[Orthopedic surgery in Dhulikhel, Nepal]. / Unfallchirurgie in Dhulikhel/Nepal.

Nepal is one of the 20 poorest countries in the world. Thus, medical care in Nepal is dependent on significant medical and financial commitment from within and outside the country. Dhulikhel Hospital - Kathmandu University Hospital (DH-KUH) was founded in 1996 by Prof. Dr. Ram and colleagues. Collaboration and support of many people and institutions are, in contrast to the experience in other hospitals of the third world, characterized by an extraordinary sustainability. The reason for this is the spirit lived according to the motto "best service for the poor". The structures in DH-KUH are influenced by a very close cooperation with a number of international (university) hospitals. Most of the DH-KUH departments have an amazingly high technical standard. Assuming this development and progress can be continued, a splendid future for DH-KUH can be predicted.

[Pretreatment mass casualty incident workflow analysis : Comparison of two level 1 trauma centers]. / Prätherapeutische Ablaufanalyse bei einem Massenanfall von Verletzten : Vergleich von zwei Traumazentren der höchsten Versorgungsstufe.

BACKGROUND: Mass casualty incidents (MCI) have particularly high demands on patient care processes but occur rather rarely in daily hospital routine. Therefore, it is common to use simulations to train staff and to optimize institutional processes. OBJECTIVES: Aim of study was to compare the pre-therapeutic in-house workflow of two differently structured level 1 trauma sites in the case of a simulated mass casualty incident (MCI). MATERIALS AND METHODS: A MCI of 70 patients was simulated by actors in a manner that was as realistic as possible. The on-site triage assigned 7 cases to trauma site A with relatively long in-house distances and 4 patients to an independent trauma site B in which these distances were relatively short. During in-house treatment, time intervals for reaching milestones were measured and compared using the Mann-Whitney U test. RESULTS: As no simultaneous patient arrival occurred, the Patient Distribution Matrix proved to be effective. Site A needed more time (minutes) from admission to endpoints (A: 31.85 ± 7.99; B: 21.62 ± 4.76; p = 0.059). In detail, the time intervals were particularly longer for both patient stay in trauma room (A: 8.46 ± 3.02; B: 2.73 ± 0.78, p < 0.01) and transfer time to the CT room (A: 1.81 ± 0.62; B: 0.06 ± 0.03, p < 0.01). A shorter stay in the CT room did not compensate these effects (A: 8.86 ± 1.84; B: 10.40 ± 2.89, p = 0.571). For both sites, image calculation and distribution were relatively time consuming (17.36 ± 3.05). CONCLUSIONS: Although short in-house distances accelerated pretherapeutic treatment processes significantly, both sites remained clearly within the "golden hour". The strongest potential bottleneck was the time interval until images were available at the endpoints.

[Long-term survival after severe trauma]. / Langzeitüberleben nach schwerem Trauma.

Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.

[Relevance of Vascular Trauma in Trauma Care - Impact on Clinical Course and Mortality]. / Bedeutung des Gefäßtraumas für die Schwerverletztenversorgung ­ Einfluss auf Verlauf und Mortalität.

There is a lack of evidence as to the relevance of vascular trauma (VT) in patients with severe injuries. Therefore, we reviewed registry data in the present study in order to systematically objectify the effect of VT in these patients. This study aimed to provide an adequate picture of the relevance of vascular trauma and to identify adverse prognostic factors. In a retrospective analysis of records from the TraumaRegister DGU® (TR-DGU) in two subgroups with moderate and severe VT, we examined the records for differences in terms of morbidity, mortality, follow-up and prognostic parameters compared to patients without VT with the same ISS. From a total of 42,326 patients, 2,961 (7 %) had a VT, and in 2,437 cases a severe VT (AIS ≥ 3) was diagnosed (5.8 %). In addition to a higher incidence of shock and a 2 to 3-fold increase in fluid replacement and erythrocyte transfusion, patients with severe VT had a 60 % higher rate of multiple organ failure, and in-hospital mortality was twice as high (33.8 %). The massively increased early mortality (8.0 vs. 25.2 %) clearly illustrates how severely injured patients are placed at risk by the presence of a relevant VT with a comparable ISS. In our opinion, due to an unexpected poor prognosis in the TR-DGU data for vascular injuries, increased attention is required in the care of severely injured patients. Based on our comprehensive analysis of negative prognostic factors, a further adjustment to the standards of vascular medicine could be advisable. The influence of the level of care provided by the admitting hospital and the relevance of a further hospital transfer to prognosis and clinical outcome is currently being analysed.

[Arthroscopic tibiotalocalcaneal arthrodesis]. / Arthroskopische Rückfußkorrekturarthrodese.

Tibiotalocalcaneal arthrodesis (TTCA) is indicated for a variety of disorders, including end-stage osteoarthritis, severe deformities and complications after operative interventions on the upper and lower ankle joints. Due to the biomechanical advantages, TTCA is predominantly performed with curved retrograde intramedullary nails allowing compression before locking. Hindfoot arthrodesis is most commonly performed by extensive open surgical approaches. Despite a patient satisfaction rate greater than 80 %, current reviews have reported mean complication rates of more than 50 % with a pronounced variance in bone union rates. This is influenced by the sometimes severe preexisting diseases in this patient collective. A predictive risk assessment for complications following TTCA revealed a significantly increased risk in the presence of diabetes mellitus, revision surgery or preoperative ulceration. In these high-risk patients, a reduction of the invasiveness of the procedure could possibly reduce the complication rates. Arthroscopic TTCA therefore appears to be a promising alternative approach. Even though only few case reports and one case series have been published, in the total collective of 17 patients only one subtalar non-union and one minor complication were reported. Despite the limited evidence available, arthroscopic TTCA appears to be a promising therapy option in patients with an increased risk profile and comorbidities, such as critical soft tissue situations, plantar ulceration, peripheral arterial occlusive disease (PAOD) and diabetes mellitus.