[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.

[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.

In vivo comparison of bioactive glass particles in rabbits.

Bioglass particles of the compositions 45s5, 52s and 55s were implanted in the distal femoral epiphysis of rabbits. Animals were sacrificed at 7, 28, and 84 d postoperatively and specimens investigated using light microscopy and histomorphometry. Bone bonding occurred in a zentripetal fashion and fastest for 45s5. Bone formation was hampered at the core of the implantation bed where bone bonding showed a peak at 28d and diminished at 84d (except for 55s). This went along with a significant increase in numerous multinuclear giant cells (MNGC). Implantation model, particle size and surface-area-to-volume ratio are discussed as possible parameters determining bone regeneration.

Nanoapatite and organoapatite implants in bone: histology and ultrastructure of the interface.

This article reports on the reaction of bone to a new family of nanocrystalline hydroxyapatite biomaterials with crystal sizes similar to those of human bone. Pure nanoapatite cylinders and organoapatite cylinders containing a synthetic nanopeptide were analyzed 28 days after implantation into the spongy bone of Chinchilla rabbits. The experimental techniques used for analysis were light microscopy, scanning electron microscopy, and transmission electron microscopy. Both implant types were well incorporated, and interface events were found to be similar to those observed on human bone surfaces with regard to resorption by osteoclast-like cells and bone formation by osteoblasts. Different types of giant cells were observed resorbing the outermost surfaces of implants. There seemed to be both dissolution of the implant and particulate biodegradation leading to less dense implant regions near the interface, whereas the bulk of the implants remained denser. Transmission electron micrographs revealed that bone bonding occurred with and without an afibrillar intervening layer. Given the biologic reaction observed, these implant materials should be suitable for bone replacement and the organoapatite form could be useful for additional functions such as the release of drugs and optimized release of antibiotics, growth factors, or other substances. The organic component can also be used to control physical properties in a bony implantation bed.

Effect of titanium implants on primary mineralization following 6 and 14 days of rat tibial healing.

The effect of pure commercial titanium implants on the process of primary mineralization was studied. This was examined by insertion of titanium implants into rat tibial bone after ablation. The effects of the titanium were studied through the behaviour of extracellular matrix vesicles (MV). Methods of morphometric analysis at the TEM level were applied. The insertion of titanium implants was followed by an increase in the number of MV as well as vesicular diameter and by a decrease in vesicular distance from the calcified front when compared to normal healing. These results suggest that the process of MV maturation around titanium implants was delayed when compared to normal primary bone formation during bone healing. The delay in mineralization was compensated by an increase in vesicle production, resulting in an enhancement of primary mineralization by the titanium.

Effect of glass ceramic and titanium implants on primary calcification during rat tibial bone healing.

The effect of bone bonding (KG Cera, Mina 13, and titanium) and nonbone bonding (KGy-213, M 8/1) implants on primary calcification in endosteal bone was examined by comparing changes in the morphometry of matrix vesicles to those occurring during normal bone healing following ablation of rat tibial marrow. The concentration of matrix vesicles, their diameter, and their distance from the calcification front were determined using computerized cytomorphometry at the transmission electron microscopic level. The results demonstrated that bone bonding materials supported an increase in matrix vesicle concentration when compared with control bone at 6 and 14 days postimplantation. At 14 days, there were fewer matrix vesicles in the bone adjacent to the nonbonding implants. Though matrix vesicle diameter decreased in the control bone between 6 and 14 days, it increased in all of the experimental samples. Diameters were significantly greater in the bone bonding samples at 14 days and significantly lower in the nonbonding samples at 6 days. Distance from the calcification front decreased between 6 and 14 days in all groups except in bone adjacent to the KGy-213 implants. In bone adjacent to the bone bonding implants, distance from the calcification front was comparable to or further than that of control bone; in the nonbonding samples it was closer to the calcification front. These results demonstrate that production and maturation of matrix vesicles is influenced in a differential manner by the presence of implant materials.

Histological and ultrastructural observations at the interface of expanded polytetrafluorethylene anterior cruciate ligament implants.

Anterior cruciate ligament (ACL) grafts made from expanded polytetrafluorethylene (ePTFE) were examined after failure (n = 7; 3 instabilities, 2 partial ruptures, and 2 complete ruptures) to provide information about secondary fixation mechanisms via ingrowth of the different tissues. The ultrastructural evaluation clearly evidenced the existence of two main interface areas of ePTFE ACL-replacement: First, in areas without a dense cellular infiltrate there was interdigitating collagen producing a dense ePTFE-collagen network. Additionally, in a few areas of the graft/bone-tunnel interface a fibrous cartilage or bone regenerate could be demonstrated to be in contact with the prosthesis. Second, there was a dense infiltration of macrophages and multinuclear giant cells, partially containing birefringent material of implant origin, with and without a neosynovia-like reaction product, indicating a disturbance of tissue integration of the prosthesis. In areas of inflammation there was no bone development and only few collagen interdigitation with the graft material. This study provides further knowledge about mechanisms of secondary graft fixation due to tissue ingrowth. The interdigitation of collagen fibers and ePTFE filaments provides interfaces which should be at least partially resistant against load.

Incorporation and degradation of hydroxyapatite implants of different surface roughness and surface structure in bone.

The interface of dense hydroxyapatite (HA) implants with different surface roughness was investigated after implantation into the spongy bone of the distal femur of rabbits by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) following transverse fractures in the interface. Each implant displayed considerable changes in surface morphology caused by leaching (increasing pore diameter), corrosion (particulate disintegration), and active resorption by osteoclasts. Macrophages were involved in "cleaning" the surface via phagocytosis of loose implant particles. Newly formed surface elevations provided adhesion points for fibers and fibrils. Subsequent mineralization of these areas stabilized the interdigitation of surface elevations and extracellular matrix with adhering fibers and contributed to the tensile strength in the interface. This investigation provides further knowledge about HA implants, which seem to be partially resorbed by osteoclast-like cells.

The interface of calcium-phosphate and glass-ceramic in bone, a structural analysis.

Bone bonding (BB) glass-ceramics and hydroxyapatite (HA) materials displayed considerable changes in their surface morphology after implantation which seem to be due to leaching, corrosion and active resorption by osteoclasts. Macrophages seem to play a central role in 'cleaning' and conditioning of the implant surface. Projections of the surface of BB glass-ceramics and HA serve as adhesion points for fibrillar structures. Thereafter, mineralization of fibres and interfibrillar spaces mediates and biomechanically stabilizes the interdigitation between surface elevations of implant and organic fibres and provides a tensile strength in the interface. Non-bonding (NB) glass-ceramic lacks considerable changes of surface morphology and displays a prolongated settlement of macrophages on their surfaces.