[Urgency of neurosurgical interventions for severe traumatic brain injury]

BACKGROUND

The aim of this study was to assess whether the time interval between accident and neurosurgical intervention has an influence on functional neurological outcome and mortality in severe traumatic brain injury (sTBI) or whether the further clinical course has already been determined by the initial severity of the injury.

METHODS

Data were derived from the Trauma Registry of the German Society of Trauma Surgery. A total of 770 patients were identified who had undergone decompressive surgery, had an ISS ≥ 9 and for whom time of accident and start of surgery had been documented. To evaluate the possible influence of the time factor on outcome and mortality, these patients were subdivided into five groups according to time until decompression (I: < 2 h, II: 2-3 h, III: 3-6 h, IV: 6-24 h and V: > 24 h). Aside from mortality we analysed AIS, GCS, age and ISS in survivors and non-survivors.

RESULTS

Complete data were available for 770 patients with sTBI (AIS skull ≥3). The average age was 39.9 years and 71.6% were male. The average overall injury severity was reflected by an ISS score of 31.3 and the average AIS head score was 4.51. Of the 570 who underwent surgery in less than 6 h (groups 1-III), 33% died (188/570). Of the remaining 200 patients 40 died (20%). Mortality decreased throughout the groups (49 to 14%), as did the severity of the head injury (AIS 4.66 to 4.23); GCS on the other hand increased with the time between accident and surgery (5.9 to 8.8).

CONCLUSION

We could not substantiate that reducing the time between accident and neurosurgical decompression could decrease mortality. It rather seems that the initial magnitude of brain damage determines prognosis and outcome after sTBI. The interval between the appearance of neurological symptoms (e.g. anisocoria) and neurosurgical intervention plays an important role and should be kept as short as possible.

[Rehabilitation of severely injured patients in acute care hospitals: who is doing what? A nationwide survey in the Trauma Network DGU]

BACKGROUND

During the treatment of severely injured patients, rehabilitation takes an important role. In this study we examined the present structures in acute care hospitals, which influence the process of rehabiliation.

MATERIALS AND METHODS

The data was captured in a questionnaire. The questions deal with the personal and structural situation of acute care hospitals in Germany. The questionnaires were sent to all clinics, which are registered in the TraumaNetwork DGU.

RESULTS

424 hospitals answered the questionnaire. This is a response rate of 57.3% regarding 740 acitve clinics in the TraumaNetwork DGU. 58% have no opportunity for rehabilitation. The majority of the hospitals have a physiotherapy, (98.6%) or an occupational therapy (71.0%); 33.3% have a case management. Only 17.0% of the hospitals have rehabilitation teams which take care during the hospital stay. These teams consist mainly of internal rehabilitation physicians and physical therapists. Supraregional Trauma Center have better organized structures, as hospitals with lower level of care. Only 56.6% of all hospitals reported that they were familiar with the cooperating rehabilitation hospitals. There are special cooperations with rehabilita­tion hospitals in 34.4% of all cases.

CONCLUSION

The early mobilisation of severely injured patients is an integral part of the postoperative course in German hospitals. While on the one hand a large number of hospitals have good structural conditions on the other hand these structures are little integrated in the daily treamtment. There are major gaps and uncertainties in the cooperation between acute care clincs and rehabilitation hospitals. The integra­tion of rehabilitation hospitals in the TraumaNetwork DGU could be a good chance to improve this collaboration.

[Atlas fracture due to aneurysmal bone cyst after minor trauma]

Aneurysmal bone cysts predominantly occur in young adults and the long bones, the lumbar spine and the pelvis are mainly affected. This article presents the case of a 22-year-old woman with the very rare localization of an aneurysmal bone cyst of the atlas and an atlas fracture after a minor trauma. The initial radiological diagnosis was a suspicted aneurysmal bone cyst which was confirmed histologically. Due to the unstable fracture it was decided to carry out surgical treatment with occipitocervical stabilization in combination with a transoral bone graft. After a period of 11 months the fracture had completely healed and the implants were removed without any complications.

[Grade IIb alkali burns of the lower extremities. Working with concrete]

The irritating effects of concrete (calcium oxide) on skin have long been known. The effect by long-term skin exposure is not only irritating but also erosive and alkali skin erosion may result due to colliquative skin necrosis. A complicated course may ensue potentially necessitating plastic reconstructive treatment due to the development of unstable scars and defects. Correct interpretation of the skin trauma and adequate treatment are mandatory for functional restitution.

[Surgical treatment of proximal femoral fractures--a training intervention?]

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.

[Organizational, personnel and structural alterations due to participation in TraumaNetworkD DGU. The first stocktaking]

BACKGROUND

By implementation of a nationwide trauma network in Germany a high quality standard of technical, personnel and scientific conditions should be attained in hospitals participating in care for severely injured patients. All hospitals audited within the framework of TraumaNetwork(D) DGU are also evaluated for the modifications undertaken by answering a questionnaire. Using this data it was possible to 1) obtain information about hitherto existing personnel and technical infrastructures of all participating hospitals and 2) to present first positive effects achieved by implementation and participating in TraumaNetwork(D) DGU.

MATERIALS AND METHODS

The questionnaire contained 41 questions concerning organizational, personnel and structural changes to justify the motivation for participating in TraumaNetwork(D) DGU and regarding the degree of confidence with reference to the work of the AKUT office. Analysis of data has been carried out and given as a percentage of all useable questionnaires.

RESULTS

Data of 138 hospitals has been evaluated. Regarding organizational changes 29% of national/supraregional trauma centers made fewer adjustments than local (44%) and regional (55%) trauma centers. Personnel changes mainly affected participation in ATLS courses, cooperation with a neurosurgical department and reorganization of work schedules. With respect to structural changes most frequently emergency operating sets for emergency surgery have been established, teleradiology systems have been implemented and in 25% of the cases a sonography unit has been acquired. The rarest, but also most cost-intensive, new acquisition has been a CT scanner in or close to the emergency trauma room (10%). The work of the AKUT office has been rated altogether more satisfying by local trauma centers (mean 2.4) than by regional and national trauma centers (mean 2.6). Prompt information by AKUT has been especially praised (mean 2.1).

CONCLUSION

Being organized in trauma networks motivates hospitals to optimize their operational sequences and personnel and structural conditions. How much the care for multiple injured patients can be improved nationwide in Germany will be shown over the next few years. Through compulsive participation in TraumaRegister(QM) DGU (quality management) as a measurement for quality assurance this will be analyzed and evaluated scientifically.

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.

NCB-plating in the treatment of geriatric and periprosthetic femoral fractures

BACKGROUND

The aim of this study is the presentation of the polyaxial locking NCB-plate in the treatment of femoral fractures, especially in elderly patients and in proximity of a prosthetic implant. The reduction and fixation of these fractures is a challenging surgical procedure with high complication rates reported up to 40%.

PATIENTS AND METHODS

A total of 72 patients with femoral fractures had polyaxial locking plate osteosynthesis. Indications included fractures of the shaft and around an implant. Concerning surgical procedures, three different standardized techniques were performed: (1) minimally invasive with percutaneous distal insertion using a targeting device; (2) mini-open with additional cerclage wire via the same approach and (3) a conventional open reduction and internal fixation. Data collection included intraoperative data and early complications at 6, 24 and 52 weeks. Fifty-two patients had an implant or prosthesis in situ. Thirty-three patients were treated by technique (1), 32 patients had mini-open surgery and seven patients conventional open surgery.

RESULTS

Thirty-nine patients attended clinical follow-up after 52 weeks. Twenty-two patients were interviewed by telephone, two were untraceable and nine patients had died. Bony consolidation without secondary loss of reduction was confirmed after 52 weeks in all patients but two. Plate breakage occurred in these two at 25 and 31 weeks after surgery due to non-union. Implant related complications (17% in total) lead to surgical revision in five other cases: two deep wound infections as well as three minor revisions. When itemizing complications according to surgical technique used, most major complications occurred following open surgery.

CONCLUSION

The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures. The advantages of the polyaxial locking implant combined with minimally invasive surgical technique contribute to successful management of this population category. Early revision rate is noticeably lower compared to similar procedures.

LEVEL OF EVIDENCE

IV retrospective series.

[Reimbursement for kyphoplasty in the Germann diagnosis-related groups system 2011/2012. Material costs versus treatment costs]

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.

[Subsequent treatment following proximal femoral fracture - who, when, where? Assessment of the current situation in Germany]

BACKGROUND

Geriatric fractures are an increasing challenge for the German health-care system. While the acute care for patients with proximal femoral fractures is already standardised, differences remain in the further treatment and rehabilitation. A survey was conducted in cooperation with the section of geriatric trauma (AG Alterstraumatologie) of the German Association of Trauma Surgery (DGU) to point out existing problems in this group of patients.

MATERIAL AND METHODS

In October/November 2010 an electronic questionnaire, assessing the medical care for patients after proximal femoral fracture, was sent to 1080 medical directors of trauma and orthopaedic surgery departments in Germany.

RESULTS

339 (31.4 %) departments participated. The analysis revealed that 57 % of the hospitals had cooperation agreements with aftercare hospitals. 37 % of all hospitals had problems in finding a rehabilitation hospital. The initiation of a rehabilitation procedure is almost exclusively based on the doctors' decision. Influence of employees with other professions is marginal. Mobility and Barthel index before the release from the acute care hospital are major factors in the decision making.

CONCLUSION

The questionnaire confirms that there are problems in the aftercare service of geriatric patients all around Germany. A further improvement of collaboration between acute and aftercare hospitals is required.

Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients

PURPOSE

The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome.

METHODS

We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993-2007) with an Injury Severity Score (ISS) ≥9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT).

RESULTS

Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n = 1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5 days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group.

CONCLUSIONS

Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients.

[Effective skill training by means of E-learning in orthopaedic surgery]

BACKGROUND

The effectiveness of e-learning for reporting of x-ray-findings in a prospective, randomized trial was tested.

MATERIAL AND METHODS

Twenty advanced medical students were randomized into two groups. The test group practiced 4-6 hours with the newly developed software, the control group used conventional learning material. Afterwards, a test was carried out including 30 pathologic x-ray films that were randomly spread through 200 non-pathologic images. The required time, the number of correctly appraised images and the frequency of falsely suspected pathologies were recorded. In addition, we asked for an assessment of the own capabilities in evaluating x-ray films and of passing the radiology training.

RESULTS

The test group showed a markedly improved efficiency in comparison to the control group in all parameters. The required time was 57.4% shorter than in the control group (p < 0.05), 18.3% more cases were evaluated correctly (p < 0.05). The frequency of falsely suspected pathologies decreased by 61% (p < 0.05). There was no significant correlation of the objective abilities of a student with his/her self-assessment or of passing the radiology course.

CONCLUSION

This study shows that an effective standardized training of practical skills by means of e-learning is feasible and reasonable.

No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of The trauma registry of the DGU with 1,630 patients

Objective

Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure.

Methods

13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score > 16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)).

Results

From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (> 10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%).

Conclusions

Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

[The importance of CT angiography for screening supra-aortic vascular damage in severely injured patients]

PURPOSE

Traumatic injury of supra-aortic vessels remains a challenge in the initial diagnostics of severely injured patients. The presented prospective study analyzed the impact of multislice computed tomography angiography (CTA) as the primary diagnostic method.

METHODS

Patients with the following criteria were included and screened for a dissection of the supra-aortic vessels: a) admission directly from the scene, b) resuscitation room treatment indicated by the official criteria of the DGU (German Society for the Surgery of Trauma), c) suspected blunt trauma to head or trunk as well as d) age over 16 years.

RESULTS

During a period of 18 months 374 patients were treated for blunt trauma in the resuscitation room. In 176 cases CTA of the supra-aortic vessels was performed and pathological findings were observed in 16 patients. In 4 cases (2%) a traumatic dissection of supra-aortal vessels was diagnosed and confirmed by magnetic resonance imaging (MRI). All patients received heparin in a PTT effective dosage for 2 weeks and after rehabilitation there were no neurologic deficits.

CONCLUSION

Traumatic supra-aortic dissection was found in 2% of cases in the presented study group. The mechanisms of injury were not distinct in this group. Essentially MSCT angiography screening was demonstrated to be a safe diagnostic tool.

[The Trauma Network of the German Society for Trauma 2009]

In 2009, 3 years after the foundation of the Trauma Network of the German Society for Trauma (TraumaNetzwerkD DGU), the majority of German hospitals participating in the treatment of seriously injured patients is registered in regional trauma networks (TNW). Currently there are 41 trauma networks with more than 660 hospitals in existence, 18 more are registered but are still in the planning phase. Each Federal State has an average of 39 trauma centres of different levels taking part in the treatment of seriously injured patients and every trauma network has an average catchment area of 8708 km(2). The most favourable geographical infrastructure conditions exist in Nordrhein-Westfalen, the least favourable in Sachsen-Anhalt and Mecklenburg-Vorpommern. A total of 95 hospitals have already fulfilled the first audit of the structural, personnel and qualitative requirements by the certification bodies. Examination of the check lists of 26 hospitals showed shortcomings in the clinical structure so that these hospitals must be rechecked after correction of the shortcomings. A total of 59 hospitals throughout Germany were successfully audited and only one failed to fulfil the requirements. Because of the varying sizes of the trauma networks there are differences in the areas covered by each trauma network and trauma centre. Concerning the process of certification and auditing (together with the company DIOcert) it could be seen that by careful examination of the check lists of each hospital unforeseen problems during the audit could be avoided. The following article will present the current state of development of the Trauma Network of the German Society for Trauma and describe the certification and auditing process.

[University benchmarking. A current status analysis]

Lump sum reimbursement and the resulting concentration of medical treatment in maximum care clinics have led to substantial increase in economic pressure on university hospitals. Nearly all hospitals have introduced business ratios to economically judge each department. In order to evaluate the validity and comparability the business ratios of seven university traumatology departments were evaluated. Structural data as well as cost calculation results in different cost groups were evaluated. Major differences could be identified despite the fact that the cost calculations were all based on the same method (InEK method). In particular the costs for distribution to other medical specialties such as radiology or anesthesiology differed widely. Costs for infrastructure also showed a great variation. Differences in efficiency cannot be the only cause for these discrepancies and lacking standardization of cost calculation methodology is also another major cause. All the business ratios analyzed must be looked at critically and unless a thoroughly standardized methodology of cost calculation is implemented, cost ratios will have a limited potential for hospital benchmarking.