Treatment strategies for partial chronic instability of the distal syndesmosis: an arthroscopic grading scale and operative staging concept.

INTRODUCTION: The aim of this study was to evaluate three different anatomical reconstruction techniques for the partial chronic isolated instability of the syndesmosis based on own arthroscopic classification criteria. MATERIALS AND METHODS: A retrospective study was conducted to review 32 patients (15 female, 17 male; average age 41; range 18-71) with isolated partial chronic instability of the syndesmosis. During the arthroscopic examination of the patient, the instability of the syndesmosis was assessed by inserting a dissector of defined size into the distal tibiofibular joint. The lateralization of the fibula in the distal tibiofibular joint was then semi-quantitatively evaluated and classified. In all cases, open reconstructive surgery was carried out at the same time. Depending on the grading of the instability assessed arthroscopically (Grades I-III), one of three different anatomical reconstruction techniques was performed: suture of the anterior inferior tibiofibular ligament (AITFL), ligament repair using periosteal flaps, or autogenous plantaris tendon graft. Patients in all three groups were treated with a screw and an additional preassembled suture-button device. At 8 weeks after surgery, the screw was removed and full weight bearing was allowed. Clinical and radiological follow up were obtained at an average time of 17 months after surgery. Clinical evaluation of the reconstruction techniques was assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) and the Weber Score. RESULTS: The median AOFAS score was significantly higher than before surgery for all three groups. In addition, the Weber score was significantly lower in all three groups than before surgery, indicating substantial improvement. There were no complications after the arthroscopies and the reconstructive surgeries. But in two cases, suture granuloma occurred within the 17-month window, which was treated with a revision operation and removal of the suture-button device. CONCLUSION: Depending on the arthroscopic classification of the partial chronic instability of the syndesmosis, the three different anatomical reconstruction techniques potentially provide appropriate treatment options based on the grade of injury.

[Reimbursement of patients with high costs in a department of otorhinolaryngology of maximum care and refinancing by the German DRG system]. / Analyse von Patienten mit hohen Fallkosten im Patientengut einer HNO-Klinik der Maximalversorgung und ihre Refinanzierung durch das G-DRG-System.

BACKGROUND: With the introduction of a diagnosis related groups (DRG)-system in Germany, the medical analysis of the total costs of caring for a given patient is of significance. The medical identification of cost intensive patients becomes of increasing importance for the financial perspective of a department, because the averaged lump sum system might not break even these treatments. PATIENTS AND METHODS: In the Department of Otorhinolaryngology, University Ulm, a tertiary referral center, the 56 most expensive patients from 3131 inpatients which were treated in 2002 were retrospectively identified and expenses for diagnostic tests, therapy and post-operative complications were analyzed. All patients' related costs, including all costs for personnel, were assigned to a DRG (Version 1.0 G-DRG and G-DRG 2004). RESULTS: The most expensive treatments included extensive tumor surgeries, surgery of the trachea, emergency procedures and reconstructive surgery. Costs increased with complications, prolonged stay in the intensive care unit and simultaneous internal diseases. The cost at our institution for an pharynocutaneous fistula added 3000 Euro. CONCLUSION: The assignment of treatment costs to a DRG is complex. Based on our data extensive surgeries for head and neck malignancies showed a homogeneous cost distribution in the DRG group of G-DRG 2004 which was however inadequately reimbursed. Detailed prospective analyses from multiple centers to identify expensive treatments in the field of otorhinolaryngology are necessary to incorporate modifications into the German DRG-system.