[One-year outcomes after proximal humeral fractures : A risk-adjusted regression analysis of routine data based on 17,322 cases]. / Einjahresverläufe nach proximalen Humerusfrakturen : Eine risikoadjustierte Regressionsanalyse mittels Routinedaten anhand von 17.322 Fällen.

BACKGROUND: Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of a targeted treatment strategy. OBJECTIVE: Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures. MATERIAL AND METHODS: A routine data analysis of 17,322 cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year. RESULTS: In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival. DISCUSSION: Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.

[Development of the inpatient quality of care of surgically treated patients with a proximal femoral fracture in North Rhine-Westphalia : Analysis of 61,249 treatment courses based on data from external inpatient quality assurance]. / Entwicklung der stationären Versorgungsqualität operativ behandelter Patienten mit einer proximalen Femurfraktur in Nordrhein-Westfalen : Eine Analyse über 61.249 Behandlungsverläufe auf Grundlage der Daten der externen stationären Qualitätssicherung.

BACKGROUND AND OBJECTIVE: Every year in Germany over 100,000 people, mostly of older age, suffer a proximal femoral fracture. Increasing case numbers in connection with an aging population and a relatively large number of concomitant diseases requiring treatment make everyday care more difficult. It is therefore of great importance to observe the quality of care for these patients using relevant quality parameters in order to be able to derive implications for everyday treatment practice. MATERIAL AND METHODS: The data of the external inpatient quality assurance from North Rhine-Westphalia for the years 2007-2008 and 2017-2018 were analyzed and the time periods compared. In addition, based on the documented secondary diagnosis and other influencing parameters, a risk adjustment was carried out with the aid of a logistic regression model with respect to the outcomes of general and surgical complications and mortality. Both osteosynthetically and endoprosthetically treated patients were taken into account. A total of 61,249 cases were included in the study. RESULTS: Positive developments could be observed in the area of surgical complications and wound infections with decreases of 1.2% and 0.8%, respectively. Patients with cardiovascular diseases had a particularly poor outcome. Here, improvements in the subcategory of cardiovascular events were found for general complications. The mortality remained unchanged at 6%. Operative activity on the weekends increased significantly. Patients whose hospital admission was related to the weekend did not show an increased risk of complications or mortality. Although the proportion of patients who were operated on after more than 48 h was reduced from 11.4% to 8.2%, the operation (> 24 h) was still delayed in 26.8% of cases. CONCLUSION: Against the background of increasing performance demands on the healthcare system, the results document improvements in some central areas of inpatient treatment. Nevertheless, the development of strategies for the further reduction of the preoperative waiting times in a medically justifiable manner is required. Internal concomitant diseases have a decisive influence on patient outcome. Thus, an adequate treatment of the multimorbid patient collective is to be established in everyday practice on the basis of close cooperation between geriatric traumatology and geriatric internal medicine departments.

[Subtrochanteric femur fractures-epidemiology, surgical procedures, influence of time to surgery and comorbidities on complications : A risk-adjusted regression analysis of routine data from 2124 cases]. / Subtrochantäre Femurfrakturen ­ Epidemiologie, Operationsverfahren sowie Einfluss der präoperativen Verweildauer und von Nebendiagnosen auf Komplikationen : Eine risikoadjustierte Regressionsanalyse mittels Routinedaten anhand von 2124 Fällen.

BACKGROUND: There are approximately 12,000 subtrochanteric femur fractures in Germany per year with a rising trend but studies about the epidemiology and the surgical outcome are rare. Furthermore, there are no guidelines from expert societies and there is no adequate quality assurance. OBJECTIVE: Presentation of the epidemiology and the current treatment situation with respect to the patient collective, comorbidities, time to surgery and surgical procedures used as well as the identification of modifiable risk factors with respect to complications. MATERIAL AND METHODS: Analysis of routine data based on an established data model in 2124 cases. The descriptive statistics contain data on basic patient characteristics, such as age, comorbidities, surgical procedure, time to surgery and mortality. In the analytical statistics the impact of risk factors (surgical procedure, time to surgery etc.) on the endpoints mortality, complications and decubitus was investigated by logistical regression analyses. RESULTS: Of the patients 55% were operated on within the first 24h. Intramedullary osteosynthesis (89%) is the most frequently used surgical method (prostheses 2%, extramedullary procedures 5%). Within the first postoperative year 37% of the patients received a higher level of care, where the care was moved from outpatient to inpatient treatment. The mortality in the first postoperative year was 26%, while early complications were observed in 6%. A delay in surgical treatment was associated with an increased mortality and intrinsic factors, which were difficult to influence. Intramedullary osteosynthesis had the lowest mortality and revision rates. CONCLUSION: Concerning the epidemiological data, the patient collectives of subtrochanteric fractures and femoral neck or pertrochanteric fractures were very similar. Major delays in the time to surgery of subtrochanteric fractures can be associated with increased complication rates and mortality. Therefore, programs to prevent older patients from falling have a high priority.

[Osteosynthetic treatment of proximal femoral fractures: the timing of treatment is delayed in cases of pre-existing anticoagulation : Results of the data of external inpatient quality assurance from North Rhine-Westphalia with 24,786 cases within the framework of using secondary data]. / Proximale osteosynthetisch versorgte Femurfrakturen: Der Versorgungszeitpunkt verzögert sich bei vorbestehender Antikoagulation : Ergebnisse der Daten der externen stationären Qualitätssicherung aus Nordrhein-Westfalen mit einer Fallzahl von 24.786 Fällen im Rahmen sekundärer Datennutzung.

BACKGROUND AND OBJECTIVE: Proximal femoral fractures are common in Germany with approximately 100,000 affected patients per year. The mortality could be considerably reduced by timely treatment (<24 h). The objectives of this work were to demonstrate the prevalence of anticoagulation and associated complications in osteosynthetically treated proximal femoral fractures, the impact of anticoagulation on the preoperative period and potential optimization of perioperative anticoagulation management. MATERIAL AND METHODS: External quality control data for North Rhine-Westphalia for the years 2015-2016 were evaluated. Only cases in which a femoral fracture near the hip joint was treated osteosynthetically were analyzed. A total of 24,786 cases of femoral fractures near the hip joint were included in the study. RESULTS: In the largest subgroup with acetylsalicylic acid (ASS) medication (n = 4005) 17% underwent delayed surgery, in the second largest group with vitamin K antagonists (VKA, n = 2157) 44.6% underwent delayed surgery and in the third largest group with direct oral anticoagulant (DOACs) medication (n = 994) 18.2% underwent delayed surgery. CONCLUSION: The biggest potential of shortening the preoperative period can be found in the ASS and vitamin K antagonist subgroups (17% and 44.6% delayed surgery, respectively). The antagonization of the effect of VKA can be achieved within a short time by the administration of prothrombin complex (PPSB). Even when taking DOACs, the current common procedure of delayed surgical treatment must be critically questioned. A coagulation management should be established in the SOP. In addition to medical interventions (administration of antidotes), structures must be created that enable prompt care.

[Quality in Revision Arthroplasty: A Comparison between Claims Data Analysis and External Quality Assurance]. / Ergebnisqualität in der Revisionsendoprothetik: Eine Analyse von Routinedaten mit dem Vergleich zur externen Qualitätssicherung.

BACKGROUND: External quality assurance for revisions of total knee arthroplasty (TKA) and total hip arthroplasty (THA) are carried out through the AQUA institute in Germany. Data are collected by the providers and are analyzed based on predefined quality indicators from the hospital stay in which the revision was performed. The present study explores the possibility to add routine data analysis to the existing external quality assurance (EQS). Differences between methods are displayed. The study aims to quantify the benefit of an additional analysis that allows patients to be followed up beyond the hospitalization itself. MATERIAL AND METHODS: All persons insured in an AOK sickness fund formed the population for analysis. Revisions were identified using the same algorithm as the existing external quality assurance. Adverse events were defined according to the AQUA indicators for the years 2008 to 2011.The hospital stay in which the revision took place and a follow-up of 30 days were included. For re-operation and dislocation we also defined a 365 days interval for additional follow-up. The results were compared to the external quality control reports. RESULTS: Almost all indicators showed higher events in claims data analysis than in external quality control. Major differences are seen for dislocation (EQS SD: 1.87 vs. claims data [cd] SD: 2.06 %, cd+30 d: 2.91 %, cd+365 d: 7.27 %) and reoperation (hip revision: EQS SD: 5.88 % vs. claims data SD: 8.79 % cd+30 d: 9.82 %, cd+365 d: 15.0 %/knee revision: EQS SD: 3.21 % vs. claims data SD: 4.07 %, cd+30 d: 4.6 %, cd+365 d: 15.43 %). Claims data could show additional adverse events for all indicators after the initial hospital stay, rising to 77 % of all events. CONCLUSIONS: The number of adverse events differs between the existing external quality control and our claims data analysis. Claims data give the opportunity to complement existing methods of quality control though a longer follow-up, when many complications become evident.

[One-year outcomes for proximal femoral fractures: Posthospital analysis of mortality and care levels based on health insurance data]. / Einjahresverläufe nach proximalen Femurfrakturen: Poststationäre Analyse von Letalität und Pflegestufen durch Kassendaten.

BACKGROUND: Proximal femur fractures are common and treatment is expensive. The aim of the present study was - after matching of hospital and health insurance data - to evaluate the influence of early operation on certain outcome parameters. Data from a German health insurance were used to identify then influence of the day of operation after admittance on the rate of mortality, decubitus, and revision surgery during the hospital stay and on the care level of the patients up to 1 year and in some cases longer after operation. MATERIALS AND METHODS: In all, 7905 patients were included. The descriptive data, specifying the given population, described the hospital stay (occurrence, surgical procedures, early complications, secondary diagnoses, length of stay) and the course of patient recovery up to 1 year after the hospital stay (care level, late complications). The calculated data (analytical statistics) give correlations evaluating the influence of the length of the preoperative hospital stay on the outcome parameters mentioned above. Risk adjustment was performed by using secondary diagnoses. RESULTS: The study included more women (mean age 81.5 years). Most common was the femoral neck fracture. Of the operations 77% were carried out on the first day after admission; dominating procedures were intramedullary nails and prostheses. Most common secondary diagnoses were diabetes, dementia, ischemic heart disease, and chronic heart insufficiency. Descriptive data revealed 6% early as well as late complications. In all, 50% of patients had a higher care level after operation. Almost 40% of patients changed from outpatient care to inpatient care. The time interval between admission and operation negatively influenced all outcome parameters. The relative risk to die, to develop decubitus, or to receive early revision was increased by approximately one third when patients were operated on later than the first day after admission. A total of 3172 patients died during the study period. Mortality after operation reached 9.9% within 30 days and 26.9% at 1 year. The mortality of patients operated after the first day was increased by more than 6% compared to patients treated within the first 24 h. CONCLUSION: The present study clearly presents the importance of analysis of routine records after discharge and it demonstrates that longer periods up to 1 year and more can be evaluated. The data show that a longer time period between hospital admission and operation negatively influences all outcome parameters. The care data give impressive evidence for a significant loss of quality of life and the importance of intense postoperative rehabilitation.

[More patients in a shorter inpatient stay with better outcome in treatment of femoral neck fracture: external quality assurance in Westfalia-Lippe on 50,354 patients]. / Mehr Patienten in kürzerer Zeit bei besserer Qualität in der Behandlung der Schenkelhalsfraktur : Externe chirurgische Qualitätssicherung in Westfalen-Lippe an über 50.354 Patienten.

BACKGROUND: We show a comparison between two patient groups of the inpatient population suffering from femoral neck fractures registered in the external quality assurance between 1993 and 1997 and between 2005 and 2009. RESULTS: The comparison between two patient groups showed the following developments: an increase in patient numbers per year from 4,229 to 5,842 where the average age remained constant but the proportion of elderly patients over 70 years old increased; the period of hospitalization was clearly shorter (from 27 days to 18 days); an increase in comorbidities (according to the ASA classification) with simultaneous decrease of the complication rate (from 11.1% to 7.6%). The inhospital mortality remained constant at 5.3%. At the same time the number of hospitals which treat patients with femoral neck fractures decreased from 166 to 150. Concurrently the number of patients per hospital and year increased from 23.6 to 41.3 cases. CONCLUSION: The technique of operative treatment changed and while during the 1990s many patients with femoral neck fractures were treated by implanting a total endoprosthesis, in the 2000s treatment was dominated by the hemi prosthesis. During the two periods of study use of the osteosynthesis technique decreased. In conclusion, the study showed an obvious compression of performance in trauma surgery but despite everything there was a clear improvement of treatment quality with respect to complication rates.

[Medial femoral neck fractures: possible reasons for delayed surgery. Part 2: Results of data from external inpatient quality assurance within the framework of secondary data evaluation]. / Mediale Schenkelhalsfraktur: mögliche Gründe für eine verzögerte operative Versorgung. Teil 2: Ergebnisse der Daten der externen stationären Qualitätssicherung im Rahmen sekundärer Datennutzung.

PROBLEM: In Germany a disproportionate number of patients with a femoral neck fracture still experience a delay in surgery. In 2008 delays of more than 48 h after admission occurred for 15.4 % of patients. This leads to increases in surgical and general complications as well as pressure sores. OBJECTIVE: Possible reasons that lead to delayed operations were investigated in a nationwide study. DATA AND METHODS: Using nationwide data from the German inpatient external quality assurance program from the year 2008 the reasons for performing operations later than 48 h after hospital admission were examined both exploratory and analytically using a multiple logistic regression model considering combined effects. RESULTS: Surgery was more frequently delayed for patients who were admitted to hospital on Friday or Saturday, patients with a higher American Society of Anesthesiologists (ASA) classification, men, patients with malignant diseases, in the presence of infectious diseases and patients with heart disease. Operations carried out within the first 48 h were more frequent with displaced fractures and in the presence of hypertension or mental illness. The volume per hospital had no consistent effect on the time delay of surgery. During the week no significant differences between the departments were detected. On Friday or Saturday surgery was delayed more often when patients were admitted to a department of general surgery than to a department of trauma surgery or orthopedics. CONCLUSIONS: There are medical and non-medical reasons for delayed surgery of femoral neck fractures. Studies have confirmed that delayed surgery for femoral neck fracture harms the patients. Organizational reasons which prevent an immediate operation, e.g. admission on Friday or Saturday, should therefore be eliminated by improvements in hospital organization and staffing. These can be measures of individual hospitals or of several hospitals in cooperation. The target should be to ensure a comprehensive and timely provision of the highest quality care even at the weekend.

[Pertrochanteric fractures. What impact do surgical timing and implant choice have on the outcome?]. / Pertrochantäre Frakturen. Welchen Einfluss haben Operationszeitpunkt und Implantatwahl auf das Outcome?

Pertrochanteric fractures are grouped together with femoral neck fractures to represent the most frequent femur fractures in the region of the hip joint and usually occur in elderly people with preexisting conditions. Analysis of the data from the 2004/2005 quality assurance program of North Rhine-Westphalia shows, just as is the case for medial femoral neck fractures, that not only does delayed management increase risk-adjusted general and surgical complications but also mortality.

[The influence of timing of surgery on mortality and early complications in femoral neck fractures, by surgical procedure: an analysis of 22,566 cases from the German External Quality Assurance Program]. / Einfluss des Operationszeitpunkts und -verfahrens auf Mortalität und Frühkomplikationen der Schenkelhalsfraktur : Eine Analyse von 22.566 Fällen der verpflichtenden externen Qualitätssicherung.

BACKGROUND: The current S2 guideline recommends treatment of a femoral neck fracture within the first 24 h; this becomes evident by the significant rise in general and early surgical complications, when the surgical treatment was delayed for more than 48 h. The influence of different surgical procedures was investigated. PATIENTS UND METHODS: A total of 22,566 records from the external Quality Assurance Program in North Rhine-Westphalia for treatment of femoral neck fractures in 2004/2005 (BQS specification 7.0 and 8.0) were risk-adjusted and evaluated. RESULTS: Surgery was performed within 48 h in 83.9% of the patients. A significant rise in general and early surgical complications was registered when the surgical treatment was delayed for more than 48 h. Mortality and general complications were significantly lower for percutaneous screw fixation. All kinds of joint replacement show significantly higher general and surgical complications. CONCLUSION: The analyzed data support the rating of femoral neck fracture as requiring the intervention of urgent early surgery, as stated in the guideline. Percutaneous screw fixation can be considered for immobile and multimorbid patients with undislocated fractures. Advantages of total hip replacement compared to hemiarthroplasty cannot be supported by the QS-NRW data.

[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.

[Minimal provider volume in total knee replacement : an analysis of the external quality assurance program of North Rhine-Westphalia (QS-NRW)]. / Mindestmengen in der Kniegelenkendoprothetik : Analyse der externen Qualitätssicherung für das Land Nordrhein-Westfalen.

BACKGROUND: A minimal provider volume for total knee replacement (TKR) was introduced in 2006. Does this lead to an improvenment in quality or not? The records of treatment in the compulsory external quality assurance program of the Land of North Rhine-Westphalia (QS-NRW) were evaluated. METHOD: A total of 125,324 comparable records from the QS-NRW program were available to determine the appearance of general and surgical complications. In a logistical regression model the risk factors age, gender, ASA classification, comorbidity and duration were taken into account. RESULTS: A significant reduction could only be shown for pneumonia, thrombotic events and lung embolisms as well as vascular injury. In 2006 and 2007 malpositioning of implants was significantly higher and from 2005 to 2008 the number of fractures rose compared to 2004. Deep infections and reoperations did not change significantly during the whole study period. CONCLUSION: This evaluation could not show an improvement in quality due to the minimal provider volume. Thus the minimal provider volume should not be taken into account as a main criterion to improve quality. Further outcome studies and creating an arthroplasty register in Germany are more useful.

[Quality assurance using routine data. Is outcome quality now measurable?]. / Qualitätssicherung mithilfe von Routinedaten. Ist ergebnisqualität ab jetzt messbar?

Health service quality in Germany can be shown by the data from the external quality assurance program (BQS) but as these records are limited to the period of in-hospital stay no information about outcome after discharge from hospital can be obtained. Secondary routine administrative data contain information about long-term outcome, such as mortality, subsequent revision and the need for care following surgical treatment due to a hip fracture.Experiences in the use of secondary data dealing with treatment of hip fractures from the BQS are available in our department. In addition we analyzed routine administrative data from the health insurance companies Knappschaft Bahn-See and AOK in a cooperative study with the WidO (scientific institute of the AOK). These routine data clearly show a bias because of poor quality in coding as well as broad interpretation possibilities of some of the ICD-10 codes used.Consequently quality assurance using routine data is less valid than register-based conclusions. Nevertheless medical expertise is necessary to avoid misinterpretation of routine administrative data.

[Medial hip neck fracture: influence of pre-operative delay on the quality of outcome. Results of data from the external in-hospital quality assurance within the framework of secondary data analysis]. / Mediale Schenkelhalsfraktur: Einfluss des Versorgungszeitpunkts auf die Ergebnisqualität. Ergebnisse der Daten der externen stationären Qualitätssicherung im Rahmen sekundärer Datennutzung.

PROBLEM: According to international and national studies and clinical guidelines, patients with medial hip neck fracture should receive surgery as soon as medically reasonable after hospitalization, preferably within 48 h. Analysis of the German quality registry data of 2006 showed, however, that in 13 out of the 16 federal states less than 85% of patients were operated on within 48. Delayed surgery was found especially during the weekend. OBJECTIVE: The objective of the study was to examine whether German data confirm that a short preoperative waiting time after hip fracture improves the outcome. The study was commissioned by the Federal Joint Committee (G-BA) and was jointly performed by the German Society for Accident Surgery (DGU) and the National Institute for Quality in Healthcare (BQS). DATA AND METHODS: The analysis is based on the data of the nationwide quality registry of the years 2004-2006. Out of a total of 129,075 patients with a medial hip neck fracture 22,171 received operative treatment later than 48 h after hospital admission. Comparable study groups were constructed with the help of a propensity score (1-to-1 matching). Study and control groups only differed in terms of delay of surgery. The comparison concerning the outcomes was made with the Fisher exact test (bilateral). RESULTS: In the group of patients with a delay of surgery longer than 48 h significantly higher rates of surgical complications (OR 1.10), general complications (OR 1.09) and pressure ulcers (1.27) were observed (all p<0.001). The in-hospital mortality showed no significant difference (OR 0.96, p=0.302). CONCLUSIONS: Patients with medial hip neck fracture should receive operative treatment without delay, if no medical contra-indications for immediate surgery. In particular appropriate organizational measures should be taken to ensure an early surgical treatment even during weekends.

[Quality of care after distal radius fracture in Germany. Results of a fracture register of 1,201 elderly patients]. / Die stationäre Behandlungsqualität der distalen Radiusfraktur in Deutschland: Ergebnisse eines Frakturregisters mit 1201 älteren Patienten.

BACKGROUND: This study is the first to document the quality of inpatient care provided to elderly patients with distal radius fracture in Germany. PATIENTS AND METHODS: Inpatient care provided to 1,201 patients age 65 or older with isolated distal radius fracture was documented in a prospective cohort study conducted at 242 acute care clinics in Germany between January 2002 and September 2003. RESULTS: The median patient age was 75, and nearly 90% of patients were female. Approximately 71% of patients were classified as ASA I or II, and 28% were ASA III. The most common comorbidity was arterial hypertension (60%). Seventy-five percent of patients were admitted on the day of the accident; of these, 63% had surgery on the same day, and 20% on the following day. The primary form of anaesthesia was general anaesthesia (55%). The predominant fracture management procedure was percutaneous K-wire osteosynthesis (56% of cases), followed by plate osteosynthesis (44%). The length of hospital stay after plate osteosynthesis (median 8.5 days) was more than twice as long as after K-wire osteosynthesis (median 4 days). The rate of postoperative complications typical of each procedure was around 10%. Roughly 90% of patients were discharged to home. Although evidence of osteoporosis was observed in 62% of women and 50% of men, only 7.9% of patients were prescribed osteoporosis-specific medication. CONCLUSIONS: Unexpected findings were the predominance of general anaesthesia and percutaneous K-wire osteosynthesis. Osteoporosis, affecting a majority of elderly women, is neglected in clinical practice. Good quality of care is reflected by the low rate of complications.

[Guideline compliance in hip fracture: results of an external quality-assurance program in North Rhine Westphalia: 2003-2005]. / Leitlinienkonforme Versorgung: Hüftgelenknahe Fraktur: Auswertung der QS-Daten NRW 2003 bis 2005.

BACKGROUND: Whereas the Scottish guidelines are audited annually, nobody evaluates guideline compliance in Germany. Thus, can external quality assurance data pursuant to section 137 of the German Social Code Book V be suitable for auditing guideline compliance? MATERIALS AND METHODS: From North Rhine Westphalia, a total of 48,831 cases of femoral fractures near the hip joint were evaluated. Compliance with the guidelines was determined based on preoperative hospital stay, thrombosis, and antibiotic prophylaxis. Guideline rationale was reviewed in terms of mortality and thromboembolism rate. RESULTS: Sixty-four percent of the interventions were performed in a timely manner. Thrombosis prophylaxis was given in 99% of cases. Antibiotics were given as a single shot. There was no connection between mortality and thromboembolism rates or time to surgery. CONCLUSION: Guideline compliance is similar in German and Scotland. The external quality assurance data are suitable for evaluating guideline compliance. The literature recommends a short time to surgery. Given the short observation period, it was not possible to demonstrate any improvement in outcomes.

[Influence of operation time point on the frequency of early complications after surgical femoral neck fracture treatment]. / Frühkomplikationen nach Versorgung der Schenkelhalsfraktur. Einfluss des Operationszeitpunktes -- Analyse von 30.254 Fällen der externen Qualitätssicherung in Westfalen-Lippe.

AIM: The current publication deals with surgically treated medial and lateral femoral neck fracture of patients aged 60 and older. MATERIAL/METHODS: All patients were evaluated who received operative treatment between day of trauma and day 14 after trauma. Therefore, 30,254 patients (77,44%) were included. All early complications observed during hospital treatment were recorded as general and special complications, and we calculated whether the day of operation influenced the occurrence of early complications. Statistically significant differences were gained for revision operations. RESULTS: If the primary operation was performed on days 2 to 3 or 4 to 5 after trauma, fewer revisions necessary. Similar results were gained for revisions due to seroma and haematoma or postoperative bleeding. In these cases, fewer revision operations were performed when primary treatment was achieved on day 2 or 3. CONCLUSIONS: From the data presented, it is postulated that early complications provide no decisive reason for treating femoral neck fracture as an emergency. However, considering late complications such as the rate of femoral head necrosis, treatment for retaining the femoral head should be performed as early as possible. German guidelines suggest early but not emergency treatment in case of operations not saving the femoral head. Emergency operation within 6 h is not mandatory.

[Are there relevant minimum procedure volumes in trauma and orthopedic surgery?]. / Gibt es relevante Mindestmengen in der unfallchirurgischen und orthopädischen Chirurgie?

INTRODUCTION: The introduction of minimum surgical volumes aimed at improving the quality of care is currently the subject of controversial debate. One relevant issue is whether the data from external quality assurance can be used to predict outcomes that justify the introduction of minimum surgical volumes. METHOD: Analysis was carried out on the procedures total knee replacements (arthroplasties) (TKA) and femoral neck fractures (FNF). A total of 31,657 data records from North Rhine Westphalia (2002/2003) were included in TKA evaluation. The data records provided by the External Quality Assurance Department of the General Medical Council, Westphalia Lippe (from 1993 to 2000) were merged with data compiled between 2001 and 2004 by the German National Quality Assurance Center (BQS) in a survey conducted in North Rhine Westphalia. A total of 49,928 cases were analyzed. The analysis aimed to determine any connections between number of cases and outcome quality. RESULTS: No connection between outcome quality and number of cases was postulated for TKA in terms of general complications such as cardiovascular events, pneumonia, pulmonary embolism and thrombosis. By contrast, the incidence of specific complications secondary to TKA (wound infections, abscesses, hematomas and postoperative bleeding) was much rarer in hospitals with high case volumes. The trend noted in the overall group may appear a contrary one when the individual departments and hospitals are considered. No connection was established for FNF outcomes. DISCUSSION: In line with reports in the literature, it can be presumed that a connection exists between outcome quality and surgical volume for TKA. However, no threshold value can be deduced on the basis of current outcome data. Debate continues as to whether the introduction of minimum surgical volumes might be economically motivated and how minimum surgical volumes might impact healthcare structures. Lastly, it is discussed whether or not diagnostic related groups (DRG) inherently lead to a concentration of services that would make the introduction of minimum surgical volumes superfluous.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

[Atypical HHS-syndrome--a rare differential diagnosis of circulatory disorders of the hand]. / Das atypische Hypothenar-Hammer-Syndrom--eine seltene Differenzialdiagnose der akralen Durchblutungsstörung der Hand.

We report on an acral circulatory disorder of the hand, representing a Hypothenar-Hammer-Syndrome (HHS) with atypical symptoms. The patient suffered from a radial circulatory disorder of his right hand, clinically representing a secondary M. Raynaud. The symptoms occurred after a single severe trauma of the right hand and after using both hands like a hammer. Angiography showed a cork-screw sign of the A. ulnaris at the typical area and an open Arcus palmaris superficialis as well as occlusions of multiple finger arteries. Symptoms improved significantly after lysis. The most important differential diagnosis is endangiitis obliterans according to angiography. If symptoms occur again, histology is recommended to exclude vasculitis. Surgery should be discussed if the HHS is confirmed, since a cork-screw morphology of the A. ulnaris exists as well as perfusion of the fingers mainly via the A. ulnaris. Also a radial circulatory disorder of the hand combined with typical anamnesis may represent a HHS.