[Hybrid stabilization and geriatric complex treatment of type A spinal fractures]. / Die Hybridstabilisierung und geriatrische Komplexbehandlung in der Therapie von A-Frakturen der Wirbelsäule.

Approximately 200,000 spinal fractures occur each year in Germany. The decimated stability of the vertebra often leads to type A fractures with a substantial influence by osteoporosis. A mobility preserving and gentle treatment has clear advantages compared to conservative treatment. The hybrid stabilization as a combination of minimally invasive dorsal stabilization and vertebral augmentation has become an established method. In the period from July 2014 to June 2015 a total of 205 spinal operations were documented. In the group of very old patients more than 80% were treated for a geriatric type A vertebral fracture, 24 with hybrid stabilization, 5 by percutaneous bisegmental, 22 by kyphoplasty stabilization and 13 by percutaneous polysegmental procedures. Furthermore, these 4 groups were also considered with respect to the treatment in geriatric trauma centers (GTC). The 4 forms of treatment achieved a mean remuneration of 11,238.77 €. For the individual treatment form of kyphoplasty there was an increase in the remuneration of 4276.54 €, when patients undergo geriatric complex treatment and the remuneration is according to the diagnosis-related groups (DRG) classification I34Z. In the field of operative treatment of geriatric vertebral fractures, the augmentative procedures of kyphoplasty and vertebroplasty are well-established but an injury-related involvement of adjacent spinal segments and continuity fractures are frequent occurrences so that a bisegmental hybrid stabilization is advantageous. In addition, the perioperative stress in hybrid stabilization is only negligibly longer so that hybrid stabilization and geriatric complex treatment can be recommended as the new standard in spinal surgery for the treatment of type A fractures in aged patients.

[Adjacent segment degeneration following spinal fusion of vertebral fractures in paraplegic patients]. / Anschlusssegmentdegenerationen nach Wirbelkörperfrakturen beim Querschnitt.

The effects of adjacent segment degeneration (ASD) after spinal fusion of vertebral fractures have previously not been demonstrated in patients with trauma-related paraplegia. The aim of this study was to evaluate the role of ASD in patients with paraplegia caused by vertebral fractures and to observe whether there is a difference between unilateral or combined spinal fusion in long-term results regarding the degeneration of cranial or caudal adjacent spinal segments. A total of 111 paraplegic patients with an average age of 45 years who underwent spinal fusion of vertebral fractures were observed in a retrospective longitudinal study with a follow-up period of 4 years. Conventional X­ray images and magnetic resonance imaging (MRI) scans were used to assess the ASD in the adjacent free vertebral segments cranial and caudal to the spinal fusion using the following elements: ventral spondylophytes, intervertebral space, intervertebral disc signal in MRI, posterior spondylophytes, facet joint arthrosis, bone bridging and ossification of the anterior longitudinal ligament. Additionally, the classification by the American Spinal Injury Association (ASIA) impairment scale and spinal cord independence measure version 3 score were surveyed. The 4­year incidence of radiographically detectable ASD was 3-12 % in this study. The majority of ASDs were observed in the cranial segments adjacent to the interbody fusion. The dorsoventral spinal fusion showed the least effects on the adjacent segments. In conclusion, a concept of prompt surgery using short dorsoventral segment fusion carried out by an interdisciplinary paralysis center is recommended. The role of natural degeneration processes and whether they are influenced by iatrogenic manipulation through the vertebral stabilization is unclear. For this reason it is important to further investigate strategies for ASD reduction in the future to ensure the best possible treatment success including the lowest degree of additional impairments for this special patient group.

Spondylodiscitis severity code: scoring system for the classification and treatment of non-specific spondylodiscitis.

INTRODUCTION: Established treatment options of spondylodiscitis, a rare but serious infection of the spine, are immobilization and systemic antibiosis. However, the available data for specific treatment recommendations are very heterogeneous. Our intention was to develop a classification of the severity of spondylodiscitis with appropriate treatment recommendations. MATERIALS AND METHODS: From 10/1/1998 until 12/31/2004, 37 cases of spondylodiscitis were examined regarding medical history, gender status, location and extent of spondylodiscitis, type and number of operations. Subsequently, a classification of six grades according to severity has been developed with specific treatment recommendations. The further evaluation of our classification and corresponding treatment modalities from 1/1/2005 to 12/31/2009 including further 132 cases, resulted in a classification of only three grades of severity (the SSC--spondylodiscitis severity code), with a follow-up until 12/31/2011. Between 01/01/2012 and 12/31/2013, a prospective study of 42 cases was carried out. Overall, 296 cases were included in the study. 26 conservatively treated cases were excluded. RESULTS AND CONCLUSION: The main localization of spondylodiscitis was the lumbar spine (55%) followed by the thoracic spine (34%). The classification of patients into 3 grades of severity depends on clinical and laboratory parameters, the morphological vertebral destruction seen in radiological examinations and the current neurological status. Therapies are adapted according to severity and they include a specific surgical management, systemic antibiotic therapy according to culture and sensitivity tests, physiotherapy and initiation of post-hospital follow-up. 40.6% of patients are associated with neurological deficits, classified as severity grade 3 and treated surgically with spinal stabilization and decompression. 46.9% of patients corresponded to severity grade 2, with concomitant vertebral destruction were dorsoventrally stabilized. The 31 patients of severity Grade 1 were treated surgically with dorsal stabilization. From 1998 to 2013, the time from the onset of symptoms to the first surgical treatment was about 69.4 days and has not changed significantly. However, the time from admission to surgical treatment had been reduced to less than 2 days. Also the time of hospitalization was reduced and we see positive effects regarding the sensation of pain. 270 patients underwent surgery. We treated 89% dorsally and 21% dorsoventrally. With the spondylodiscitis severity code, a classification of the severity of spondylodiscitis could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway.

[Adjuvant systemic antibiotic therapy for surgically treated spondylodiscitis]. / Die adjuvante systemische Antibiotikatherapie der operativ versorgten Spondylodiszitis.

Recognised methods for the treatment of spondylodiscitis in correspondence to the immobilisation are systemic antibiotic therapy. However, the available data for recommendations of specific antibiotic therapy are very heterogeneous. The aim of this study was to focus on the adjuvant antibiotic therapy in surgical treated cases of spondylodiscitis and to reach a guideline regarding its application in patients' spondylodiscitis. Between 01.10.1998 and 31.12.2011 276 inpatient cases of spondylodiscitis were surgically treated, documented and included in the study. The study involved medical history, germ status, localisation and extent of spondylodiscitis and antibiotic treatment. Between 01.01.2012 and 31.12.2013 a further 20 cases of spondylodiscitis were treated according to a standardised treatment regimen of antibiotic therapy and included in the study. The age distribution shows a marked prominence of 60 to 80 year-olds, with a leading localisation of spondylodiscitis in the lumbar spine with 55 % followed by the thoracic spine (33 %) and the cervical spine (12 %). A constant observation during the study periods was the delayed diagnosis of more than 1 month of spondylodiscitis, so that about 60 % of the patients were not receiving any treatment for their disease at the time of hospitalisation. The aetiology of spondylodiscitis is very heterogeneous and remained unknown in 34 % of cases. However, diabetes mellitus appeared as a disease favouring the occurrence of spondylodiscitis since it was concomitant with almost 50 % of patients with spondylodiscitis. The bacterial spectrum is limited in our area to staphylococci, with a predominance of Staphylococcus aureus. At least about 10 % of the germs are multi-drug resistant. In 45 % of cases, pathogen detection was unsuccessful. Clindamycin is the most commonly used antibiotic in the treatment of spondylodiscitis and is used in 26.8 % in combinations with other antibiotics. The antibiotic therapy is administered for at least for 3 months. The significant decrease in inflammatory markers in the course of treatment shows the positive response of patients to therapy. The recommendations for antibiotic treatment of spondylodiscitis are very heterogeneous, so our goal is to standardise the therapy without reducing the quality and effectiveness of treatment. The results show that the calculated antibiotic therapy (CAT) with clindamycin is reasonable in the treatment of spondylodiscitis especially with the predominance of Staphylococcus aureus as pathogen. In addition, suitable antibiotic therapy should be administered in correspondence to a culture and sensitivity testing and should be maintained for at least 12 weeks, even when a reduction of inflammatory markers by 50 % after 2 weeks has already been achieved. It is noteworthy to point out the high probability of coexistence of spondylodiscitis with diabetes mellitus, so that spondylodiscitis should always be considered in diabetic patients with back pain and increased levels of inflammatory markers. A significant reduction in the very long time until reaching a definitive diagnosis should be achieved.

[The sterno-vertebral instability - a new classification and therapeutic options]. / Die sternovertebrale Instabilität - Klassifikation und Behandlungsalgorithmus.

INTRODUCTION: Sternal fractures in the context of high velocity trauma are commonly referred to as impact injuries. In general, these are considered to be treated conservatively. In the literature, there are only a few studies and a small number of cases. We know that not only high velocity accidents cause combined trauma of sternum and spine, but also low velocity traumas in the elderly are relatively common. How should such combinations of injuries be treated? MATERIAL AND METHOD: Based on 11 patients from the years 2005 to 2013 with different combinations of sternal and spinal injuries, we distinguish the therapeutic approach of ventral, dorsal or combined stabilisation, with the help of a four-column classification of these injuries. RESULTS: We classify sternovertebral injury into 4 types. First the descendant type with an injury from C I to C VII and sternum, second the horizontal type (T I to T XII and sternum), third the ascendant type (L I to L V and sternum) and fourth a dissociative type. The recommended therapy of the descendant type is dorsoventral stabilisation of the spinal column plus stabilisation of the sternum. The horizontal type should be treated with dorsal stabilisation of the spine and stabilisation of the sternum. The ascendant type should be supplied with dorsoventral stabilisation of the spinal column and conservative therapy of the sternum. In case of the dissociative type one should supply each injury independently. CONCLUSION: The literature on sternal injuries and their treatment is low. Combinations of sternum and spine injuries have not yet been processed systematically in literature. Thus, there is no concerted standard of therapeutic options. The very rare occurrence of this injury combination often leads to this injury type being forgotten in the primary evaluation of casualties.

[Are IT-based clinical pathways superior to hard-copy form?]. / Sind IT-gestützte klinische Behandlungspfade der Papierform überlegen?

BACKGROUND: Today clinical pathways are established as a basis for the operational and organisational structure of surgical, interventional and conservative treatments in many hospitals. QUESTION: In our study we have evaluated the establishment and systematic applicability of IT-based clinical pathways in the department of general surgery in comparison with existing clinical pathways. Does the systematic application of IT-based clinical pathways improve the quality of medical treatment? METHODS: In our department of general surgery we evaluated and compared the treatment by laparoscopic surgery before and after establishment of IT-based clinical pathways. The preoperative duration of stay, the duration of treatment and the patients' pain perception were compared. Since July 2009 we used in our department of general surgery an IT-based clinical pathway for laparoscopic cholecystectomy and hernia repair. From January 2006 until October 2009 we compared the treatment by these procedures with and without the use of IT-based clinical pathways. RESULTS: From January 2006 until October 2009 743 patients underwent surgery and treatment following the conventional clinical pathway and 51 patients following the new, IT-based clinical pathway. In the group of patients who received a laparoscopic hernia repair we found a reduction of the preoperative duration of stay. CONCLUSION: IT-based clinical pathways are applicable for routine use in general surgery departments. For certain surgical procedures they are an eligible management device. IT-based clinical pathways lead to an improved operational structure of medical treatment and moreover to a complete and continuous documentation through the electronic file. Especially for departments which are using the electronic file, the use of IT-based clinical pathways can be recommended.

[IT-based clinical pathway as a routine tool in trauma surgery]. / Der IT-gestützte Behandlungspfad als Routinearbeitsinstrument in der Unfallchirurgie.

BACKGROUND: Today clinical pathways are established as a basis for the operational and organizational structure of surgical, interventional and conservative treatment in many hospitals. In our study we evaluate the establishment and systematic applicability of IT-based clinical pathways in a tertiary care facility. METHODS: We evaluate and compare the treatment of coxarthrosis with hip joint endoprosthesis either following an IT-based clinical pathway or without clinical pathway. RESULTS: All patients who had received a hip joint endoprosthesis from 1 January 2006 to 31 October 2009 were included. The duration of stay is significantly longer in the group without pathway. Furthermore there was a significant increase in the documentation of wound inspection after surgery in the "pathway patients". The preoperative urinalysis was done significantly more often in the pathway group. CONCLUSION: IT-based clinical pathways are applicable for routine use in trauma departments. For certain surgical procedures they are a suitable management device, even in a tertiary care facility. Clinical pathways lead to an improved operational structure of medical treatment and moreover to a complete and continuous documentation through the electronic file.

[Preservation of hip prosthesis with local surgical revision and creation of a fistula persistens : an option for palliative treatment of periprosthetic infection in old, polymorbid patients?]. / Hüftprothesenerhalt mit lokaler chirurgischer Revision und Anlage einer Fistula persistens : Ausnahmeoption zur palliativen Therapie des periprothetischen Infekts bei alten polymorbiden Patienten?

BACKGROUND: The number of implanted hip prostheses is increasing constantly. At the same time the patients are becoming older and older. Thus, also patients with periprosthetic infections are older and therefore sicker. Uniform guidelines for the treatment of infected arthroplasties are controversial. Empirical studies show that the explantation of the original prosthesis and implantation of a revision may be the option with the greatest chance of success. These very aggressive procedures may overburden the old, polymorbid patient. The aim of this study was to ascertain whether or not keeping the hip prosthesis in combination with local debridement, formation of a permanent fistula and long-term administration of antibiotics is a possible option for the treatment of infected hip prostheses in old and polymorbid patients. PATIENTS: Between 01.01.2004 and 28.01.2007, 12 patients with periprosthetic infection after hip arthroplasty (PIH) were treated. Their average age was 79.8 years. Eleven patients were rated ASA III preoperatively. The prostheses were on average 23.8 weeks old when the first signs of infection occurred. In 10 cases the infection was caused by Staphylococcus (MRSA 3x). The main comorbidities were hypertension, diabetes, coronary heart disease and thyroid malfunction. RESULTS: After a mean 8.83 months, six patients were deceased (average age 85.50 years). In five of the remaining six patients the fistula worked without any problem. In one case the fistula was occluded. None of the patients showed any sign of acute infection. All were able to walk with full weight-bearing on the affected hip. CONCLUSION: Restricting the indication to old, polymorbid patients, preservation of the arthroplasty in combination with local surgical debridement, permanent fistula and long-term systemic administration of antibiotics seems to be an alternative to explantation of the prosthesis with consecutive revision arthroplasty or resection arthroplasty.