Patient-rated long-term results after complete denervation of the wrist.

The aim of this study was to examine the long-term results after the denervation of the wrist. Between 1977 and 2001, we treated 375 patients in our clinic. The mean age was 43.5 years; 81% were male and 19% female. The long-term results were assessed by a questionnaire assessing pain on a visual analog scale and patient satisfaction and by the DASH questionnaire. After a mean follow-up of 12.23 years, we found an overall pain reduction of 52.1%. In 67.7% of the patients, we found a relief of pain: of these, 44% are free of pain until today and 56% were temporarily asymptomatic. Patients with a painful osteoarthritic condition without dynamic instability and good range of motion are ideal candidates to benefit from the denervation. The complete denervation of the wrist is an effective treatment option in patients with painful wrist conditions to reduce pain and improve the overall function.

Histological case-control study of peeling-induced skin changes by different peeling agents in surgically subcutaneous undermined skin flaps in facelift patients.

A histological evaluation of peeling-induced skin changes in subcutaneous undermined preauricular facial skin flaps of nine patients was performed. There were three treatment groups: Trichloroacetic acid (TCA) 25%, TCA 40% and phenol/croton oil; one group served as control. Two independent evaluators determined the epidermal and dermal thickness and the depth of necrosis (micrometre). The percentual tissue damage due to the peeling was calculated, and a one-sample t-test for statistical significance was performed. On the basis of the histomorphological changes, peeling depth was classified as superficial, superficial-partial, deep-partial and full thickness chemical burn. The histological results revealed a progression of wound depth for different peeling agents without full thickness necrosis. TCA peels of up to 40% can be safely applied on subcutaneous undermined facial skin flaps without impairing the vascular patency, producing a predictable chemical burn, whereas deep peels such as phenol/croton oil peels should not be applied on subcutaneous undermined skin so as to not produce skin slough or necrosis by impairing vascular patency.

[Analysis of Diagnosis Related Groups and their Impact on Health Care in Post Massive Weight Loss Surgery]. / Analyse von Fallpauschalen und deren versorgungsrelevante Effekte in der postbariatrischen Wiederherstellungschirurgie.

BACKGROUND: Diagnosis Related Groups (DRG) were introduced in Germany as a medico-economic classification system in 2004. In this analysis, we looked at restorative surgery after massive weight loss, focusing on reimbursement of this fee-per-case system in comparison to costs to deduce possible effects on health care over time. MATERIAL AND METHODS: First we analysed the algorithms for the relevant DRGs including data about length of stay and reimbursement. Furthermore, we integrated cost data from German reference hospitals of the last 5 years as well as single-centre data from a university hospital. RESULTS: Due to a diagnosis-related algorithm, coding will constantly lead to DRG K07Z. In 2016, a new diagnosis code specific to massive weight loss was introduced, which now leads to DRG J10B. As a result, reimbursement is reduced by more than half. In the cost matrix, staff, general ward, operation theatre and anaesthesia were identified as the main cost drivers. As expected, there was a statistically significant correlation between general ward costs and time of stay in hospital as well as operation theatre costs and incision-suture time. Considering the cost data of the reference hospitals, there was an average excess of EUR 781 per case whereas our own cost data revealed a deficit of EUR 1 700 to 2 700 per case. This is mainly due to the fact that approximately one third of our patient cohort underwent highly elaborate circular body lifts. CONCLUSION: It has to be questioned whether a newly introduced main diagnosis code can be applied as such without any underlying cost data having been collected in previous years. Given unchanged treatment measures, the main cost drivers identified by us remain the same, which means that there is no rationale for a drop in revenue. In addition to providing incentives for an efficient use of resources and quality optimisation, this system should offer medical service providers a sustainable and realistic possibility to break even.

[Decompression of Peripheral Nerves in the Treatment of Diabetic Polyneuropathy]. / Dekompression peripherer Nerven als Behandlungskonzept der diabetischen Polyneuropathie.

Polyneuropathy causing ulceration and amputation as a long-term consequence of diabetes mellitus is analysed for its pathophysiology, socioeconomic and medical relevance. Outcomes of decompression of peripheral nerves on the lower extremity regarding sensation, pain, development, and recurrence of ulceration, and amputation is evaluated by a systematic literature review in pubmed, medline and embase. Decompression of peripheral nerves in diabetic peripheral neuropathy seems to be a good treatment option for restoring sensation, decreasing pain, as well as for avoiding the development and recurrence of ulceration and amputation.

[Trial provision in clinical routine. Definition of terms and investigation of normal practice]. / Probestellungen im Klinikalltag. Begriffsdefinition und Untersuchung der gängigen Praxis.

BACKGROUND: It has become common for hospitals to borrow medical devices from manufacturers to test and try them during the daily routine before purchasing which today is known as trial provision. This study aims at offering a precise definition of trial provisions and a description of the way of proceeding. METHODS: A total of 60 medical practitioners in 5 German hospitals were surveyed (surgeons n = 40, 66.7 %, radiologists n = 12, 20 % and anesthesiologists n = 8, 13.3 %). Manufacturers and distributors of medical devices (n = 10) and hospital administration executives (n = 8) were also interviewed. RESULTS: Trial provisions are a promotional marketing tool for manufacturers of medical devices. By lending the device over a specific period for testing before purchasing, hospitals can gain experience in the usage and handling of devices on which a purchase decision can be made. The survey revealed that there are basically three procedural methods which can, however, differ even within one hospital. CONCLUSION: Trial provisions influence purchasing decisions in clinics. If implemented incorrectly trial provisions may compromise physical integrity, safety and health of patients and can thus lead to judicial and legal consequences for hospitals and medical staff.

[Economic profit of different injuries in a centre for hand surgery - replantation vs. amputation]. / Ökonomischer Profit von Fingerverletzungen in einem handchirurgischen Zentrum - Replantation vs. Amputation.

INTRODUCTION: The Institute for Reimbursements in Hospital (InEK) annually provides an updated DRG system to ensure the medical service providers with a cost-covering remunera-tion. However, the underlying cost data are often opaque and disclosure of the basis of calculation does not take place. On the basis of cost and revenue data from our clinic between 2010 and 2012, a profit statement for amputations and replantation of one or more fingers was employed and compared with the nationwide data of the calculation clinics. MATERIALS AND METHODS: Inpatient days, the revenue and the costs incurred in our clinic based on the cost matrix of InEK costing manual [4] were determined for amputation (DRG X05B), replantation of one (DRG X07B) and several fingers (DRG X07A). The profit was calculated as the difference between revenues and costs. Further-more, a comparison of our data with the nationwide data of InEK was applied. RESULTS: For each of the 3 DRGs the actual costs in our clinic were higher than the costs generated by InEK. Only amputation appeared profitable, while all limb-preserving interventions were associated with losses for our hospital. There was a clear discrepancy between the data of cost of InEK GmbH to the data of our clinic. CONCLUSION: In order not to create any monetary disincentives at the expense of quality of care of individual patients, a cost-covering patient care for all case groups mentioned above should be ensured. The general distrust in the InEK's data that results from such a discrepancy in the cost data can only be rebutted by increasing transparency and disclosure of the calculation basis.

[Clinical functional assessment of various surgical hand arthrodesis techniques]. / Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden.

BACKGROUND: Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis. MATERIALS AND METHODS: Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n = 43, STT fusion n = 30 and midcarpal arthrodesis n = 25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n = 21, STT fusion n = 17 and midcarpal arthrodesis n = 10). RESULTS: Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist. CONCLUSION: Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.

Severe posttraumatic radiocarpal cartilage damage: first report of autologous chondrocyte implantation.

STUDY DESIGN: Case report. CLINICAL QUESTION: Traumatic articular cartilage defects predispose to secondary osteoarthritis accompanied by impairment or complete loss of function in the corresponding joint. On this account, the timely and correct diagnosis as well as the selection of an appropriate therapy for reconstruction of articular cartilage defects is important. METHODS: A 22-year-old healthy male patient with history of traumatic intra-articular distal radius fracture is presented with in the course detectable 4° cartilage damage in the fovea scaphoidea and into the fovea lunata. For the first time, autologous chondrocyte implantation by the use of an in situ polymerizable albumin-hyaluronic acid gel was performed to restore the articular cartilage. RESULTS: The assessment 6 months after autologous chondrocyte implantation using the standard DASH questionnaire for upper extremity pointed out an improvement in the patient outcome (DASH score pre-operative: 10.8 and 6 months post-operative: 7.5). The clinical examination also showed an improvement in the range of movement of the wrist without pain. The radiological control investigation (MRI- examination) of the wrist 6 months after implantation also revealed a good integration of the implant. CONCLUSION: The case presented here demonstrates the first use of autologous chondrocyte implantation for cartilage reconstruction using an in situ polymerizable albumin-hyaluronic acid gel after traumatic cartilage lesion with 4° cartilage damage of the wrist in a 22-year-old non-smoking, active and healthy man. Initial results are promising in terms of mobility, pain and patient outcome. However, further clinical studies have to be performed with larger number of cases.

[Development of length of stay and reimbursement in elective hand surgery after the introduction of DRGs in Germany]. / Entwicklung von Verweildauer und Vergütung handchirurgischer Elektiveingriffe durch Einführung der DRGs in Deutschland.

BACKGROUND: Since its introduction in Germany, the DRG (Diagnosis-Related Groups) system is often fraught with negative connotations. Frequent points of criticism are a deterioration of patient care by decreasing length of stay (LOS) in hospital and a decline in reimbursement. The following investigation analyzes and compares the development of length of stay and reimbursement in hand surgery based on the 3 most common elective procedures. MATERIAL AND METHODS: The main diagnoses scaphoid nonunion (PSA), Dupuytren's contracture (DK) and rhizarthrosis (RIA) were evaluated for number of cases, length of stay, reimbursement per day and total reimbursement in 2000 as well as 2010 based on the data of our clinic. Patients covered by the Employers' Liability Insurance were not included. Only inpatient cases were considered. RESULTS: In PSA and RIA an increase in the number of cases is reported (PSA: +11 cases; RIA: +26 cases) and a decrease in DK ( - 7 cases). The sum of the total hospital days declined despite rising case numbers predominantly between 65 (RIA) and 260 days (DK). The average LOS decreased by 3.1 days at DK (48.4%) to 4.1 days at PSA (52.6%). Average revenues per day in 2000 amounted to 379 €, which corresponds to 442 € adjusted for inflation in 2010. Average revenue per day in 2010 was 755 € (RIA), 797 € (PSA) and 876 € (DK). Revenue per case in 2010 were only higher than in 2000, when 5 (RIA) or 6 hospital days (DK and PSA) were not exceeded. CONCLUSION: With declining revenue per case, the average income per day increased by a reduction in hospital days. A positive or at least equivalent revenue situation can thus only be achieved by a distinct concentration of labor and reduction of hospital days under the DRG-system.

Culturally competent care for members of sexual minorities.

Culture has historically been interpreted as the beliefs, mores, and lifeways of groups of people primarily related to race and ethnicity. However, individuals who self identify as being lesbian, gay, bisexual and/or transgendered experience ethnocentrism when seeking care from medical and health professionals. Using the principles and concepts of Lenninger's theory of Culture Care Diversity and Universality, members of sexual minorities can assist their health care providers to provide culturally sensitive and ethical care.