Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fractu... more Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fracture patients undergoing intensive-care unit (ICU) treatment, including invasive ventilatory management (IVM) and hemodiafiltration (CVVHDF), is sparse. Methods. Single-center prospective observational study including 402 geriatric hip-fracture patients. Age, gender, the American Society of Anesthesiologists (ASA) classification, and the Barthel index (BI) were documented. Underlying reasons for prolonged ICU stay were registered, as well as assessed procedures like IVM and CVVHDF. Outcome parameters were in-hospital, 6-month, and 1-year mortality and need for nursing care. Results. 15% were treated > 3 days and 68% < 3 days in ICU. Both cohorts had similar ASA, BI, and age. In-hospital, 6-month, and 12-month mortality of ICU > 3d cohort were significantly increased (p = 0.001). Most frequent indications were cardiocirculatory pathology followed by respiratory failure, renal impairment, and infection. 18% of patients needed CVVHDF and 41% IVM. In these cohorts, 6-month mortality ranged > 80% and 12-month mortality > 90%. 100% needed nursing care after 6 and 12 months. Conclusions. ICU treatment > 3 days showed considerable difference in mortality and nursing care needed after 6 and 12 months. Particularly, patients requiring CVVHDF or IVM had disastrous long-term results. Our study may add one further element in complex decision making serving this vulnerable patient cohort.
New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from ... more New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from biomechanical changes induced by cementation. Fact or fiction? The reported incidences for new vertebral fractures after cementation or after conservative therapy vary widely. This is mainly due to differences in their design, more specifically as to the duration of followup. Therefore a systematic review of the literature was performed, searching for comparable publications to assess the potential risk of new vertebral fractures following vertebroplasty and kyphoplasty versus conservative treatment. Studies were only included if they granted a standardized one-year radiological follow-up, so improving comparability. However, a high degree of heterogeneity was still seen among the results, which made it impossible to state that cement augmentation is as safe as conservative treatment with respect to new fractures. In other words, it was impossible to separate facts from fiction with the studies available to-day. The combined odds ratio of vertebroplasty and kyphoplasty versus conservative treatment, namely 0.96, gave a hint that there might be little difference. Large scale randomized studies will be necessary.
OBJECT The treatment of traumatic burst fractures unaccompanied by neurological impairment remain... more OBJECT The treatment of traumatic burst fractures unaccompanied by neurological impairment remains controversial and ranges from conservative management to 360° fusion. Because of the heterogeneity of fracture types, classification systems, and treatment options, comparative biomechanical studies might help to improve our knowledge. The aim of the current study was to create a standardized fracture model to investigate burst fractures in a multisegmental setting. METHODS A total of 28 thoracolumbar fresh-frozen human cadaveric spines were used. The spines were dissected into segments (T11-L3). The T-11 and L-3 vertebral bodies were embedded in Technovit 3040 (cold-curing resin for surface testing and impressions). To simulate high energy, a metallic drop tower was designed. Stress risers were used to ensure comparable fractures. CT scans were acquired before and after fracture. All fractures were classified using the AO/OTA classification. RESULTS The preparation and embedding of the spine segments worked well. No repositioning or second embedding of the specimen, even after fracture, was required. It was possible to create single burst fractures at the L-1 level in all 28 spine segments. Among the 28 fractures there were 16 incomplete burst fractures (Type A3.1), 8 burst-split fractures (Type A3.2), and 4 complete burst fractures (Type A3.3). The differences before and after fracture for stiffness and for anterior, posterior, and central heights were all significant (p < 0.05). CONCLUSIONS The ability to create reproducible burst fractures of a single vertebral body in a thoracolumbar spine segment may serve as a basis for future biomechanical studies that will provide better understanding of mechanical properties or fixation techniques.
Patients with Parkinson's disease (PD) have a hei... more Patients with Parkinson's disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures. A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors. A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p > 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038). PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.
The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Close... more The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Closed reduction and percutaneous fixation with cannulated sacroiliac screws is well-established in the operative treatment of osteoporotic posterior pelvic ring fractures. However, osteoporotic bone quality might lead to the risk of screw loosening. For this reason, cement augmentation of the iliosacral screws is more frequently performed and recommended. The aim of the present biomechanical study was to evaluate the primary stability of three methods of iliosacral screw fixation in human osteoporotic sacrum specimens. This study used methodical cadaver study. A total of 15 fresh frozen human cadaveric specimens with osteoporosis were used (os sacrum). After matched pair randomization regarding bone quality (T-score), three operation technique groups were generated: screw fixation (cannulated screws) without cement augmentation (Group A); screw fixation with cement augmentation before screw placement (cannulated screws) (Group B); and screw fixation with perforated screws and cement augmentation after screw placement (Group C). In all specimens both sides of the os sacrum were used for operative treatment, resulting in a group size of 10 specimens per group. One operation technique was used on each side of the sacral bone to compare biomechanical properties in the same bone quality. Pull-out tests were performed with a rate of 6 mm/min. A load versus displacement curve was generated. Subgroup 1 (Group A vs. Group B): Screw fixation without cement augmentation: 594.4 N±463.7 and screw fixation with cement augmentation before screw placement: 1,020.8 N±333.3; values were significantly different (p=.025). Subgroup 2 (Group A vs. Group C): Screw fixation without cement augmentation: 641.8 N±242.0 and perforated screw fixation with cement augmentation after screw placement: 1,029.6 N±326.5; values were significantly different (p=.048). Subgroup 3 (Group B vs. Group C): Screw fixation with cement augmentation before screw placement: 804.0 N±515.3 and perforated screw fixation with cement augmentation after screw placement: 889.8 N±503.3; values were not significantly different (p=.472). Regarding iliosacral screw fixation in osteoporotic bone, the primary stability of techniques involving cement augmentation is significantly higher compared with screw fixation without cement augmentation. Perforated screws with the same primary stability as that of conventional screw fixation in combination with cement augmentation might be a promising alternative in reducing complications of cement leakage. These biomechanical results have to be transferred into clinical practice and prove their clinical value.
The relevance of proximal femoral fractures results from its high incidence and its mainly old an... more The relevance of proximal femoral fractures results from its high incidence and its mainly old and multi-morbid patient collective. Correct fracture classification is essential for a successful surgical treatment. Dependent on the fracture classification today different primary stable implants (prosthesis and osteosyntheses) are available, allowing postoperative full weight bearing of the patient. By this means a significant reduction of secondary complications related to immobilization, and therefore of mortality during inpatient stay, was achieved. The current task in care of patients with proximal femoral fractures lies in the reintegration of patients through an interdisciplinary organization of a smooth, geriatric oriented aftercare. Additionally underlying osteoporosis has to be treated. In this context a good cooperation between hospitals, geriatric aftercare and physicians in private practice is essential.
New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from ... more New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from biomechanical changes induced by cementation. Fact or fiction? The reported incidences for new vertebral fractures after cementation or after conservative therapy vary widely. This is mainly due to differences in their design, more specifically as to the duration of followup. Therefore a systematic review of the literature was performed, searching for comparable publications to assess the potential risk of new vertebral fractures following vertebroplasty and kyphoplasty versus conservative treatment. Studies were only included if they granted a standardized one-year radiological follow-up, so improving comparability. However, a high degree of heterogeneity was still seen among the results, which made it impossible to state that cement augmentation is as safe as conservative treatment with respect to new fractures. In other words, it was impossible to separate facts from fiction with the ...
There is no consensus about whether isolated anterior cruciate ligament reconstruction using mult... more There is no consensus about whether isolated anterior cruciate ligament reconstruction using multistrand hamstring tendon with nonoperative treatment for chronic medial collateral ligament injury is sufficient. To assess clinical outcome for patients with chronic anterior cruciate ligament injury and accompanying grade II valgus laxity who received medial hamstring anterior cruciate ligament reconstruction alone. Results were compared with those of patients with isolated chronic anterior cruciate ligament injury without valgus laxity. Cohort study; Level of evidence, 2. Two hundred eighty-nine patients with isolated anterior cruciate ligament injury were compared with 53 patients with accompanying valgus laxity (minimum follow-up, 24 months). The following parameters were compared between the 2 groups at the last follow-up: range of motion, KT-1000 arthrometer value, pivot-shift test result, Lysholm knee scale, knee extensor muscle strength, return to sporting activities, subjective recovery, and International Knee Documentation Committee grade. Differences in clinical outcome were evaluated between those with preoperative International Knee Documentation Committee grade B and grade C and between those with grade A and grade B or C at final evaluation. Postoperative KT-1000 arthrometer value averaged 1.2 mm for those with isolated anterior cruciate ligament injury and 1.6 mm for those with accompanying valgus laxity (not significant, P = .281). There was no significant difference between these 2 groups regarding the other items. In patients with preoperative valgus laxity, KT-1000 arthrometer values at final evaluation between patients with preoperative grade B and C were not significantly different. The value for subjects with grade A at final evaluation was 1.3 mm and for those with grade B or C at final evaluation was 2.7 mm (P = .065). There was no clinically significant difference regarding outcome of anterior cruciate ligament multistrand hamstring reconstruction alone for 90% of patients with grade II valgus laxity who regained medial stability with nonoperative management compared with those who underwent the same anterior cruciate ligament reconstruction for an isolated anterior cruciate ligament tear.
The quality of medical education is an ongoing challenge due to the continuing changes of the hea... more The quality of medical education is an ongoing challenge due to the continuing changes of the health-care politics and general social conditions. At many German university hospitals the dominating picture is overfilled courses, lack of hands-on practice, reduced patient contact and the dull provision of theoretical, abstract knowledge. The reformed surgical curriculum at the University of Marburg university hospital is used to demonstrate that, in spite of large student numbers, a practice-oriented, small-group training at a high didactic level is possible. The surgical training courses are organized in detail and coordinated. Course contents and structure are media available in print and online versions for both students and teachers and thus fulfill not only transparency needs but also contemporary requirements. The strategy of a practice- and patient-oriented, small-group training is followed strictly in the surgical curriculum. In addition, accompanying tutorial possibilities for individual study in an up-to-date learning center are offered. Here the students have the opportunity to intensify knowledge acquired in previous or future courses with numerous attractive education means. Continuous evaluation of the individual training courses at the end of each semester not only document motivation of the students but also serve to continuously improve the training concepts.
The treatment of osteoporotic vertebral fractures by means of kyphoplasty is an accepted and safe... more The treatment of osteoporotic vertebral fractures by means of kyphoplasty is an accepted and safe procedure. In Germany the reimbursement for kyphoplasty and vertebroplasty differs greatly. The growing diversity of suppliers and systems makes a comparison possible and necessary. Besides the illustration of kyphoplasty in the German diagnosis-related group (G-DRG) system and the amendments for 2012 we analyzed the procedures and associated costs. Using the example of two manufacturers and different system approaches, both of which can be charged as kyphoplasty, we try to point out the importance of selecting exact comparison parameters. In particular material and treatment costs are compared for both methods.
Dementia and geriatric cognitive disorders, Jan 21, 2015
To examine the influence of cognitive impairment on the functional outcomes and complication rate... more To examine the influence of cognitive impairment on the functional outcomes and complication rates of patients with hip fracture during in-patient treatment. A total of 402 patients who were surgically treated for hip fractures were consecutively enrolled at a single trauma center. The patients were grouped according to their results on the Mini-Mental State Examination (MMSE), i.e., ≥20 points (group I) and ≤19 points (group II). Complication and in-hospital mortality rates as well as postoperative functional outcomes according to the Barthel Index (BI) were compared between the groups. A multivariate regression analysis was performed to control for additional factors. 33% of the patients had MMSE scores ≤19 points. The complication rates were similar between the groups (p > 0.05). Likewise, the overall in-hospital mortality rates were similar between the patients in group I (4.5%) and those in group II (9.8%; β = 0.218, p < 0.740). Functional outcomes, as assessed by the BI,...
For many type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more For many type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Alonzo classification), a double anterior screw fixation is performed. If screw disruption occurs, the location is most often at the anterior caudal endplate and body of the axis and not directly at the fracture line. The authors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; objective was to determine the differences in primary mechanical stability at 2 insertion points used in ventral screw fixation of type II fractures of the C-2 dens. Screw fixation was performed on 16 formalin-fixed human C-2 dens specimens. The specimens were divided into 2 groups. For group 1, the screws were inserted directly at the anterior lower endplates; for group 2, the screws were inserted 2 mm dorsal to the anterior wall of the vertebral body. After a type II odontoid fracture was created with an oscillating saw, screw fixation was performed using two 3.5-mm partially threaded lag screws with washers. Subsequently, each vertebral body was continuously loaded. The criterion for breakage was reversal of the force vector. In group 1, screw disruption occurred at the point of entry; the mean load failure was 290.5 ± 106 N. In group 2, no screw disruption occurred; the mean load failure was 574.2 ± 170.5 N. These results were significant (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). For double screw fixation of type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Alonzo classification), placement of the screws as far dorsal to the anterior lower endplate as possible seems to favorably affect primary stability. In actual clinical practice, care should be taken to not damage the anterior wall of the vertebral body of the axis during screw insertion.
Vitamin K antagonists are often used for anticoagulant treatment in hip fracture patients. The op... more Vitamin K antagonists are often used for anticoagulant treatment in hip fracture patients. The optimal handling with such anticoagulants is unclear. We aimed to determine when anticoagulation reversal occurred after vitamin K administration and how often prothrombin complex concentrates (PCCs) were administered. We compared patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; treatments and outcomes with those of a control group not receiving treatment for anticoagulation. A total of 402 geriatric hip fracture patients were included in this observational study. We collected data on treatment for anticoagulation, time to surgery, and reasons for delay of surgery. In patients taking vitamin K antagonists, we measured the INR (international normalized ratio) on admission and prior to surgery, along with the frequency of PCC administration. Finally, we compared in-hospital mortality and complications between patient groups. A total of 62 (15%) patients received phenprocoumon prior to their fractures. Surgery was delayed in these patients compared to controls (27h; 95%CI 23-31 vs. 16h; 95%CI 19-19; p=0.001), but surgery delay &amp;amp;amp;amp;amp;amp;amp;amp;gt;48h (n=5; 8%) was not due to a failure of INR reversal. The main reason for these delays was a lack of capacity for surgery. The average INR on admission was 2.1 (±0.7; range 1.0-3.5) in patients taking phenprocoumon, which decreased to 1.3 (±0.3; range 1.0-1.6) until surgery. PCCs were administered to 19% of patients. We found no differences in the in-hospital mortality (6.2% vs. 8.1%, p=0.575) or complication rates (12.9% vs. 9.4%, p=0.364). The use of vitamin K seemed to be sufficient for anticoagulation reversal in geriatric hip fracture patients, and it generally led to timely surgery; despite this success, PCCs were sometimes administered for logistical reasons.
As a part of aging, hip fractures are becoming more common. The connection between increased pain... more As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients&amp;amp;amp;amp;#39; pain levels during the prehospital phase of treatment and prehospital analgesic therapy. We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department. Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P &amp;amp;amp;amp;lt; 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092). Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief.
Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fractu... more Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fracture patients undergoing intensive-care unit (ICU) treatment, including invasive ventilatory management (IVM) and hemodiafiltration (CVVHDF), is sparse. Methods. Single-center prospective observational study including 402 geriatric hip-fracture patients. Age, gender, the American Society of Anesthesiologists (ASA) classification, and the Barthel index (BI) were documented. Underlying reasons for prolonged ICU stay were registered, as well as assessed procedures like IVM and CVVHDF. Outcome parameters were in-hospital, 6-month, and 1-year mortality and need for nursing care. Results. 15% were treated &amp;amp;amp;amp;amp;amp;gt; 3 days and 68% &amp;amp;amp;amp;amp;amp;lt; 3 days in ICU. Both cohorts had similar ASA, BI, and age. In-hospital, 6-month, and 12-month mortality of ICU &amp;amp;amp;amp;amp;amp;gt; 3d cohort were significantly increased (p = 0.001). Most frequent indications were cardiocirculatory pathology followed by respiratory failure, renal impairment, and infection. 18% of patients needed CVVHDF and 41% IVM. In these cohorts, 6-month mortality ranged &amp;amp;amp;amp;amp;amp;gt; 80% and 12-month mortality &amp;amp;amp;amp;amp;amp;gt; 90%. 100% needed nursing care after 6 and 12 months. Conclusions. ICU treatment &amp;amp;amp;amp;amp;amp;gt; 3 days showed considerable difference in mortality and nursing care needed after 6 and 12 months. Particularly, patients requiring CVVHDF or IVM had disastrous long-term results. Our study may add one further element in complex decision making serving this vulnerable patient cohort.
New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from ... more New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from biomechanical changes induced by cementation. Fact or fiction? The reported incidences for new vertebral fractures after cementation or after conservative therapy vary widely. This is mainly due to differences in their design, more specifically as to the duration of followup. Therefore a systematic review of the literature was performed, searching for comparable publications to assess the potential risk of new vertebral fractures following vertebroplasty and kyphoplasty versus conservative treatment. Studies were only included if they granted a standardized one-year radiological follow-up, so improving comparability. However, a high degree of heterogeneity was still seen among the results, which made it impossible to state that cement augmentation is as safe as conservative treatment with respect to new fractures. In other words, it was impossible to separate facts from fiction with the studies available to-day. The combined odds ratio of vertebroplasty and kyphoplasty versus conservative treatment, namely 0.96, gave a hint that there might be little difference. Large scale randomized studies will be necessary.
OBJECT The treatment of traumatic burst fractures unaccompanied by neurological impairment remain... more OBJECT The treatment of traumatic burst fractures unaccompanied by neurological impairment remains controversial and ranges from conservative management to 360° fusion. Because of the heterogeneity of fracture types, classification systems, and treatment options, comparative biomechanical studies might help to improve our knowledge. The aim of the current study was to create a standardized fracture model to investigate burst fractures in a multisegmental setting. METHODS A total of 28 thoracolumbar fresh-frozen human cadaveric spines were used. The spines were dissected into segments (T11-L3). The T-11 and L-3 vertebral bodies were embedded in Technovit 3040 (cold-curing resin for surface testing and impressions). To simulate high energy, a metallic drop tower was designed. Stress risers were used to ensure comparable fractures. CT scans were acquired before and after fracture. All fractures were classified using the AO/OTA classification. RESULTS The preparation and embedding of the spine segments worked well. No repositioning or second embedding of the specimen, even after fracture, was required. It was possible to create single burst fractures at the L-1 level in all 28 spine segments. Among the 28 fractures there were 16 incomplete burst fractures (Type A3.1), 8 burst-split fractures (Type A3.2), and 4 complete burst fractures (Type A3.3). The differences before and after fracture for stiffness and for anterior, posterior, and central heights were all significant (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). CONCLUSIONS The ability to create reproducible burst fractures of a single vertebral body in a thoracolumbar spine segment may serve as a basis for future biomechanical studies that will provide better understanding of mechanical properties or fixation techniques.
Patients with Parkinson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (PD) have a hei... more Patients with Parkinson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures. A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors. A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038). PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.
The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Close... more The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Closed reduction and percutaneous fixation with cannulated sacroiliac screws is well-established in the operative treatment of osteoporotic posterior pelvic ring fractures. However, osteoporotic bone quality might lead to the risk of screw loosening. For this reason, cement augmentation of the iliosacral screws is more frequently performed and recommended. The aim of the present biomechanical study was to evaluate the primary stability of three methods of iliosacral screw fixation in human osteoporotic sacrum specimens. This study used methodical cadaver study. A total of 15 fresh frozen human cadaveric specimens with osteoporosis were used (os sacrum). After matched pair randomization regarding bone quality (T-score), three operation technique groups were generated: screw fixation (cannulated screws) without cement augmentation (Group A); screw fixation with cement augmentation before screw placement (cannulated screws) (Group B); and screw fixation with perforated screws and cement augmentation after screw placement (Group C). In all specimens both sides of the os sacrum were used for operative treatment, resulting in a group size of 10 specimens per group. One operation technique was used on each side of the sacral bone to compare biomechanical properties in the same bone quality. Pull-out tests were performed with a rate of 6 mm/min. A load versus displacement curve was generated. Subgroup 1 (Group A vs. Group B): Screw fixation without cement augmentation: 594.4 N±463.7 and screw fixation with cement augmentation before screw placement: 1,020.8 N±333.3; values were significantly different (p=.025). Subgroup 2 (Group A vs. Group C): Screw fixation without cement augmentation: 641.8 N±242.0 and perforated screw fixation with cement augmentation after screw placement: 1,029.6 N±326.5; values were significantly different (p=.048). Subgroup 3 (Group B vs. Group C): Screw fixation with cement augmentation before screw placement: 804.0 N±515.3 and perforated screw fixation with cement augmentation after screw placement: 889.8 N±503.3; values were not significantly different (p=.472). Regarding iliosacral screw fixation in osteoporotic bone, the primary stability of techniques involving cement augmentation is significantly higher compared with screw fixation without cement augmentation. Perforated screws with the same primary stability as that of conventional screw fixation in combination with cement augmentation might be a promising alternative in reducing complications of cement leakage. These biomechanical results have to be transferred into clinical practice and prove their clinical value.
The relevance of proximal femoral fractures results from its high incidence and its mainly old an... more The relevance of proximal femoral fractures results from its high incidence and its mainly old and multi-morbid patient collective. Correct fracture classification is essential for a successful surgical treatment. Dependent on the fracture classification today different primary stable implants (prosthesis and osteosyntheses) are available, allowing postoperative full weight bearing of the patient. By this means a significant reduction of secondary complications related to immobilization, and therefore of mortality during inpatient stay, was achieved. The current task in care of patients with proximal femoral fractures lies in the reintegration of patients through an interdisciplinary organization of a smooth, geriatric oriented aftercare. Additionally underlying osteoporosis has to be treated. In this context a good cooperation between hospitals, geriatric aftercare and physicians in private practice is essential.
New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from ... more New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from biomechanical changes induced by cementation. Fact or fiction? The reported incidences for new vertebral fractures after cementation or after conservative therapy vary widely. This is mainly due to differences in their design, more specifically as to the duration of followup. Therefore a systematic review of the literature was performed, searching for comparable publications to assess the potential risk of new vertebral fractures following vertebroplasty and kyphoplasty versus conservative treatment. Studies were only included if they granted a standardized one-year radiological follow-up, so improving comparability. However, a high degree of heterogeneity was still seen among the results, which made it impossible to state that cement augmentation is as safe as conservative treatment with respect to new fractures. In other words, it was impossible to separate facts from fiction with the ...
There is no consensus about whether isolated anterior cruciate ligament reconstruction using mult... more There is no consensus about whether isolated anterior cruciate ligament reconstruction using multistrand hamstring tendon with nonoperative treatment for chronic medial collateral ligament injury is sufficient. To assess clinical outcome for patients with chronic anterior cruciate ligament injury and accompanying grade II valgus laxity who received medial hamstring anterior cruciate ligament reconstruction alone. Results were compared with those of patients with isolated chronic anterior cruciate ligament injury without valgus laxity. Cohort study; Level of evidence, 2. Two hundred eighty-nine patients with isolated anterior cruciate ligament injury were compared with 53 patients with accompanying valgus laxity (minimum follow-up, 24 months). The following parameters were compared between the 2 groups at the last follow-up: range of motion, KT-1000 arthrometer value, pivot-shift test result, Lysholm knee scale, knee extensor muscle strength, return to sporting activities, subjective recovery, and International Knee Documentation Committee grade. Differences in clinical outcome were evaluated between those with preoperative International Knee Documentation Committee grade B and grade C and between those with grade A and grade B or C at final evaluation. Postoperative KT-1000 arthrometer value averaged 1.2 mm for those with isolated anterior cruciate ligament injury and 1.6 mm for those with accompanying valgus laxity (not significant, P = .281). There was no significant difference between these 2 groups regarding the other items. In patients with preoperative valgus laxity, KT-1000 arthrometer values at final evaluation between patients with preoperative grade B and C were not significantly different. The value for subjects with grade A at final evaluation was 1.3 mm and for those with grade B or C at final evaluation was 2.7 mm (P = .065). There was no clinically significant difference regarding outcome of anterior cruciate ligament multistrand hamstring reconstruction alone for 90% of patients with grade II valgus laxity who regained medial stability with nonoperative management compared with those who underwent the same anterior cruciate ligament reconstruction for an isolated anterior cruciate ligament tear.
The quality of medical education is an ongoing challenge due to the continuing changes of the hea... more The quality of medical education is an ongoing challenge due to the continuing changes of the health-care politics and general social conditions. At many German university hospitals the dominating picture is overfilled courses, lack of hands-on practice, reduced patient contact and the dull provision of theoretical, abstract knowledge. The reformed surgical curriculum at the University of Marburg university hospital is used to demonstrate that, in spite of large student numbers, a practice-oriented, small-group training at a high didactic level is possible. The surgical training courses are organized in detail and coordinated. Course contents and structure are media available in print and online versions for both students and teachers and thus fulfill not only transparency needs but also contemporary requirements. The strategy of a practice- and patient-oriented, small-group training is followed strictly in the surgical curriculum. In addition, accompanying tutorial possibilities for individual study in an up-to-date learning center are offered. Here the students have the opportunity to intensify knowledge acquired in previous or future courses with numerous attractive education means. Continuous evaluation of the individual training courses at the end of each semester not only document motivation of the students but also serve to continuously improve the training concepts.
The treatment of osteoporotic vertebral fractures by means of kyphoplasty is an accepted and safe... more The treatment of osteoporotic vertebral fractures by means of kyphoplasty is an accepted and safe procedure. In Germany the reimbursement for kyphoplasty and vertebroplasty differs greatly. The growing diversity of suppliers and systems makes a comparison possible and necessary. Besides the illustration of kyphoplasty in the German diagnosis-related group (G-DRG) system and the amendments for 2012 we analyzed the procedures and associated costs. Using the example of two manufacturers and different system approaches, both of which can be charged as kyphoplasty, we try to point out the importance of selecting exact comparison parameters. In particular material and treatment costs are compared for both methods.
Dementia and geriatric cognitive disorders, Jan 21, 2015
To examine the influence of cognitive impairment on the functional outcomes and complication rate... more To examine the influence of cognitive impairment on the functional outcomes and complication rates of patients with hip fracture during in-patient treatment. A total of 402 patients who were surgically treated for hip fractures were consecutively enrolled at a single trauma center. The patients were grouped according to their results on the Mini-Mental State Examination (MMSE), i.e., ≥20 points (group I) and ≤19 points (group II). Complication and in-hospital mortality rates as well as postoperative functional outcomes according to the Barthel Index (BI) were compared between the groups. A multivariate regression analysis was performed to control for additional factors. 33% of the patients had MMSE scores ≤19 points. The complication rates were similar between the groups (p > 0.05). Likewise, the overall in-hospital mortality rates were similar between the patients in group I (4.5%) and those in group II (9.8%; β = 0.218, p < 0.740). Functional outcomes, as assessed by the BI,...
For many type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more For many type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Alonzo classification), a double anterior screw fixation is performed. If screw disruption occurs, the location is most often at the anterior caudal endplate and body of the axis and not directly at the fracture line. The authors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; objective was to determine the differences in primary mechanical stability at 2 insertion points used in ventral screw fixation of type II fractures of the C-2 dens. Screw fixation was performed on 16 formalin-fixed human C-2 dens specimens. The specimens were divided into 2 groups. For group 1, the screws were inserted directly at the anterior lower endplates; for group 2, the screws were inserted 2 mm dorsal to the anterior wall of the vertebral body. After a type II odontoid fracture was created with an oscillating saw, screw fixation was performed using two 3.5-mm partially threaded lag screws with washers. Subsequently, each vertebral body was continuously loaded. The criterion for breakage was reversal of the force vector. In group 1, screw disruption occurred at the point of entry; the mean load failure was 290.5 ± 106 N. In group 2, no screw disruption occurred; the mean load failure was 574.2 ± 170.5 N. These results were significant (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). For double screw fixation of type II fractures of the dens (Anderson and D&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Alonzo classification), placement of the screws as far dorsal to the anterior lower endplate as possible seems to favorably affect primary stability. In actual clinical practice, care should be taken to not damage the anterior wall of the vertebral body of the axis during screw insertion.
Vitamin K antagonists are often used for anticoagulant treatment in hip fracture patients. The op... more Vitamin K antagonists are often used for anticoagulant treatment in hip fracture patients. The optimal handling with such anticoagulants is unclear. We aimed to determine when anticoagulation reversal occurred after vitamin K administration and how often prothrombin complex concentrates (PCCs) were administered. We compared patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; treatments and outcomes with those of a control group not receiving treatment for anticoagulation. A total of 402 geriatric hip fracture patients were included in this observational study. We collected data on treatment for anticoagulation, time to surgery, and reasons for delay of surgery. In patients taking vitamin K antagonists, we measured the INR (international normalized ratio) on admission and prior to surgery, along with the frequency of PCC administration. Finally, we compared in-hospital mortality and complications between patient groups. A total of 62 (15%) patients received phenprocoumon prior to their fractures. Surgery was delayed in these patients compared to controls (27h; 95%CI 23-31 vs. 16h; 95%CI 19-19; p=0.001), but surgery delay &amp;amp;amp;amp;amp;amp;amp;amp;gt;48h (n=5; 8%) was not due to a failure of INR reversal. The main reason for these delays was a lack of capacity for surgery. The average INR on admission was 2.1 (±0.7; range 1.0-3.5) in patients taking phenprocoumon, which decreased to 1.3 (±0.3; range 1.0-1.6) until surgery. PCCs were administered to 19% of patients. We found no differences in the in-hospital mortality (6.2% vs. 8.1%, p=0.575) or complication rates (12.9% vs. 9.4%, p=0.364). The use of vitamin K seemed to be sufficient for anticoagulation reversal in geriatric hip fracture patients, and it generally led to timely surgery; despite this success, PCCs were sometimes administered for logistical reasons.
As a part of aging, hip fractures are becoming more common. The connection between increased pain... more As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients&amp;amp;amp;amp;#39; pain levels during the prehospital phase of treatment and prehospital analgesic therapy. We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department. Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P &amp;amp;amp;amp;lt; 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092). Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief.
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