[Individual aspects in eldery patients with fragility fractures]. / Individuelle Besonderheiten bei hochbetagten Patienten mit Fragilitätsfrakturen.

BACKGROUND: Due to our ageing population, the number of elderly patients who are treated in the emergency department due to low-energy trauma (e.g., tripping) continues to rise. These minor accidents often result in fragility fractures classically located in the proximal humerus, distal radius, spine, pelvis, and near the hip joint. Pre-existing conditions, polypharmacy, and general frailty increase the risk of fragility fractures in this patient population. METHODS: Geriatric trauma fractures and especially insufficiency fractures of the posterior pelvic ring are often difficult to diagnose by plain X­ray. Therefore, in geriatric trauma patients, cross-sectional imaging, e.g., computed tomography (CT), dual-energy CT (DECT), or magnetic resonance imaging (MRI), should be considered early for reliable evaluation of a suspected fracture. This also allows for the identification of older fractures. Particularly in cognitively impaired elderly patients, difficult examination conditions or an unclear fall event, cross-sectional imaging is often indicated. However, this may also involve risks, e.g., use of contrast medium in patients with impaired renal function, so that each case must be considered individually. Furthermore, the diagnosis and treatment of osteoporosis, which is an underlying disease that leads to fragility fractures, is of particular importance. In the diagnostic workup, measurement of bone density using dual energy X­ray absorptiometry (DXA) is the standard method according to guidelines. In specific situations, high-resolution peripheral quantitative CT (HR-pQCT) may also be used. CONCLUSION: Due to the special challenges of correctly detecting fragility fractures and being able to quickly initiate adequate therapy, good cooperation between radiologists and trauma surgeons is necessary.

[Subsequent treatment following proximal femoral fracture - who, when, where? Assessment of the current situation in Germany]. / Weiterbehandlung nach proximaler Femurfraktur - Wer, wann, wohin? Eine deutschlandweite Statuserhebung mit Unterstützung der AG Alterstraumatologie der DGU.

BACKGROUND: Geriatric fractures are an increasing challenge for the German health-care system. While the acute care for patients with proximal femoral fractures is already standardised, differences remain in the further treatment and rehabilitation. A survey was conducted in cooperation with the section of geriatric trauma (AG Alterstraumatologie) of the German Association of Trauma Surgery (DGU) to point out existing problems in this group of patients. MATERIAL AND METHODS: In October/November 2010 an electronic questionnaire, assessing the medical care for patients after proximal femoral fracture, was sent to 1080 medical directors of trauma and orthopaedic surgery departments in Germany. RESULTS: 339 (31.4 %) departments participated. The analysis revealed that 57 % of the hospitals had cooperation agreements with aftercare hospitals. 37 % of all hospitals had problems in finding a rehabilitation hospital. The initiation of a rehabilitation procedure is almost exclusively based on the doctors' decision. Influence of employees with other professions is marginal. Mobility and Barthel index before the release from the acute care hospital are major factors in the decision making. CONCLUSION: The questionnaire confirms that there are problems in the aftercare service of geriatric patients all around Germany. A further improvement of collaboration between acute and aftercare hospitals is required.

[Run-over injuries : causes, injury pattern, treatment and long-term sequelae]. / Überrollverletzungen : Ursachen, Verletzungsmuster, Therapie und Langzeitfolgen.

BACKGROUND: The rate of long-term disability following run-over injuries has not been investigated so far. Therefore the aim of this study was to evaluate the long-term outcome following run-over injuries. MATERIAL AND METHODS: A total of 71 patients were enrolled in the study. Data were collected regarding the injury pattern, surgical treatment and clinical outcome. The quality of life was measured with the POLO chart RESULTS: The median ISS was 15. Eight patients died. The injuries were predominantly located at the lower extremities (39%) with severe soft tissue injuries in 68% of the cases. Patients were operated on a median of four times. In the follow-up evaluation with the SF36 7 years post-trauma, 57% of the patients had reduced physical functioning and 46% reduced psychological health. CONCLUSIONS: The long-term disability following run-over injuries is severe and requires a multidisciplinary approach. Treatment should therefore be conducted in appropriate trauma centres.

[Results and complications in the treatment of periprosthetic femur fractures with a locked plate system]. / Ergebnisse und Komplikationen der Behandlung periprothetischer Femurfrakturen mit einem winkelstabilen Plattensystem.

BACKGROUND: Locked plate devices offer advantages in the treatment of periprosthetic femur fractures associated with fixed total hip or total knee arthroplasty. The purpose of this study was to evaluate the early results and complications with a locked plate system (NCB-DF(R)). PATIENTS AND METHODS: A total of 31 patients (mean age 76 years, 7 males, 24 females) with a femur fracture above a fixed total knee arthroplasty (TKA, n=12) or a total hip arthroplasty (THA, n=19) were treated with a locked plate. RESULTS: There were 11 complications necessitating revision: 6 implant failures, 2 in patients with a THA and 4 in patients with a TKA, 4 hematomas and 1 infection and 2 patients died. After 6 months all fractures had healed securely but a secondary correction was necessary in one patient. CONCLUSION: Fixation of periprosthetic femur fractures with a locked plate system provided satisfactory results in patients with a THA, however, the relatively high implant failure rate in fractures above a stable TKA is a cause for concern.

[Emergency surgery for chest injuries in the multiply injured: a systematic review]. / Operative Versorgung von Thoraxverletzungen innerhalb der ersten Operationsphase: Eine systematische Literaturübersicht.

OBJECTIVE: Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy. METHODS: Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (>1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay. CONCLUSION: A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.

[Incidence of severe injuries. Results of a population-based analysis]. / Inzidenz schwerer Verletzungen. Ergebnisse einer populationsbezogenen Untersuchung.

It is still unknown exactly how many persons sustain a severe injury (ISS > or =16) in Germany each year. Considering the growing restrictions and the introduction of DRGs, it was necessary to acquire data about this rather resource-intensive aspect of trauma care. The aim of this study was therefore to assess the incidence of severe trauma within a defined population. In a retrospective study all surgical emergencies within a 5-year period (1996-2000) were reviewed. Data on type, pattern, severity of injury, and mortality were extracted from the patients' records. During the study period 454 persons sustained a severe injury (ISS > or =16), 112 individuals died at the scene of the accident, and 64 during the hospital stay. The average ISS of the surviving patients was 27 (ISS 16-75). The calculated incidence of severe trauma was 25/100,000 inhabitants per year. Extrapolated, up to 40,000 persons sustain a severe injury each year in Germany. For the first time, this study has provided data on the incidence of major trauma in Germany. Based on the acquired data and a previous cost analysis, hospital treatment costs for severely injured patients amount to up to 2 billion Euros per year in Germany.

[Quality of life after surgical treatment of osteitis]. / Lebensqualität nach operativer Osteitisbehandlung.

Although many studies have measured the functional outcome after surgical treatment of osteomyelitis, there have been few published attempts to evaluate the long-term quality of life. We therefore undertook this study to assess the quality of life in a large patient population after operative treatment for this condition. All patients who underwent operative treatment for osteomyelitis from 1993 until 1997 at our institution were included in the study. The patients were assessed with a questionnaire which contained the SF-36 (German version) and questions about the activity and history of the illness. The result was compared to the data set from a standard population. Of the 502 patients, 345 (69%) returned questionnaires for evaluation. The infection was inactive in 301 (88%). Compared to a standard population, the investigated patients showed a significant reduction in their overall psychological well being and physical functional capacities. Surgical treatment was able to inactivate the infection in 88% of the patients. Because of persistent deficits, the psychological well being and physical functional capacities are reduced compared to a standard population.

[New methods in polytrauma surgery. Results of a Study Congress at castle Reisenburg 27/28 February 2000]. / Neue Wege in der Polytraumaforschung. Ergebnisse einer Arbeitstagung auf Schloss Reisensburg, 27./28.02.2000.

Recently, in Germany the academic environment has changed and an upheaval occurred that directly do affect academic research activities. Increasingly, the funding of scientific projects is not provided anymore by the universities themselves or the government, but has to be acquired as grants. While in the past, research was conducted by single departments, nowadays and more and more in the future scientific networks have to be established by combining 'local' and even 'distant' knowledge. With this changing background in mind representatives of different scientific institutions met at the Reisensburg castle to discuss the current state and future trends in four major research fields: "Epidemiology of Severe Trauma", "Head Injury", "Pathophysiology of Damage to the Chest", and "Posttraumatic Soft Tissue Injury".

Trauma severity-dependent changes in AT III activity.

Trauma may cause a relevant reduction in antithrombin (AT) III activity, which is associated with adverse events. The very early changes in AT III activity after accident trauma are still unclear and possible relations with Interleukin (IL)-6, which is known to interact with AT III, have not been investigated so far. Upon approval of the IRB/IEC, 30 patients were enrolled with multiple injuries (ISS 9-75). Groups were performed according to injury severity, IL-6 concentration, and survivors versus non-survivors. Blood samples were collected at the scene of accident then at 2, 4, 6, 12, and 24 h and at day 3, 5, 10 and 15. No patient received AT III concentrates. In all groups a reduction in AT III activity occurred, which was most pronounced in very severe injuries. The activity re-increased spontaneously and steadily in all groups regardless of the IL-6 concentration. There was no clear impact of the AT III activity on survival.

Volume replacement in trauma patients within the first 24 h and its impact on the interpretation of biochemical data.

BACKGROUND AND AIMS: Patients of the same and particularly of different trauma studies are primarily incomparable due to different volume replacements. The aim of this prospective study was to analyze the amount of initially administered fluids in trauma patients during the first 24 h and to estimate the impact of dilution on plasma protein concentrations (PPCs) of prostanoids. These substances are vascular endothelium-derived and are thus influenced by blood pressure. PATIENTS/METHODS: Sixty-nine casualties suffering from multiple injuries were enrolled in the study. The amount of any fluid administered was scrutinized during the first 24 h. Patients were divided into subsets according to trauma severity by Injury Severity Score (ISS) (group=G-I: < or = 9; G-II: 10-18; G-III: 19-32; G-IV: >32) and between survivors and non-survivors. At corresponding time points, hemoglobin, hematocrit (Hct) and PPC as well as prostaglandins (PGI, TxA, PGF2a) were evaluated at the site of accident, at hospital admission, and every hour thereafter for the first 24 h. RESULTS: During this period, the total amount of infused fluids ranged between 0.51 (G-I) and >481 (G-IV). The higher the trauma severity, the greater the volume infused (G-III/IV P=0.0003 vs G-I/II). Simultaneously, PPC dropped markedly (P<0.01). Patients who died within 36 h required higher volumes (P<0.003) than survivors. PPC was linearly related (r2=.6685, P<0.001) to Hct. During the first 24 h, the time course of prostanoid concentration was altered when dilution is not taken into account. CONCLUSION: PPC proved a suitable parameter to estimate dilution effects and to adjust plasma concentrations of prostanoids. We recommend that consideration be given to possible dilution effects during the first 24 h when interpreting biochemical data in trauma patients.

[Tibiocalcaneal fusion for the treatment of talar necrosis. An analysis of 21 cases]. / Die tibiokalkaneare Arthrodese. Eine Analyse von 21 Fällen.

Between 1986 and 1996, 21 patients had a tibiocalcanear arthrodesis. Indications for surgery were in all cases either osteomyelitis or avascular necrosis of the talus. External stabilisation was used in 17 patients due to severe soft tissue damage or extensive infection of the talus, internal screw fixation was used in four patients. There were eight complications in seven patients, one patient had a below the knee amputation. The leg length discrepancies after resection of the talus was equalized in four cases with callus distraction using an Ilisarov ring fixator. Follow up evaluation was available in 18 patients after an average of 38 months (12-86 mo.). There were no infectious recurrencies during the follow up period and a solid fusion was achieved in all patients that were followed. According to a modified Kitaoka score, results were excellent and good in 12 of the 18 patients. External stabilisation, especially the Ilisarov ring fixator is the primary method of treatment in cases with severe infection or soft tissue damage.

[Trauma surgery 2020. Past developments - future demands and perspectives. III: Ideas on future care]. / Unfallchirurgie 2020. Entwicklungen der Vergangenheit - Forderungen und Perspektiven der Zukunft. Teil III. Thesenpapier zur künftigen Versorgung.

A growing number of casualties and the increasing restrictions of funding will lead as a consequence to changes within the field of trauma surgery. Despite these developments trauma surgery must maintain its major responsibility towards the victims of accidents. Therefore the German Society for Trauma Surgery (DGU) has to face the future economic and social challenges to influence the coming changes. This role compromises the engagement in a continuous struggle for the high and global standard of injury care in Germany, for quality assessment, education and training, research and adequate public relations. This paper outlines the aspects and visions of future trauma surgery and the means which may continue to guarantee international acknowledged standard of trauma care in Germany.

[Trauma surgery 2020. Developments in the past--challenges and perspectives for the future. I: Trauma surgery management]. / Unfallchirurgie 2020. Entwicklungen der Vergangenheit--Herausforderungen und Perspektiven der Zukunft. Teil I: Unfallchirurgische Versorgung.

In germany over 5 million individuals are involved in an accident annually. The economical consequences are huge with direct treatment cost amounting to approx. 72 billion marks. The available data indicates an increase in the incidence of overall trauma and trauma cases treated in specialised trauma departments. An identical development can be documented for severe trauma, especially for for fractures of the spinal column, whereas the incidence of automobile and occupational accidents has declined in recent years. The current system of reimbursement in the treatment of severely traumatized patients is deficitary for trauma departments. Therefore, to avoid a reduction in the standard of care, new methods of reimbursement have to be devised. In a limited financial environment the benefit of high level trauma care for the individual and the society has to be demonstrated with adequate public relations.

[Trauma surgery 2020. Development in the past, definition of future topics and programs. II. Research in trauma surgery 1998]. / Unfallchirurgie 2020. Entwicklungen der Vergangenheit--Herausforderungen und Perspektiven der Zukunft. Teil II. Unfallchirurgische Forschung 1998.

The field surgery has been structured into four specialties of equal importance that are Thoracic Surgery, Vascular Surgery, Visceral Surgery and last but not least Trauma Surgery. Each specialty defines its research tasks. Therefore it is necessary to evaluate the situation of research in trauma surgery and define future topics and programs. The aim of this survey was to cover the present research situation in Germany. Out of the 200 questionnaires 112 were available for evaluation. The major deficiencies were stated to be a lack of personnel, budget and coordination of topics and resources. Of general interest was to initiate activities of the German Society for Trauma Surgery (DGU) in view of coordination of research activities, setting up of new funds and integration of teaching hospitals into university research programs. The data, shown in this article, may serve to start a discussion aiming on the improvement of the financial and scientific environment.

A new approach to computer guidance in orthopedic surgery using real time volume rendering.

The purpose of this paper was to evaluate the ability of a new real time volume rendering system using raw unprocessed CT data on a four processor Pentium PC. A CT data set of the pelvic area was used to demonstrate the systems ability to integrate and visualize both data from a CT scan and a tracking system. The computer system consisted of a four processor Pentium PC and the software tool VGInsight (Volume Graphics GmbH). For study purposes in a laboratory setting a magnetic tracking system (Polemus Inc.) was used to simulate tracked surgical tools. With this new software tool and the tracking system the exact relative location of a tracked instrument within all structures of the pelvic area, soft tissue as well as bone, could be displayed in 3D and real time without preprocessing of the data set. Until recently real time volume rendering required expensive workstations. With a new software tool on a four processor Pentium PC the authors were able to introduce a 3D real time processed data supply to the surgeon.

Discoid lateral meniscus in children. Long-term follow-up after excision.

We retrospectively reviewed the results for fifteen patients, eight girls and seven boys, who had had a total of eighteen meniscectomies performed for a discoid meniscus at The Hospital for Special Surgery between January 1, 1955, and December 31, 1983. The average age was ten and a half years (range, six to sixteen years) at the time of the operation and twenty-eight years (range, twenty to thirty-six years) at the time of follow-up. The average duration of follow-up was seventeen years (range, eight to twenty-eight years). The primary indication for the meniscectomy was continuing pain in fourteen knees and locking or snapping in three. One patient had tenderness and walked with a limp. A meniscal tear was found in twelve knees at the time of the operation. According to the scale of Ikeuchi, the result was excellent for ten knees, good for three, and fair for five. Of the five patients (five knees) who had a fair result, four had mild intermittent discomfort after strenuous physical activity as well as clicking (three knees) or swelling (one knee), and one had clicking. One of these five patients was subsequently found to have rheumatoid arthritis, and two subsequently had a patellar realignment. No degenerative changes were evident on the roentgenograms of the eight patients (nine knees) for whom they were made at the latest follow-up evaluation.