[Orthopaedic and trauma surgical care until 2050. Analysis of the utilization behavior for relevant diseases and derivation of the number of medical service providers]. / Orthopädisch-unfallchirurgische Versorgung bis 2050. Analyse des Inanspruchnahmeverhaltens bei relevanten Erkrankungen und Ableitung der Häufigkeit ärztlicher Leistungserbringer.

BACKGROUND: Due to current and prospective demographic developments, the provision of high-quality medical care is not guaranteed in Germany. OBJECTIVES: The aim of this study is to analyze the utilization of medical service providers for diseases related to orthopedic/trauma surgery and deduce the corresponding number of medical service providers until 2050. MATERIALS AND METHODS: Data provided by the Statistical Offices of the Federal Republic and the Federal States and the Scientific Institute of the AOK (2008-2012) were used to analyze the utilization behavior of four pre-determined orthopedic/trauma surgery disease groups (osteoarthritis, back pain, osteoporosis, trauma). Routine data of the current (2012) health care provision delivered by the compulsory health insurances (GKV) are the basis of the prognosis. Using population projections from the Federal Statistical Office, the health care demand until 2050 was predicted and using statistics from the German Medical Association, the number of required health care providers was determined. RESULTS: An increase in physician consultations until 2040 is expected for osteoarthritis (+ 21 %), osteoporosis (26 %), and trauma (+ 13 %). From 2040-2050 the health care utilization behavior of all examined diseases is expected to decrease. The increasing health care usage behavior until 2040 is associated with an increase in health care providers. CONCLUSIONS: Until 2030 a significant increase in the burden of orthopedic/trauma surgery diseases is expected. In 2050 the level of health care needs will be equivalent to that in 2030. Comprehensive needs assessment and planning are needed in order to create health care provision structures and processes that address potential changes in utilization behavior.

[Re-evaluation of the AOK hospital navigator with a focus on total knee replacement]. / Re-Evaluation des Krankenhausnavigators der AOK für das "QSR-Verfahren" unter besonderer Berücksichtigung des Themenschwerpunkts Knieendoprothetik.

BACKGROUND: One of the biggest health insurance companies in Germany (AOK, Allgemeine Ortskrankenkasse) has published new results focussing on process quality of total knee replacement in 2010. These results were published in the online portal "Weiße Liste", which is based on health insurance routine data. The German Association of Orthopeadic Surgery questions the credibility of the rating system of the "Weiße Liste". To prove the system an interdisciplinary task force was created. MATERIAL AND METHODS: The task force identified patient-specific parameters, which influence the outcome of total knee replacement based on the literature and expert opinions. Out of 907 orthopaedic departments, 4 above average and four below average were identified. The AOK was asked to provide 80 data sets for each department. These anonymised data sets could be converted into patient-specific data sets in the identified departments. Statistical analysis was performed to answer the question of whether there are differences between the below and the above average groups. RESULTS: 625 cases could be investigated. We found an increased rate of postoperative complications in the below average group. There are differences between both groups in terms of factors influencing the procedure. In the below average group an increased rate of patients with one or more comorbidities and a preoperative extension lag of over 10° was found. The above average group has a higher rate of operations before the knee replacement. CONCLUSION: The results need to be proven on a larger scale. Further, prospective investigations are planned.

[Undergraduate curricular training in musculoskeletal ultrasound: the impact of preexisting anatomic knowledge]. / Kurrikulare Ultraschallausbildung am Bewegungsapparat: Einfluss der anatomischen Vorbildung auf die Weitergabe von Basis-Skills an der Schulter.

OBJECTIVE: The aim of this study was to evaluate the impact of students preexisting anatomic proficiency to address the fundamental problems related to musculoskeletal ultrasound (MSUS) training by assessing the peer-assisted learning (PAL) system. METHODS: Students without anatomic knowledge (first semester, n = 38) and students in their fourth semester of medical school (n = 49) were randomly assigned to two groups: 1) The PAL group - teaching by a group of three minimally trained student-teachers and 2) the Staff group - students were taught by a group of three ultrasound-experienced operators. Sessions included both a theoretical and a praxis component (DEGUM/EULAR, Toshiba Nemio™ XG, 10 MHz). A multiple choice questionnaire (MCQ) and an objective structured clinical examination (OSCE) were performed. Qualitative differences were evaluated by the Likert scale. RESULTS: Exposure included three separate lessons (each 120 minutes, 65 minutes of active scanning). The results of the MCQ were better among the fourth semester students than among those without anatomic knowledge (p < 0.001). Among first semester students, the MCQ results were better for those who had been taught by medical staff than for those who had been instructed by means of PAL (4.3 vs. 3.1; p = 0.045). At no point during the practical evaluation did significant differences arise between students of fourth and first semesters after medical staff tutoring (19.6 vs. 19.7 points; p = 0.978). PAL did result in worse results with regard to practical MSUS competence levels in the students possessing no previous knowledge (OSCE score 16.1; p = 0.042). CONCLUSIONS: Although deficits in theoretical knowledge cannot be compensated for, basic MSUS content appears to be adequately transferable to students with limited anatomic knowledge. Thus, an early implementation of MSUS during medical school education would be prudent, provided that the training is performed by an experienced MSUS operator.

Nano-material aspects of shock absorption in bone joints.

This theoretical study is based on a nano-technological evaluation of the effect of pressure on the composite bone fine structure. It turned out, that the well known macroscopic mechano-elastic performance of bones in combination with muscles and tendons is just one functional aspect which is critically supported by additional micro- and nano- shock damping technology aimed at minimising local bone material damage within the joints and supporting spongy bone material. The identified mechanisms comprise essentially three phenomena localised within the three-dimensional spongy structure with channels and so called perforated flexible tensulae membranes of different dimensions intersecting and linking them. Kinetic energy of a mechanical shock may be dissipated within the solid-liquid composite bone structure into heat via the generation of quasi-chaotic hydromechanic micro-turbulence. It may generate electro-kinetic energy in terms of electric currents and potentials. And the resulting specific structural and surface electrochemical changes may induce the compressible intra-osseal liquid to build up pressure dependent free chemical energy. Innovative bone joint prostheses will have to consider and to be adapted to the nano-material aspects of shock absorption in the operated bones.

[Unstable pertrochanteric femur fractures. Failure rate, lag screw sliding and outcome with extra- and intramedullary devices (PCCP, DHS and PFN)]. / Die instabile pertrochantäre Femurfraktur. Komplikationen, Fraktursinterung und Funktion nach extra- und intramedullärer Versorgung (PCCP, DHS und PFN).

AIM OF THE STUDY: The dynamic hip screw (DHS) often shows a high incidence of therapeutic failure and an impared outcome in the treatment of the unstable pertrochanteric femur fracture (31A2). Therefore often an intramedullary device is recommended. In a retrospective clinical study we examined whether the percutaneous compression plate (PCCP, Gotfried) provides advantages following unstable fractures in comparison to DHS and PFN. METHODS: From January 2002 to April 2007 135 patients with unstable pertrochanteric femur fractures underwent internal fixation with the PCCP (n = 46, age 78.3, ASA 2.8), DHS (n = 36, age 75.9, ASA 3.0) or PFN (n = 53, age 77.2, ASA 2.8). Radiological and clinical re-examination of the patients (33 PCCP, 24 DHS, 34 PFN) was performed 17 months later. RESULTS AND DISCUSSION: The PCCP was implanted in less time than the DHS and PFN (59 vs. 80 vs. 79 min, p = 0.004). Radiographic screening time was low (PCCP 143 vs. DHS 146 vs. PFN 280 s, p = 0.001). Re-operations for wound infections and haematomas occurred in 2 % after PCCP, 14 % after DHS and 4 % after PFN (p = 0.058). There was a low re-operation rate for fracture fixation complications in PCCP (9 %), in contrast to DHS (25 %) and PFN (13 %, p = 0.109). Cut-out was seen more in DHS (19 %, PCCP 2 %, PFN 4 %, p = 0.005). Lag screw sliding was high with DHS (PCCP 4 mm vs. DHS 9 mm vs. PFN 6 mm, p = 0.032). There was no correlation between lag screw sliding and outcome. PCCP, DHS and PFN had the same functional results in Merle d'Aubigné and Harris hip scores. CONCLUSIONS: Using the minimally invasive PCCP technique in unstable pertrochanteric femur fractures provides a promising therapy option especially with regard to surgical time, radiographic screening time and failure rate. Lag screw sliding was low. There was no advantage of the intramedullary device PFN.

[Hip centralising forces of the iliotibial tract with various femoral neck angles]. / Die hüftkopfzentrierenden Kräfte des Tractus iliotibialis bei variierendem Schenkelhalswinkel.

AIM: Concerning the biomechanical properties of the iliotibial tract different opinions can be found in the literature. Due to this fact it was the aim of this study to take measurements about the hip centralising forces of the iliotibial tract in a neutral position as well as in abduction, adduction and flexion of the hip joint at different femoral neck angles by using a custom-made hip prosthesis. METHOD: By using a custom-made measuring endoprothesis with the capability for adjusting different femoral neck angles and lengths and, furthermore, by measuring the intra- and subligamentous forces at the height of the greater trochanter, we measured the forces for validating the influence of the iliotibial tract for hip joint centralisation. RESULTS: By increasing the CCD angle (coxa valga) a higher load on the hip joint results. By decreasing the CCD angle (coxa vara) a lowering of the coxalfemoral load results. Flexion of the knee joint leads to a decrease of the iliotibial tract tension. By extension of the knee joint and resulting tightening of the iliotibial tract, a triplication of the forces at the femoral neck was measured. Flexion of the hip joint exerted a ventralising of the iliotibial tract with an initial decrease of the centralising hip forces. Subligamentous measurement of the iliotibial tract showed increasing forces upon adduction as well as decreasing forces upon abduction of the hip joint. In the investigations about the forces with various femoral neck lengths, we saw a considerable increase by lengthening the femoral neck and resulting higher forces in the acetabulum. CONCLUSION: The clinical relevance of these results concerns the predictability of the in- or decreasing tension band wiring effect of the iliotibial tract in correlation to the CCD angle and the direction of motion of the hip joint. The measurements give the clinical users a benchmark for the expected subligamentous forces of the iliotibial tract and the resulting hip centralising forces. The influence of the lengthening of the femoral neck for the hip centralising forces clarifies the importance of the iliotibial tract when planning displacement osteotomies or hip joint replacement.

[The orthoMIT project. Gentle surgery using innovative technology]. / Das Projekt orthoMIT. Schonendes Operieren mit innovativer Technik.

The main objective of orthoMIT is to develop an integrated platform for "gentle" surgery in orthopedics and traumatology with particular emphasis on hip, knee and spinal column surgery. The goal of the 24 partners of the orthoMIT consortium and further associated industrial partners is an integrated approach to reduce the cost of orthopedic interventions: full workflow integration in the operating room, full treatment integration extending through to rehabilitation, and full integration of the typical value chain of medical product development, from the laboratory to production and commercialization by the firms and industrial partners involved in the project including education and training. Development, therefore, focuses on new strategies in minimally invasive surgery and improved, knowledge-based planning and navigation systems. Other topics include the development of improved methods of interventional imaging using ultrasound and computed tomography (flat panel detectors) and new, miniaturized instruments with integrated sensors and a modular integration of various applications and components into an integrated surgical workstation.