Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques.

OBJECTIVE: Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques. METHODS: All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation. RESULTS: In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications. CONCLUSION: Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?

BACKGROUND: While several studies report on accuracy rates of pedicle screws, risk factors associated with inaccurate pedicle screw positioning in patients with thoracolumbar fractures are reported rarely. CT scan as a routine postoperative control is advocated by various authors, however its necessity remains unclear. METHODS: Two hundred forty-five patients were included in this retrospective study. Percutaneous dorsal instrumentation was most commonly performed (n = 201). Classification of Zdichavsky et al. and Rao et al. were used to classify screw misplacement and anterior perforation was further evaluated according to the extent of perforation (< 2 mm; > 2 mm). Multivariate analysis was performed to identify risk factors for misplacement of screws. RESULTS: One thousand sixty-eight pedicle screws were inserted in 245 patients. Misplacement was found in 51 screws (4.8%) in 42 patients (17.1%) according to the classification of Zdichavsky et al. and in 75 screws (7.0%) in 64 patients (26.1%) according to the classification of Rao et al.. An anterior perforation of the vertebral cortex was found in 56 screws (5.2%). Multivariate analysis showed fracture location in the upper thoracic (p = 0.048) and lumbar spine (p = 0.013) to be the only independent predictors for screw misplacement. In addition a significant correlation between pedicle diameter and the occurrence of screw malposition was found (p = 0.003). No consequences were drawn from postoperative routine CT in asymptomatic patients. CONCLUSION: An overall low rate of screw misplacement was found with fracture location in the upper thoracic and lumbar spine being the only factors independently associated with the risk of screw misplacement. No consequences were drawn from postoperative routine CT in asymptomatic patients. Therefore its use has to be discussed critically.

Stability of internal versus external fixation in osteoporotic pelvic fractures - a biomechanical analysis.

INTRODUCTION: Osteoporosis-related fragility fractures of the pelvic ring (FFP) differ fundamentally from pelvic fractures in younger patients. However, very little is known about biomechanical stability of different osteosynthesis procedures addressing the anterior pelvic ring in these fractures. The aim of this study was to compare standard external fixation with internal fixation using a novel screw-and-rod system in osteoporotic fractures of the pelvic ring in terms of stiffness, plastic deformation and maximum load under cyclic loading in a human cadaveric model. MATERIALS AND METHODS: A total of 18 embalmed osteoporotic cadaver pelvis specimens were randomized based on the T-score into a group for external fixation and a group for internal fixation. FFP type-IIB fractures were created. In addition to the external or internal fixator, a cement-augmented sacroiliac screw was implanted. Afterwards, axial cyclic loading was performed in a testing setup simulating one-leg stand. RESULTS: Mean plastic deformation and stiffness both were significantly better in the internal fixation group than in the external fixation group (plastic deformation: 0.37 mm (SD: 0.23) versus 0.71 mm (SD: 0.26), p = 0.011; stiffness: 43.69 N/mm (SD: 18.39) versus 26.52 N/mm (SD: 9.76), p = 0.029). Maximum load did not differ significantly between internal fixator (506.3 N; SD: 129.4) and external fixator (461.1 N; SD: 147.4) (p = 0.515). CONCLUSIONS: Submuscular internal fixation might be an interesting alternative to external fixation in clinical practice because of better biomechanical properties as well as several advantages in clinical use.

Cement-augmented sacroiliac screw fixation with cannulated versus perforated screws - A biomechanical study in an osteoporotic hemipelvis model.

INTRODUCTION: Cement-augmentation is a well-established way to improve the stability of sacroiliac screw fixation in osteoporosis-associated fragility fractures of the posterior pelvic ring. However, to date little is known about the influence of different techniques of cement augmentation on construct stability. The aim of this study was to evaluate the primary stability of cement-augmented sacroiliac screw fixation with cannulated versus perforated screws under cyclic loading. MATERIALS AND METHODS: A total of eight fresh-frozen human cadaveric hemipelvis specimens with osteoporosis were used. After generating ventral osteotomies on both sides of the sacrum, each specimen was treated using a cement-augmented cannulated screw on one side and a cement-augmented perforated screw on the other side. Afterwards, axial cyclic loading was performed. RESULTS: No statistically significant difference was found between cannulated and perforated screws concerning maximum load (356.25 N versus 368.75 N, p = 0.749), plastic deformation (1.95 mm versus 1.43 mm, p = 0.798) and stiffness (27.04 N/mm versus 40.40 N/mm, p = 0.645). CONCLUSIONS: Considering the at least equivalent results for perforated screws, cement augmentation via perforated screws might be an interesting option in clinical practice because of potential advantages, e.g. radiological control before cement application, reduced risk of cement displacement and time saving.

One year after proximal or distal periprosthetic fracture of the femur -two conditions with divergent outcomes?

INTRODUCTION: Arthroplasty of the hip and knee is 1 of the 20 most frequent operations in Germany. Periprosthetic fracture is one of the most feared complications following primary or revision arthroplasty. Present publication aims to analyse differences between patients with periprosthetic fracture around total knee arthroplasty (PFTKA) and patients with periprosthetic fracture around total hip arthroplasty (PFTHA) concerning demographics, clinical course, complications and return to pre-fracture mobility. METHODS: Prospective single-centre observation study of periprosthetic femoral fractures with stable implants. Present subgroup analysis includes patients with PFTKA and PFTHA. All patients were treated with polyaxial angular stable plates using two standardized techniques: a minimally invasive percutaneous distal insertion technique and a mini-open technique. Data collection included implant- and operation-related information as well as demographics, clinical course, complications and return to pre-fracture mobility. Data were collected during a 12-month follow-up. RESULTS: We were able to analyse the data of 73 patients. The PFTKA group had 37 patients with a mean age of 76 ±â€¯10 years; 88% were female. After 1 year, 3 patients in this cohort had died; 68% of survivors had reached their pre-fracture mobility; 22% had undergone operative revisions for various reasons. The PFTHA cohort included 36 patients with a mean age of 80 ±â€¯13 years, 72% were female. After 1 year, 9 patients had died in this cohort, 42% of survivors had reached their pre-fracture mobility. Non-operative complications occurred for 16% in the PFTKA group and 64% in the PFTHA group (p < 0.001). 11% had undergone operative revisions for various reasons, among them, two cases of nonunion but no primary infection. CONCLUSION: On average, compared to the PFTHA patients, PFTKA patients were younger, underwent significantly lower rates of non-operative complications, had a tendency towards lower mortality, and returned to pre-fracture mobility at higher rates, although they tended to have more revisions when compared to treatment for PFTHA. Overall, when periprosthetic fractures of the femur were treated using polyaxial locking plate osteosynthesis, patients showed very low rates of nonunion and no primary infection.

Nutritional intervention in cognitively impaired geriatric trauma patients: a feasibility study.

BACKGROUND: Most studies focusing on improving the nutritional status of geriatric trauma patients exclude patients with cognitive impairment. These patients are especially at risk of malnutrition at admission and of worsening during the perioperative fasting period. This study was planned as a feasibility study to identify the difficulties involved in including this high-risk collective of cognitively impaired geriatric trauma patients. PATIENTS AND METHODS: This prospective intervention study included cognitively impaired geriatric patients (Mini-Mental State Examination <25, age >65 years) with hip-related fractures. We assessed Mini Nutritional Assessment (MNA), Nutritional Risk Screening (NRS 2002), body mass index, calf circumference, American Society of Anesthesiologists' classification, and Braden Scale. All patients received parenteral nutritional supplementation of 800 kcal/d for the 96-hour perioperative period. Serum albumin and pseudocholinesterase were monitored. Information related to the study design and any complications in the clinical course were documented. RESULTS: A total of 96 patients were screened, among whom eleven women (median age: 87 years; age range: 74-91 years) and nine men (median age: 82 years; age range: 73-89 years) were included. The Mini-Mental State Examination score was 9.5 (0-24). All patients were manifestly undernourished or at risk according to MNA and NRS 2002. The body mass index was 23 kg/m2 (13-30 kg/m2), the calf circumference was 29.5 cm (18-34 cm), and the mean American Society of Anesthesiologists' classification status was 3 (2-4). Braden Scale showed 18 patients at high risk of developing pressure ulcers. In all, 12 patients had nonsurgical complications with 10% mortality. Albumin as well as pseudocholinesterase dropped significantly from admission to discharge. The study design proved to be feasible. CONCLUSION: The testing of MNA and NRS 2002 was feasible. Cognitively impaired trauma patients proved to be especially at risk of malnutrition. Since 96 hours of parenteral nutrition as a crisis intervention was insufficient, additional supplementation could be considered. Laboratory and functional outcome parameters for measuring successive supplementation certainly need further evaluations involving randomized controlled trials.

Management of malnutrition in geriatric trauma patients: results of a nationwide survey.

PURPOSE: Prevalence of malnutrition in geriatric trauma patients ranges between 30 and 50 % in Germany. Malnutrition is associated with impaired wound healing, a prolonged in-hospital stay, reduced post-traumatic mobility, as well as a higher mortality. Thus, detection and improvement of nutritional status could be a fundamental contribution in optimizing the treatment of these patients. METHODS: We sent a web-based questionnaire to 579 German hospitals with traumatological expertise, seeking information on the institutional care level, number of beds, use of nutritional assessments, and use of defined laboratory parameters for the detection of malnutrition. Furthermore, we focused on the presence and frequency of nutrition ward rounds on the intensive care unit. RESULTS: We received 151 answers. Nutritional status was analysed in one-third (N = 50). The half of these 50 clinics (54 %, N = 27) were using the body mass index (BMI), 20 % (N = 10) were using the nutritional risk screening (NRS), and 14 % (N = 7) used the mini nutritional assessment. 38 hospitals indicated a regular nutrition ward round; 63 % of them occurred daily, 13 % had a weekly frequency, and 24 % were on demand. Laboratory parameters were used inhomogeneously. Except for the more frequent use of the NRS (p = 0.026) in local trauma centres, we found no significant difference in the detection of malnutrition according to the care level. CONCLUSIONS: Although we know malnutrition is a frequent condition in geriatric patients, a minority of clinics considered it. The BMI and the NRS showed acceptance in practice; other parameters were used inhomogeneously. Although these findings may be limited in their significance, they indicate that the detection of malnutrition needs further investigation.

[Reimbursement for kyphoplasty in the Germann diagnosis-related groups system 2011/2012. Material costs versus treatment costs]. / Vergütung der Kyphoplastie im DRG-System 2011/2012. Materialkosten vs. Versorgungskosten.

BACKGROUND: The treatment of osteoporotic vertebral fractures by means of kyphoplasty is an accepted and safe procedure. AIM: In Germany the reimbursement for kyphoplasty and vertebroplasty differs greatly. The growing diversity of suppliers and systems makes a comparison possible and necessary. Besides the illustration of kyphoplasty in the German diagnosis-related group (G-DRG) system and the amendments for 2012 we analyzed the procedures and associated costs. METHOD: Using the example of two manufacturers and different system approaches, both of which can be charged as kyphoplasty, we try to point out the importance of selecting exact comparison parameters. In particular material and treatment costs are compared for both methods.

[Surgical treatment of proximal femoral fractures--a training intervention?]. / Die operative Versorgung proximaler Femurfrakturen--ein Weiterbildungseingriff?

BACKGROUND: Proximal femoral fractures are common in the elderly. Surgical and postoperative complications are of major importance in this population. Numerous factors affecting the treatment results could be identified so far. The effect of surgeons' experience in terms of educational status is not entirely clarified yet. The aim of the present study was to analyse the effect of surgeons' educational status on the outcome in proximal femoral fractures. Therefore treatment results were compared in terms of individual surgeons' experience. Furthermore, the surgical education concept of our department was evaluated. MATERIAL AND METHODS: At a national trauma centre, patients of at least 60 years of age with proximal femoral fractures were prospectively screened. Patient-specific parameters like Barthel index, ASA score, Charlson score, patients' age and type of fracture were collected at the time of hospital admission. During the in-hospital stay type of fracture treatment, surgery time, number of blood transfusions, perioperative complications, duration of in-hospital stay as well as in-hospital mortality were recorded. Results were analysed for osteosynthesis and prosthesis depending on the surgeons' educational status. Four different groups of surgeons were distinguished (inexperienced senior house officer; experienced senior house officer; specialist in orthopaedics and accident surgery; specialist in orthopaedics and accident surgery with an additional qualification for special accident surgery). RESULTS: 402 patients with coxal femoral fractures could be included into the study. 160 patients (40 %) sustained complications of different severity. In-hospital mortality was shown to be 6.2 %. Separate consideration of osteosynthesis and prosthesis revealed no difference between the four groups of surgeons regarding mortality rate, number of blood transfusions and in-hospital stay. In terms of cutting/suture time consultants with a further specialisation in trauma surgery were significantly faster. CONCLUSION: Apart from cutting/suture time, surgeons' educational status had no statistically significant impact on the rate of complications, rate of blood transfusions, hospital mortality and in-hospital stay. It can be presumed that surgical education according to our educational concept has no negative effects on treatment quality of patients with proximal femoral fractures. Differences in cutting/suture time give a hint for the additional expense that is connected with surgical education.

[Current status of vertebroplasty and kyphoplasty in Germany: an analysis of surgical disciplines]. / Aktueller Stand der Vertebroplastie und Kyphoplastie in Deutschland: Eine Untersuchung in den operativen Fachdisziplinen.

OBJECTIVE: This study was performed to provide an overview of the current practice of balloon kyphoplasty (BKP) and percutaneous vertebroplasty (PVP) in Germany. All surgical departments were evaluated for indications, experience and expertise, and the complications. METHODS: Questionnaires were mailed to 1330 surgical departments. RESULTS: A total of 582 (43.76%) surveys were returned; 257 departments perform neither BKP nor PVP. Osteoporotic compression fractures and to a lesser extent hemangiomas and metastasis were treated. About 30% of the BKP users consider traumatic vertebral fractures in young patients as an indication, 76% of the respondents perform further spinal surgery, and 71% of the users operate within the first 2 weeks. For both interventions cement leakage is the most common complication. CONCLUSION: Nationwide kyphoplasty and vertebroplasty are widely used by surgeons. The number of users as well as the annual number of cases in each center are increasing continuously. The partially incomplete present state of the studies must be validated by future high-quality, randomized studies.

Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients.

The number of agile patients in the 10th decade with a strong need for postoperative mobility will increase in the following decades. The present prospective study sought to prove if very old patients with hip-related fractures are disadvantaged according to incidence of complications, length of ICU and in-hospital stay, and in-hospital mortality. We included 402 patients, age 60 years and older, with hip related fractures. Operative treatment consisted of osteosynthesis or endoprothesis. ASA score, body mass index, Charlson Comorbidity Index, Barthel Index and Mini-Mental-Status were documented. We noted length of in-hospital stay and ICU stay as well as readmission to ICU and complications, including their dispersal according to Clavien-Dindo Classification. After univariate analysis, a multivariate analysis was performed. The examined cohorts were 85 patients aged 60-74 years, 253 75-90 years old and 64 >90 year old patients. In-hospital periods (13-14 days) mean stay on ICU (2 days) and frequency of readmission on ICU did not significantly differ statistically. Most complications were grade II, with comparable frequency and modality, displaying no significant difference throughout age-related groups (p=0.461). In-hospital mortality showing significance (p=0.014) only between 75-89 (4.4%) and >90-year-old (12.5%) cohort. Nevertheless, according to multivariate analysis, including the common risk factors, increased age was not an independent risk factor for dying (p=0.132). Patients at an advanced age with hip-related fractures showed neither a prolonged in-hospital nor ICU stay. There was no significant relation of advanced age to number and type of complications.

[Revenue and losses with vertebral augmentation under the G-DRG system 2012 - a comparison of supply costs in the context of vertebroplasty and kyphoplasty]. / Ertrag und Verlust bei vertebralen Augmentationen im G-DRG-System 2012 - Ein Vergleich des Versorgungsaufwands bei Vertebroplastie und Kyphoplastie.

BACKGROUND: If clearly indicated and implemented, augmentations of vertebral bodies with cement are standardized, safe and low-risk procedures. However, the multiplicity of providers and systems are today more varied than ever. At present, the systems differ starkly from one another not only in specifications, possible applications and extensions of indications, but they are also extremely variable in price. Publications have shown that in times of medical-economic change, vertebral augmentations make sense not only medically, but also in terms of economics and the national economy. Our analysis targets the question of how insurance costs with vertebroplasty and kyphoplasty affect profit margins per G-DRG (German Diagnosis Related Groups) in consideration of the different system approaches of the providers. MATERIALS AND METHODS: After reviewing the literature, extremely varied, minimally invasive augmentation methods and techniques for treating vertebral body fractures were identified and classified. These were grouped based also [sic: on] OPS and possibly further subdivisions. Material costs were gathered based on average price quotations of different providers and techniques and aligned with those from the literature. The inpatient costs per day were estimated as a lump sum according to published information, since our analysis was interested in less detailed process costs as these are difficult to transfer to other clinics due to parameters being unique to each facility. The G-DRGs concerned were likewise determined according to the case-based lump sum catalogue from 2012. Based on this, the material costs as well as the daily costs per day of inpatient stay according to the average length of stay per G-DRG were subtracted. RESULTS: Vertebral augmentation methods are classified into vertebroplasty and kyphoplasty according to OPS. In addition, according to current literature, a further subdivision of kyphoplasty into substance-conserving or direct cement injection techniques and substance-destroying or indirect cement injection techniques took place. The procedures involve material costs between 10-40 % of G-DRG revenue. The profit margin of vertebral augmentation ranges from approx. 4100 € to approx. 11 400 €. The calculative costs of the inpatient care per day amount to 488.86 €. Based on the average lengths of stay per G-DRG (7.8-12.6 days) for 2012 determined by the InEK (Institut für das Entgeltsystem im Krankenhaus [Institute for the Hospital Remuneration System]), the financial costs of inpatient care were calculated between 3813.11 € and 6159.65 €. A shortfall of -197.53 € for the treatment of a vertebral body resulted for the vertebroplasty. This shortfall increases with the treatment of three vertebral bodies and a PCCL = 4 to -466.30 €. The indirect cement injection techniques accounted for a positive profit margin of 196.03 € for the treatment of a vertebra. Due to high material costs, however, this dips into the negative in the amount of -1227.70 € for two vertebrae and increases to -2522.50 € for the treatment of three vertebral bodies. In contrast, the multilevel care in substance-preserving kyphoplasty techniques show a positive profit margin of 72.30 € for the treatment of two vertebrae and 577.50 € for the treatment of three vertebrae. CONCLUSION: Against the background of the increasing economization of the health care system, it should be emphasized once more that the decision for a therapy or a system based on medical reasons should only be made by the treating physician. The vertebroplasty could not be performed at a profit in our analysis, despite comparatively low material costs. A shortfall between -197.53 € and -466.30 € was determined. The comparatively higher material costs of the kyphoplasty make comparisons important. The results of our investigation also show that supposedly inexpensive purchases of materials are not automatically a favorable alternative. In addition, the kyphoplasty techniques currently available on the market are not necessarily comparable. According to our investigation, profits of between 196.03 € and 577.50 € are to be realized in the selection of vertebral augmentation systems based on purely economic considerations. The results of our analysis show that the pure comparison of figures of the average material costs of a G-DRG and the material price distort the picture. A calculation of the profit margin on the basis of costs of care per vertebral body is more definitive.

[The Marburg surgical curriculum - improving the attraction of medical education by teaching central surgical competence]. / Das Marburger chirurgische Curriculum - Attraktivitätssteigerung der studentischen Ausbildung in der Chirurgie durch Vermittlung von chirurgischen Kernkompetenzen.

The quality of medical education is an ongoing challenge due to the continuing changes of the health-care politics and general social conditions. At many German university hospitals the dominating picture is overfilled courses, lack of hands-on practice, reduced patient contact and the dull provision of theoretical, abstract knowledge. The reformed surgical curriculum at the University of Marburg university hospital is used to demonstrate that, in spite of large student numbers, a practice-oriented, small-group training at a high didactic level is possible. The surgical training courses are organized in detail and coordinated. Course contents and structure are media available in print and online versions for both students and teachers and thus fulfill not only transparency needs but also contemporary requirements. The strategy of a practice- and patient-oriented, small-group training is followed strictly in the surgical curriculum. In addition, accompanying tutorial possibilities for individual study in an up-to-date learning center are offered. Here the students have the opportunity to intensify knowledge acquired in previous or future courses with numerous attractive education means. Continuous evaluation of the individual training courses at the end of each semester not only document motivation of the students but also serve to continuously improve the training concepts.