Annual epidemiological and health insurance disease burden of pertrochanteric fractures in Hungary / A pertrochanter törés okozta éves epidemiológiai és egészségbiztosítási betegségteher elemzése Magyarországon.

Összefoglaló. Bevezetés: A pertrochanter töréssel kapcsolatos szolgáltatások igénybevétele jelentos terhet jelent a társadalom és az egészségügyi rendszerek számára. Célkituzés: Elemzésünk célja volt a pertrochanter törés okozta éves epidemiológiai és egészségbiztosítási betegségteher meghatározása Magyarországon. Adatok és módszerek: A felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelo (NEAK) finanszírozási adatbázisából származnak 2018. évre vonatkozóan. A betegszámok alapján meghatároztuk a 100 000 lakosra jutó prevalenciát, az éves egészségbiztosítási kiadásokat korcsoportos és nemenkénti bontásban. Az elemzésbe az érintett egészségbiztosítási ellátások teljes körét bevontuk. A pertrochanter töréseket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S7210-es kóddal azonosítottuk. Eredmények: A legnagyobb országos betegszámot a járóbeteg-szakellátás esetében találtuk: 2845 férfi, 6312 no, együtt 9157 fo. Ezt követte az aktívfekvobeteg-szakellátás (2388 férfi és 5858 no, együtt 8246 fo). A valamennyi életkorra számított, 100 000 lakosra vetített prevalencia a férfiaknál 51,1 beteg, a noknél 114,7 beteg, együtt 84,3 beteg volt az aktívfekvobeteg-szakellátásban. A pertrochanter törés kezelésére 7,329 milliárd Ft-ot költöttek 2018-ban (27,12 millió USD, illetve 22,98 millió EUR). A kiadások 28,0%-a férfiaknál, 72,0%-a noknél jelent meg. Az egészségbiztosítási kiadások 90,7%-a az aktívfekvobeteg-szakellátásban jelentkezett. Az egy betegre jutó átlagos éves összesített egészségbiztosítási kiadás 858 710 Ft (3177 USD/2693 EUR) volt a férfiak és 901 047 Ft (3334 USD/2826 EUR) a nok esetében. Következtetés: A pertrochanter törés elofordulási gyakorisága 2,5-szer magasabb a nok esetében, mint a férfiaknál. Az aktívfekvobeteg-szakellátás igénybevétele bizonyult a legfobb költségtényezonek. Orv Hetil. 2021; 162(Suppl 1): 46-53. INTRODUCTION: Health services utilization related to pertrochanteric fractures represents a significant burden for the society and health care systems. OBJECTIVE: Our aim was to analyse the epidemiological and health insurance burden of pertrochanteric fractures in Hungary. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual patient numbers, prevalence per 100 000 population in acute inpatient care, health insurance costs calculated for age groups and sex for all types of care. Patients with pertrochanteric fracture were identified with the code S7210 of the International Classification of Diseases, 10th revision. RESULTS: We found a significant patient turnover in outpatient care: 2845 men, 6312 women, in total 9157 patients, followed by acute inpatient care (2388 men, 5858 women, together: 8246 patients). Based on patient numbers in acute inpatient care, the prevalence per 100 000 among men was 51.1, among women 114.7, together 84.3 patients. In 2018, NHIFA spent 7.329 billion HUF (27.12 million USD, 22.98 million EUR) on the treatment of pertrochanteric fractures. 28.0% of the costs was spent on the treatment of male, 72.0% on female patients. Reimbursement of acute inpatient care was the main cost driver (90.7% of the total expenditure). The average annual treatment cost per patient was 858 710 HUF (3177 USD/2693 EUR) for men and 901 047 HUF (3334 USD/2826 EUR) for women. CONCLUSION: The prevalence of pertrochanteric fracture was 2.5 times higher in women compared to men. Acute inpatient care was the major cost driver in the treatment of pertrochanteric fracture. Orv Hetil. 2021; 162(Suppl 1): 46-53.

Bipolar hemiarthroplasty for the treatment of femoral neck fractures with minimally invasive anterior approach in elderly.

OBJECTIVES: The purpose of the study was to evaluate the efficacy of hemiarthroplasty with minimally invasive direct anterior approach (DAA) for the treatment of femoral neck fracture in elderly patients. We aimed to compare the DAA and the standard anterolateral approach (ALA), assessing multiple peri­ and post-operative parameters. DESIGN AND SETTING: Between December of 2015 and May of 2017, patients operated with medial femoral neck fractures using bipolar hemiarthroplasty with DAA or ALA were evaluated. The volume of bleeding and transfusion, postoperative level of pain, mobilisation and functional outcome were assessed retrospectively. PARTICIPANTS: Patients between the age of 75 and 85, suffering Garden Type III Pauwels Type III and Garden Type IV medial femoral neck fractures were entered to the study. Patients had no history of anticoagulant therapy; the operation was performed in the first 48 h. All patients received similar postoperative pain management and physiotherapy. The type of implants was determined by the patients' bone morphology and quality. MAIN OUTCOME MEASURES: The outcomes of interest were the level of postoperative pain, blood loss, rate of recovery and physiotherapy, altered gait pattern and accuracy of leg length, related to DAA and ALA techniques. RESULTS: The 51 patients operated with DAA showed significantly less pain, based on VAS (visual analogue scale), starting of the first postoperative day. Those patients who were subjected to DAA met with the criteria of hospital discharge 1.68 days earlier, compared to ALA patients. The length of leg was accurately set in 21% of ALA vs 54.9% of DAA patients. On the 12th week follow-up, limping was detected only 5.9% of DAA vs 46% of ALA groups. On the postoperative 2nd and 6th weeks, the HHS (Harris Hip Score) was significantly better in patients with DAA, compared to ALA (77 vs 65 and 91 vs 77, p < .05). CONCLUSION: The bipolar hemiarthroplasty with DAA allows earlier mobilisation, reduced postoperative pain and need for rehabilitation with an overall better functional outcome, compared to ALA. DAA is proven a reliable choice for femoral neck fractures, offering good outcome and faster recovery, similarly to total hip arthroplasties with degenerative arthritis.

Efficacy of microbiological culturing in the diagnostics of joint and periprosthetic infections.

OBJECTIVES: To evaluate the efficacy of conventional microbiological examinations in the diagnostics of septic joint and periprosthetic inflammations. DESIGN AND SETTING: Evidence Level IV, retrospective clinical study of case series. Patients treated with small and large joint septic inflammations or with periprosthetic joint infections (PJI) were entered into the study. Demographics, microbiological cultures and inflammatory mediators were evaluated. PARTICIPANTS: Between 2012 and 2016, total of 1116 hip and 241 knee surgeries were performed at our Department in relation to prostheses; including primary and revision arthroplasties and further surgeries due to PJI. During this period, 72 patients were operated with large joints infections or PJI and another 65 patients were treated due to small joint infections. MAIN OUTCOME MEASURES: The main outcome of interest was to evaluate the sensitivity of conventional microbiological cultures in the primary diagnostics of joint and periprosthetic infections. RESULTS: The most frequent bacteria strains were the Staphylococci: in 43 cases (22.16%) Staphylococcus aureus, in 22 cases (11.34%) coagulase-negative Staphylococcus, in 3 cases (1.54%) Staphylococcus epidermidis and in 4 cases (2.06%) methicillin-resistant S. aureus (MRSA) were detected. In 30 cases (21.88%), the primary microbiological investigation could not reveal the presence of bacteria. CONCLUSION: Based on our data, the efficacy of conventional microbiological testing in the diagnostics of different type of joint infections is questionable. Therefore, further studies are warranted to evaluate the efficacy of novel diagnostic testing tools in prospective randomized controlled trials.

New composite scale for evaluating peripheral nerve block quality in upper limb orthopaedics surgery.

INTRODUCTION: Developments in ultrasound guided (UG) peripheral nerve block (PNB) techniques have significant advantages for patients undergoing trauma surgery. Brachial plexus blockade (BPB) for upper extremity surgery provide superior analgesia, improve recovery and patient satisfaction. To the best of our knowledge there is no tool for evaluation of the quality of UG PNB which concerns the quality of PNB, the tolerance of the patient towards the anaesthetic approach, and postoperative analgesia as well. PATIENTS AND METHODS: Standardized UG BPB anaesthesia - was performed; interscalene-supraclavicular (ISC-SC) and axillary-supraclavicular (AX-SC) approach for upper limb surgery. A GCS like tool was developed with which the Sensory, Motor, Coping of patient and Postoperative (SMCP) pain qualities were measured. The quality of PNBs were evaluated by a quality of anaesthesia graded by anaesthesiologist (QAGA) and the SMCP scale as well, the means of midazolam and opioid consumption during surgery, vital parameters, postoperative pain intensity (VNRS) were compared between the two groups. RESULTS: Ninety three unpremedicated adult patients with ASA I-III were scheduled for unilateral upper limb surgery. Nearly the same mean volumes of local anaesthetic solution were used in the AX-SC and ISC-SC groups (28.3-31.0 ml). There were no significant difference in the quality of PNB measured by QAGA or SMCP scale between the AX-SC and the ISC-SC groups, however 75 patients were assessed as Excellent with the SMCP scale vs. 39 with the QAGA. 97.8% of the patients were in the Excellent and Good category evaluated with SMPC vs. 86% with QAGA (p < 0.001). There was no surgery abandoned due to failed PNB and no tourniquet pain was detected. There was no evidence of side effects or complications of PNB during the follow-up period. DISCUSSION: This composite tool is designed for evaluating the loss of sensory and motor function; the coping of the patient and the postoperative pain as well. Our novel SMCP evaluation tool focuses on the overall condition of the patient during surgery and in the postoperative period. This more precise outcome evaluating scale is significantly superior to the formerly used QAGA in representing the high success rate of UG PNB.

Non-operative predictors for subsequent interventions after intracapsular femoral neck fractures in elderly: A comprehensive analysis of the Hungarian nationwide health insurance database.

OBJECTIVES: To investigate the correlation between non-operative prognostic factors and non-prosthetic fracture-related treatments following internal fixation of intracapsular femoral neck fractures in elderly patients. DESIGN AND SETTING: Retrospective observational cohort study. Comprehensive analysis of the Hungarian nationwide health insurance database. PARTICIPANTS: Data of in-patient records with S7200 ICD-10 codes were collected from the Hungarian National Health Insurance Fund Administration (HNHIFA) and from the health care provider institutes. The patients with femoral neck fractures in the year of 2000, following reduction and internal fixation aged 60 years or older were evaluated. The secondary, non-prosthetic fracture related treatments during the 8 year follow-up period were registered. MAIN OUTCOME MEASURES: Of the prognostic factors, age, gender, type of fracture, season and day of the primary surgery, length of waiting time to the operation and the accompanied diseases were evaluated as risk factors for all type of fracture-related further interventions, with the exception of arthroplasties. RESULTS: A total of 2895 patients with intracapsular femoral neck fractures met the study criteria. The mean age was 77.96 years (SD: 8.54). The cohort of the patients was observed for a total of 10,077.8 person-years. The non-prosthetic fracture related treatment was performed in 265 patients (9,2%); the median of the time elapsed to the secondary definitive treatment was 3.5 months. With Cox regression analysis, significant correlation was revealed between the incidence of non-prosthetic treatment and younger age (year, HR = 0.977, p = 0.002), surgical delay (12-24 h vs 0-6 h, HR = 1.518, p = 0.023; 24h+ vs 0-6 h, HR = 1.372, p = 0.050), season of primary osteosynthesis (fall vs summer, HR = 0.636, p = 0.012), and type of femoral neck fracture (intracapsular displaced vs intracapsular undisplaced, HR = 1.340, p = 0,047). There was no significant effect of the day of primary surgery, the gender and the presence of co-morbidities on the incidence of further surgical interventions. CONCLUSION: The summertime primary surgical intervention, delay of surgery longer than 12 h and type of femoral neck fracture are independent predictors of non-prosthetic further treatment of femoral neck fractures in elderly patients. LEVEL OF EVIDENCE: Level IV, evidence from cohort studies.

Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures.

INTRODUCTION: The first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. MATERIALS AND METHODS: Between January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. RESULTS: Good functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. DISCUSSION: The treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures.

Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks.

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low dose is not unequivocal, consequently, the pharmacokinetics of local anesthetics used by various authors are difficult to compare. In this study, the onset times and duration of the analgesic effect of local anesthetic mixture solutions used for brachial plexus blocks are investigated and the quality of anesthesia is compared. 85 unpremedicated American Society of Anesthesiologist physical status I-III, 19-83-year-old patients scheduled for upper limb trauma surgery are assigned to four groups for the axillary-supraclavicular block with lidocaine 1% and bupivacaine 0,5% 1:1 mixture (Group LB) or bupivacaine 0.33% (Group BS) or lidocaine 0,66% (Group LS) or bupivacaine 0.5% and lidocaine 1% 2:1 mixture (Group BL). 0.4 ml/kg was administered to the four groups. The onset time was significantly shorter in the lidocaine group (LS 13.0 ± 1.02) than in the other study groups (LB 16.64 ± 0.89; BS 17.21 ± 0.74; BL 16.92 ± 0.51 min ±SEM, p = 0.002). No differences were observed in the onset times between LB, BS, and BL groups (p > 0.05). Statistical differences were found in the duration of local anesthetics between LB (392.9 ± 20.4), BS (546.4 ± 14.9), LS (172.85 ± 7.8), and BL (458.7 ± 11.9 min ±SEM, p = 0.001). Lidocaine does not shorten the onset times, but significantly decreases the duration of action of bupivacaine when used in mixture solutions. Lidocaine exhibits a good quality of block in the applied dose, while other solutions have excellent quality. Bupivacaine without lidocaine has the longest duration of action to achieve the longest postoperative analgesia.

[Clinical and experimental assessment of the current treatment of tibial shaft fractures]. / Lábszártörés korszerû kezelésének értékelése klinikai és kísérletes vizsgálatokkal.

Tibial shaft fractures present 15% of all fractures, which means about 2500 cases per year in Hungary. 90% of these fractures are treated surgically. Nowadays, the incidence of tibia fractures is increased, the severity of the fractures is intensified and in spite of new surgical techniques the rate of complications is not dramatically decreased. The treatment of the open tibia fractures has basically changed since the introduction of unreamed intramedullar nails. The unreamed nails turned into the primary method in the treatment of the Grade II and III open fractures and became sufficient for the fixation of the proximal and distal third tibia fractures. In Hungary, we used the Marchetti-Vicenzi nail for the treatment of tibia fractures in first time, with this method the tibial shaft and distal part fractures can be treated safely with low rate of complication. In year 1997 we prepared the treatment concept of the combination of the dynamic brace and the undreamed intramedullar nail. We proved that by the application of this method the advantages of the two treatment form could be attached and the healing period and the rehabilitation of the injured could be shortened. During the clinical exploration of the complications we proved that different pressure levels developed in the muscular compartment around the tibia during the usage of two different surgical techniques, the reamed and unreamed nailing. In the deep compartment we measured statistically higher pressure in the cases of unreamed nailing. In contrast to the literature we can draw the conclusion that there is no relationship between the compartmental pressure changes, the chance of the development of compartment syndrome and the insertion technique of the intramedullar nails. In pursuance of the basic research of the complications we investigated the muscle samples from compartment syndrome and from Volkmann ischemic contracture with differential scanning calorimetry. We proved that there is a difference between thermal features of the intact and ischemic muscles. We demonstrated that there is a close correlation between the compartmental pressure, the structural damage of muscle tissues and thermo-chemic values measured by calorimetry. Due to their sensitivity and specificity, calorimetric examinations can help and support the clinical diagnosis in atypical cases.