti-osteoporotic drug treatment according to the current guidelines is essential. Occult vertebral fractures may be difficult to detect and a differentiation between fresh and old fractures is often only possible with magnetic resonance imaging (MRI) to reveal cancellous bone edema. Treatment recommendations are predominantly based on traumatic fractures in younger adults and are thus not applicable in orthogeriatrics. A new classification currently under validation and presented in this article was developed in order to aid decision-making for operative interventions. Minimally invasive treatment options include vertebroplasty, kyphopasty and internal fixation. The application of cement provides additional stability but can be accompanied by cement-specific complications, such as extravasation and embolism.

[Rescue time and survival of severely injured patients in Germany]. / Rettungszeit und Überleben von Schwerverletzten in Deutschland.

BACKGROUND: Independent of the rescue system type, a rescue time of less than 60 min for trauma patients is usually required and considered to be crucial for the outcome. The goal of this study was to investigate the impact of the rescue time on hospital survival in severely injured patients. METHODS: With the help of the German Trauma Registry of the DGU, the population and rescue time were systematically analyzed with regard to the survival rate. A lower mortality rate was observed with a higher injury severity in metropolitan cities compared to small towns. RESULTS: A multivariate regression analysis revealed no clinically relevant impact of the rescue time length in the German rescue system on survival. This can be explained by a higher amount of preclinical medical procedures during longer rescue times. CONCLUSIONS: Within the German rescue system, the length of rescue time has no relevant impact on the survival of trauma patients admitted to a clinic. This could be explained by the higher numbers of preclinical measures and due to the limitations of a register study with selection bias. Therefore, we advocate that the necessary and suitable preclinical medical procedures be performed to stabilize the patient, even in cases that have exceeded the 60-min gold standard time window. In conclusion the "golden hour" concept today might better be interpreted as an individual and appropriate "golden period" of trauma.

[Experiences with a helical femoral nail (LFN®). A multicenter study]. / Erfahrungen mit einem helikalen Femurmarknagel (LFN®). Eine multizentrische Studie.

INTRODUCTION: Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant. MATERIAL AND METHODS: Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167). RESULTS: The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%. CONCLUSION: The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.

[Preparedness of hospital physicians for a mass casualty incident. A German survey amongst 7,700 physicians]. / Wie gut sind Ärzte auf einen Massenanfall von Verletzten vorbereitet?. Ergebnisse einer bundesweiten Umfrage bei 7700 Klinikärzten.

INTRODUCTION: The bomb attacks in Madrid (2004) and London (2005) have increased awareness that terrorist attacks are also a real threat in Germany. Hospitals and health care providers should be prepared. METHODS: We distributed an anonymous online questionnaire to physicians working in trauma centers of different categories. The results were analyzed using descriptive statistical methods. RESULTS: The questionnaire was returned by 1,204 of 7,700 physicians. This reflects a response rate of 15.6%. Of the participants, 53.3% answered that their hospital had a disaster control plan and that they knew the content; 33.9% reported that their hospital had participated in a disaster training scenario. CONCLUSION: As only 53.3% of physicians in hospitals know their disaster control plan and only 33.9% of hospitals have participated in a disaster training scenario we conclude that more action is needed to increase awareness of the problem. Furthermore standardized training programs are needed to disseminate knowledge and skills in order to enable health care providers to face the occurrence of terroristic attacks in Germany.

[Hemiarthroplasty for femoral neck fracture in the elderly--an operation suitable for teaching?]. / Ist die Versorgung der Schenkelhalsfraktur mittels Duokopfprothese beim alten Menschen ein geeigneter Ausbildungseingriff?

BACKGROUND: Hemiarthroplasty is a common procedure for treating femoral neck fractures in orthogeriatrics. For training purposes the operation may also be performed by supervised residents. Our study aims at evaluating the rates of early surgical complications after hemiarthroplasty in different age groups, comparing operations performed by consultants and residents. METHODS: All patients treated with hemiarthroplasty between December 2006 and July 2011 at our municipal, maximum-care-providing hospital were included in a retrospective cohort. The Excia® stem with a self-centering bipolar head (Aesculap, Tuttlingen) was used in all patients. Educational level of the operator (consultant vs. resident) and operation time were noted as well as early complications including luxation, infection, haematoma, seroma, and early periprosthetic fractures (e.g., intraoperative lesions of the greater trochanter). The complication rates were evaluated and compared by the chi-square test. RESULTS: 241 of 729 hemiarthroplasties were performed by supervised residents. Neither the overall complication rate nor the rates of specific complications differed significantly between the patients operated by consultants and those operated by residents. The result was still true if comparing the different age groups. On average operation time was 8 minutes longer in teaching operations. CONCLUSIONS: Focusing on early surgical complications, the teaching of hemiarthroplasty does not seem to increase the risk to patients of any age. We conclude that the hemiarthroplasty procedure is suitable for teaching younger colleagues in orthogeriatrics. As age is just one of several potential risk factors, additional studies on this topic should be undertaken.

Is proximal femoral nailing a good procedure for teaching in orthogeriatrics?

BACKGROUND: Proximal femoral nailing is a common operation in orthogeriatrics and a highly standardized procedure. For teaching purposes, this operation is often performed by residents and supervised by attending physicians. The objective of this study is to investigate if teaching this operation influences the surgical in-house complication rate. PATIENTS AND METHODS: All patients who received a proximal femoral Targon PF nail (Aesculap AG, Tuttlingen, Germany) for trochanteric fractures were included in a cohort at our urban academic teaching hospital between 1998 and 2010. To evaluate potential effects of patient age, we separately analyzed several age groups. Complications including wound infection, hematoma, intraoperative malreduction or implant malpositioning causing revision, pain, cut-out and readmission due to nonunion were recorded. RESULTS: Our collective consists of 1,516 patients (m/f: 410/1,106). The mean age was 78.7 years (range: 19-103 years). The overall complication rate was 7.9 %. In 857 cases operated by attending physicians, the complication rate was 6.9 %. However in the 659 operations performed by residents, we found a higher complication rate of 9.3 %. Further investigating this difference by χ(2) test, we found no significance (p = 0.09). Whilst analyzing the complication rates for the different age groups, we did not find a statistically significant difference except in the age group between 71 and 80 years, for which the odds ratio indicated a 2.6-fold increased complication risk for operations performed by residents (p = 0.01). Further analysis revealed that this increased complication rate was mainly due to increased numbers of cut-out. CONCLUSION: We conclude that proximal femoral nailing is an operation suitable for teaching purposes. However, patients between 71 and 80 years of age seem to be at an increased risk for cut-out if operated by a resident.

A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN).

INTRODUCTION: The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct. PATIENTS AND METHODS: 180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12 weeks and 1 year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation. RESULTS: The 1-year follow-up rate was 81 %. At 1 year, the prevalence of delayed union was 12.2 % and higher for open fractures (18.2 %) compared to closed fractures (9.7 %). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5 % in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment >5° in any plane 1 year after surgery was 5.5 %. Proximal third fractures were at a higher risk of postoperative malalignment (17.6 %). The rate of secondary malalignment was 1.4 %. The risk of unplanned reoperation was 9.2 %. CONCLUSION: Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.

[Microbiological diagnosis of implant-associated infections : Retrospective analysis of 133 patients in an arthroplasty center]. / Mikrobiologische Diagnostik bei implantatassoziierten Infektionen : Retrospektive Analyse von 133 Patienten in einem Endoprothetikzentrum.

BACKGROUND: Because standardized microbiological cultures of puncture fluids and tissue samples often do not provide pathogen detection in implant-associated infections, sonication and polymerase chain reaction (PCR) are used additionally today. OBJECTIVES: Pathogen spectra and previous microbiological standards are examined for agreement of results using the new methods sonication and PCR. MATERIALS AND METHODS: In this descriptive, retrospective observational study, we evaluated the data of 133 patients in whom a joint prosthesis, osteosynthesis material or a spacer was removed during revision surgery with suspected implant-associated infection and sent for sonication. RESULTS: Pathogen detection was achieved by culture of peri-implant material in 40.1% and by sonication in 42.5%. In each case, coagulase-negative staphylococci were detected most frequently. Overall, the results were consistent in 71.7% of cases. In the discrepant cases, more anaerobes could be detected by sonication, especially for osteosynthesis material and knee prostheses. PCR analyses in 21 cases showed pathogen detection in 14.3% and agreement with the results of peri-implant tissue culture and sonication in 57.1% and 66.7%, respectively. CONCLUSIONS: The present results indicate a gain in sensitivity of sonication, especially for anaerobes that are difficult to grow, and a gain in specificity through sonication. PCR analyses should be reserved for specific questions.

"N-active": a new comanaged, orthogeriatric ward: observations and prospects.

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit "N-active" was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.

[Distribution planning of injured persons in mass disasters or catastrophes. Structuring of hospital capacities exemplified by the catastrophe network of the German Society for Trauma Surgery (DGU)]. / Verteilungsplanung von Verletzten beim MANV oder Katastrophenfall. Strukturierung der Krankenhauskapazitäten am Beispiel des Katastrophennetzwerks der DGU.

Relevant changes have occurred in disaster management in Germany due to legal alterations and the introduction of the diagnosis-related groups (DRG) system. This has resulted in a reduction in bed capacities and an increase in bed utilization. In addition to the preclinical deployment strategy the provisional aspects of disaster medicine with the problem of the emergency service/hospital interface will be described. A suggestion for a solution for optimization of patient allocation in mass disasters or catastrophes will be demonstrated with the catastrophe network of the German Society for Trauma Surgery (DGU).

Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system.

INTRODUCTION: Fractures of the distal humerus are complex injuries that can be effectively treated with open reduction and internal fixation (ORIF). The new LCP distal humerus system allows angular stable fixation of these complex fractures with anatomically preshaped plates. The aim of the study was to evaluate operative reposition, fracture healing, and pain, function and patient satisfaction after open reduction with an angular stable fixation. METHODS: Fourteen patients with a mean age of 55.2 years (21-83) were treated with open reduction and angular stable internal fixation. Two patients were lost to follow up (1 died, one refused to be reevaluated). AO classification showed 12 C-fractures (1 x C 1.1; 1 x C 1.3; 4 x C 2.2; 4 x C 3.2; 2 x C 3.3) and 2 B-fracture (B 2.3 and B 3.3). 5 fractures were open fractures (4 x II degrees , 1 x I degrees ). The clinical and radiographic follow up (Mayo elbow performance score (MEPS), Dash Score, elbow anterior-posterior and lateral view X-rays, and flexion and extension force as % of contralateral side at 90 degrees flexion) were performed postoperatively. Mean follow up was 10 months. RESULTS: Radiographically, complete union was achieved in all patients. There were no cases of primary malposition or secondary dislocation. Complications were: (1) delayed union after olecranon osteotomy, (2) transient ulnar nerve irritation. Clinical MEPS results were good to excellent with a mean of 91 +/- 11.7 points. The mean DASH Score was 18.5 +/- 11.5 points. Mean flexion was 121 +/- 20.9, mean extension deficit was 17.9 degrees +/- 10.3. Mean flexion force was 75.3% +/- 26.7 and mean extension force was 70.7 % +/- 24.9. CONCLUSION: Treatment of supra-intercondylar fractures of the distal humerus is challenging. Anatomically preshaped angular stable implants facilitate operative reduction and stabilization of the fracture and may allow early postoperative rehabilitation. Clinical and radiological results are promising, with good range of motion and flexion and extension force.

[Developments in polytrauma management. Priority-based strategy]. / Neues zum Polytrauma. Prioritäten in der definitiven Versorgung.

The acute and early phase of polytrauma management is decisive for determining and implementing priority-based operative strategy. The patient's general condition and pattern of injury have to be considered. The highest priorities in the acute phase of operative treatment are control of mass bleeding and the release of body cavities (life-saving surgery). In the primary phase of surgical management (day 1 surgery), selected injuries are treated in the order of their urgency. Conceptual damage control surgery is distinguished from early total care. Damage control surgery should be performed only in patients meeting certain instability and risk criteria to avoid additionally burdening their condition.