[Do We Need more Volunteer Work in Medicine? Project Examples from Trauma Surgery]. / Brauchen wir mehr Ehrenamt in der Medizin? Projektbeispiele aus der Unfallchirurgie.

The nursing shortage, legal requirements, and funding deficits have led to increasingly poor patient care in German hospitals.Volunteer patient companions offer support by conversing with and caring for patients. This can work to relieve hospital staff while diminishing patients' fears/worries.Volunteer companions visited selected lonely and thus, delirium-prone patients in hospital wards and spent approximately one hour with patients conversing, playing, reading aloud, or mostly listening. A surgical escort service was also offered. Patients met the escort one day in advance. The escort then accompanied the patient to the operating room and later from recovery back to the ward. Transition companions were assigned to provide support after discharge. They contacted patients prior to discharge and assisted patients in organizing their home environment as well as continued social and medical care.From 1 July 2017 until 1 April 2023, 12000 patient companions were provided in 14 wards of 4 hospitals. Using a German school grading system (1 to 6, with 1 as the optimum), the volunteers' evaluation of their success averaged 1.3, and the patients' assessments averaged 1.2. Since November 2020, 120 surgery escorts were carried out by volunteers in trauma surgery. These were so successful that we now also make a comparable offer with a family member for all older patients. Since 2022, 30 transition companions have successfully supported patients at home in a pilot project.Volunteering in and around the hospital offers important support to older and single patients while relieving the hospital medical staff. It is a "win-win-win-win situation" for patients, volunteers, staff, and management.

Comparative outcome of different treatment options for fragility fractures of the sacrum.

BACKGROUND: Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. METHODS: Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. RESULTS: Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. CONCLUSIONS: Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]. / Sakrale Fragilitätsfrakturen: Risikofaktoren und Ergebnisse nach Zementsakroplastie.

BACKGROUND: The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP). PATIENTS AND METHODS: 68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X­ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality. RESULTS: The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement. CONCLUSION: FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin­D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.

[Clinical outcome and revenue situation after conservative, interventional and surgical/osteosynthetic treatment of sacral insufficiency fractures]. / Klinisches Outcome und Erlössituation nach konservativer, interventioneller und chirurgischer/osteosynthetischer Behandlung von sakralen Insuffizienzfrakturen.

BACKGROUND: Insufficiency fractures of the sacrum are being detected increasingly more frequently, whereby their incidence will no doubt increase further as a result of the rise in life expectancy. OBJECTIVE: The clinical appearance of sacral insufficiency fractures, the treatment approach taking into account the clinical outcomes and the DRG proceeds are discussed on the basis of clinical examples. PATIENTS AND METHODS: Three female patients (average age 78.3 years) with sacral insufficiency fractures were admitted for inpatient treatment due to increasing disabling pain. Taking into account the clinical symptoms and the recommendation of an interdisciplinary case conference, one patient was treated conservatively with short-term bed rest, accompanying analgesic medication and pain-adapted exercise measures. The second patient underwent computed tomography (CT)-guided balloon sacroplasty. Transsacroiliac screw fixation was performed on the third patient. Pain was documented over the course on a visual analogue scale (VAS) and the degree of independence on the Barthel scale. The fractures were classified according to Denis et al. and the classification of the FFP according to Rommens and Hofmann. The DRG revenue for the 2020 accounting period was then presented for each case. RESULTS: Patient No. 1: conservative therapy, unilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 4 score points, the Barthel scale increased from 55 to 75 points. After 6 days hospitalization, transferred to rehab. The DRG proceeds were €â€¯3817.95. Patient No. 2: balloon sacroplasty, bilateral Denis 1-2 fracture zone, corresponding to an FFP type IIa, baseline pain 9 score points, at discharge 2 score points, the Barthel scale increased from 35 to 95 points. After 4 days hospitalization, discharged to outpatient follow-up treatment. The DRG proceeds were €â€¯7409.44. Patient No. 3: osteosynthesis, bilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 2 score points, the Barthel scale increased from 40 to 90 points. After 5 days hospitalization, transferred to rehab. The DRG proceeds were €â€¯6714.30. CONCLUSION: The sacral insufficiency fracture is a strong indicator for the presence of manifest osteoporosis. Fracture risk factors are the female sex, advanced age, the presence of osteoporosis and vitamin D deficiency. Conservative therapy is the first step of the treatment cascade; however, in patients with persistent, disabling pain and no potential for mobilization, sacroplasty or osteosynthesis should be performed at an early stage. In patients treated with coordinated therapy processes and without clinical complications, all three treatment options are economically sufficient.

Community Service as Patients' Tutor to Avoid Delirium. / Ehrenamtliche Patientenbegleiter zur Delirvermeidung.

BACKGROUND: Today, nearly two thirds of inpatients in trauma surgery hospitals are over 70 years old and at significant risk for comorbidities. These patients frequently suffer delirium. Delirium occurs in 15 - 30% of these trauma patients and increases the risk of mortality in up to 15 - 25% of cases. Conversation, attention, and activity significantly reduce this risk. OBJECTIVES: Thus, the Centre for Geriatric Traumatology and the District Seniors Council have initiated a new project of a visiting service, to prevent delirium and anxiety conditions in elderly inpatients. Volunteers from the welfare program offer daily care for selected patients. METHODS: They care for and interact with the patients for approximately one hour per day. They accompany the patients in the hospital and during mobilization, explain, read aloud, converse, or simply listen, and thus provide calm, support, and company. The attendants are volunteers who have been previously trained by the clinic, who regularly attend team meetings and draw up reports from each admission. All patients and relatives are informed prior to these visits and are notified with an accompanying letter. There are structured visiting plans for each week. RESULTS: From July 17 to May 19, 4031 patients in our clinic and in three other hospitals have been accompanied in the program. None of the patients suffered delirium. The patients and attendants found the care very good and personally satisfying. Evaluations of the volunteers for the success of their work, using the German school-grading system, was an average 1.3. Noticeable was the markedly reduced frequency of patient calls to nursing, who were thus relieved. Travel expenses and insurance costs for the volunteers were reimbursed. CONCLUSION: In times of skilled labour shortages, patient support provided by volunteer patient attendants enables innovative care for patients at risk for delirium. The assistance of the attendants alone reduced the workload on the nursing staff.

Surgical and Non-surgical Treatment of Vertebral Fractures in Elderly. / Operative und konservative Behandlung von Wirbelfrakturen im Alter.

Demographic development in Germany has led to an aging of the population. Particularly for these patients, osteoporosis-induced vertebral fractures represent a significant decrease in quality of life and level of activity. According to current guidelines, the initial treatment of stable osteoporotic vertebral fractures is conservative management with analgesic, anti-osteoporotic, physical therapy, and orthotic measures as first line options. Personal experience, however, suggests that patients benefit from timely surgical treatment through rapid improvement of pain symptoms and thus, more rapid mobilization. The poor bone quality of elderly patients presents the treating spine surgeon a challenge in achieving stable spinal fusion with or without support, for example, through augmentation. Minimally invasive procedures have increasingly established themselves for such purposes in recent years. With over 1000 fracture treatments in the last 3.5 years, we have developed a differentiated treatment concept depending on patient age and fracture morphology, which we would like to introduce. Unstable fractures with posterior edge involvement are stabilized from posterior with a percutaneous fixator. Patients over 60 years were treated percutaneously with a polyaxial screw system. Increased stability was achieved by PMMA cement augmentation of the fenestrated screws. In elderly patients with Magerl A3 fractures without neurologic deficit, the index vertebra is supplementally treated with kyphoplasty (hybrid treatment). In acute, stable osteoporotic vertebral fractures with severe pain despite analgesics, we perform kyphoplasty, which is possible even in high thoracic fractures to T3 with smaller balloons and thinner trocars. Vertebroplasty is another option in the lumbar and lower thoracic spine. Because of invasiveness, extended posterior-anterior correction procedures are generally avoided in this population, which has frequent multiple comorbidities.

[Innovative New Evacuation Concept with Emergency Mattresses]. / Innovatives neues Evakuierungskonzept mit Rettungsmatratzen.

INDICATION: In-hospital patients with limited mobility are extremely vulnerable in cases of emergency or fire. In the past, several large fires in multi-story hospitals have resulted in deaths. METHODS: For this reason, we have developed an evacuation mattress that incorporates the functions of an evacuation towel with the comfort of a normal mattress. The retention and fixation belts are protected and hidden by the washable mattress cover and can be reached by zippers in case of emergency. One person can pull the patient from the bed, along the hallway, and through the stairwell without injury. The entire mattress costs approximately 80 - 90 € more than a normal mattress. In the meantime, all beds of our six hospital group have been equipped with these mattresses. CONCLUSION: Rapid rescue can thus be facilitated with a complete system.

[Foreign Material-Free Anterior Cruciate Ligament Repair with Hamstring Graft, Felmet Technique]. / Fremdmaterialfreie vordere Kreuzbandersatzplastik mit Hamstring-Transplantat nach Felmet.

Rupture of the anterior cruciate ligament (ACL) is a common sports injury. Shear forces can damage the articular cartilage and lead to early osteoarthritis. Ligamentary stabilisation of the knee is necessary. Today, arthroscopic ACL repair is a standard knee procedure. Transplant fixation is often performed using implants, e.g. interference screws. The foreign material-free procedure using the Felmet technique enables biological, mechanically stable fixation of the hamstring tendon graft. We demonstrate the surgical technique, including meniscus suture and a video case study.

[Venous Paravasation After Augmentation of Pedicle Screws - An Underestimated Risk]. / Venöse Paravasate nach Augmentation von Pedikelschrauben ­ ein unterschätztes Risiko.

Cement-augmented pedicle screws can increase the stability of fixators for unstable vertebral fractures in the elderly. Fixators can be inserted quickly and with minimally invasive techniques, reducing surgical risks. From March 2012 until July 2014, we treated 40 patients with percutaneous augmented fixators for unstable vertebral fractures. Average age was 77.5 years. During the six month observation period, no patients died. There were no neurological deficits. On VAS, average pain decreased from 8.5 to 4.1 points postoperatively. The average Cobb angle of 4.1° was improved after surgery. After 6 months, bony consolidation yielded angles of 1 to 4°, average 2.6°. There was often venous extravasation of cement leaking from the augmented vertebrae, even extending to pulmonary embolism. The emboli were usually asymptomatic. We report a case where the patient required resuscitation immediately after cement application because of pulmonary emboli. The patient survived because of the immediately implemented critical care measures. Little has been published about this risk, which is underestimated despite increasing numbers of augmented fixator operations. The risk can be reduced with slower cement injection, smaller cement applicators, and short term positive pressure ventilation with PEEP.

Hemiprosthesis for Femoral Neck Fractures in the Elderly: A Retrospective Study of 319 Patients.

BACKGROUND: In geriatric patients with Pauwels types II and III femoral neck fractures, hemiprosthesis is the therapy of choice. OBJECTIVES: This study was conducted to analyze the results after cemented hemiprosthesis placement, the first year after surgery. PATIENTS AND METHODS: This retrospective study was conducted on 319 patients over 70 years with displaced femoral neck fractures treated surgically at our hospital from 2007 to 2012. All medical information was available including retrospective posthospital discharge records as well as inpatient course and one-year mortality. RESULTS: From a total of 319 patients, 78% (n = 249) were female and 22% (n = 70) were male, with the mean age of 83.6 years. Seventeen percent of the patients suffered from heart failure, 23% from diabetes, and 19% from renal insufficiency. Time to surgery averaged one day postinjury. Average operative time skin-to-skin was 50 minutes. Seventy-three percent of the patients could mobilize independently on discharge. Of the remaining patients, 2/3 had already lost independent mobilization prior to the fracture. Hospital mortality averaged 5% (national average in Germany: 8%), and 30-day and 90-day mortality rates were 5% and 15%, respectively. Within one year, 22% of the patients died (national average: 27%). Also, 14 patients were re-admitted, for contralateral prosthetic implantation (n = 7) or revision after the periprosthetic fracture (n = 5). Fifty-three percent of the patients were admitted to hospital during the year for other diseases (national average: 54%). CONCLUSIONS: Hemiprosthesis placement for displaced femoral neck fractures is a common and safe procedure. Despite recent decreases in hospital mortality, the risk of death remains more than twice as high within one year than that for uninjured patients of the same age.

Anatomy of the clavicle and the intramedullary nailing of midclavicular fractures.

Intramedullary fixation is used increasingly to treat clavicular fractures. Anatomical variations in the clavicle of relevance to this procedure are analyzed. The length, diameters and curvature of the clavicle were measured in 196 specimens from the dissecting room. The calcium bone density was analyzed in 300 cross-sectional samples of 100 specimens. The thickness of cortical and medullary bone of 70 slices was analyzed from freshly plastinated clavicles with implants in place. The female clavicle was shorter, less curved, and had a lower concentration of calcium than the male clavicle. Measurement of cortical thickness showed a mean value of 1.05 +/- 0.23 mm at the most sternal measuring point, 2.05 +/- 0.29 mm at the midpoint of the clavicle, and 0.95 +/- 0.35 mm at the acromial end. The thinnest regions were the medial ventral cortex and the dorsal acromial cortex. These measurements explain clinical observations on nail perforation. The diameter of the medullary canal measured 6.7 +/- 2.6 mm at its narrowest part, so that reaming (i.e., predrilling the medullary canal) prior to 3.5 mm titanium nail insertion is not necessary. The main difficulties encountered when placing a nail are secondary to the S-curvature of the clavicle. In 80% of fractures, the break is located at the narrowest diameter of the medullary canal. Thus, the clavicle displays definite gender- and side-specific anatomical features in terms of length, diameter, curvature, and calcium concentration. These should be considered when performing intramedullary fixation.

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation.

OBJECTIVE: An experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint. METHOD: Anatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically. RESULTS: Healing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position. CONCLUSION: Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Biodegradable implants versus standard metal fixation for displaced radial head fractures. A prospective, randomized, multicenter study.

This multicenter, prospective, randomized study compares the use of biodegradable polylactide pins with standard metal mini-fragment implants for the treatment of displaced radial head fractures. It compares complication rates and clinical outcomes of both treatment methods. At 2 years, 135 (82%) of 164 patients were available for evaluation. Equivalence of treatment method was defined as a difference of 10% or less in the number of complication-free patients. Functional status was assessed by using the Broberg and Morrey Elbow Score and compared by an unpaired t test. Good or excellent clinical results were achieved by 92% (56/61) of the control patients and 96% (71/74) of the polylactide patients. The incidence of complication-free patients was 3.7% less in the polylactide group than in the control group. The 1-sided 95% confidence interval for the treatment difference between the 2 groups was more than -6.1%. Biodegradable polylactide pins have at least comparable outcomes as standard metal implants for the internal fixation of reconstructable displaced radial head fractures.

Augmentation of intraarticular calcaneal fractures with injectable calcium phosphate cement: densitometry, histology, and functional outcome of 18 patients.

Eighteen patients with intraarticular calcaneal fractures treated with open reduction and internal fixation and augmentation with an injectable carbonated apatite cement. Functional follow-up studies using the Zwipp Foot Score and densitometry were performed at 6-month intervals postoperatively. Histological samples of biopsies obtained at the time of hardware removal (6 months postoperatively) were also analyzed. The use of bone cement led to intermediate-term functional outcomes that were no better than those reported with conventional surgical procedures using bone graft. Patients demonstrated postoperative difficulties similar to those seen in other studies of this fracture, including pain, subtalar motion restrictions, peroneal impingement, and difficulties on uneven terrain and with toe- and heel-walking. However, compared to patients treated surgically without injectable carbonated apatite cement, full weight bearing on the affected extremity was regained at an average 4 weeks postoperatively. In addition, autogenous bone graft was not required to fill the osseous defect using this technique, minimizing morbidity and discomfort. During the present observation period of 3 years, only a slight decrease in the density of the peripheral zones of the cement block was observed. Histological examination revealed fibrous bone formation resulting from remodelling processes. Complete resorption and remodeling of the bone cement were not complete at 3 years. One patient developed a postoperative wound infection. Another displayed cement loosening secondary to failure of bony ingrowth.

Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children.

This prospective study investigated medium-term outcomes for 51 children treated from 1997 to 2001 for displaced diaphyseal forearm fractures with elastic stable intramedullary nailing. Forty-three patients included achieved excellent/good functional results at an average follow-up of 38 months. Four patients required open fracture-manipulation at surgery. Complications included eight cases of soft-tissue irritation at nail-insertion site (three required shortening procedures), two temporary radial nerve branch injuries, four minimal rotational mobility deficits, one 10 degrees elbow extension deficit after splinting, and five small keloid scars. All patients were pain-free, without limitations in activities for daily life or sport/play activities by 12 months after hardware removal. Elastic stable intramedullary nailing is appropriate therapy for these injuries.