A new responder criterion (relative effect per patient (REPP) > 0.2) externally validated in a large total hip replacement multicenter cohort (EUROHIP)

OBJECTIVE

To validate a new method to identify responders (relative effect per patient (REPP) >0.2) using the OMERACT-OARSI criteria as gold standard in a large multicentre sample.

METHOD

The REPP ([score before - after treatment]/score before treatment) was calculated for 845 patients of a large multicenter European cohort study for THR. The patients with a REPP >0.2 were defined as responders. The responder rate was compared to the gold standard (OMERACT-OARSI criteria) using receiver operator characteristic (ROC) curve analysis for sensitivity, specificity and percentage of appropriately classified patients.

RESULTS

With the criterion REPP>0.2 85.4% of the patients were classified as responders, applying the OARSI-OMERACT criteria 85.7%. The new method had 98.8% sensitivity, 94.2% specificity and 98.1% of the patients were correctly classified compared to the gold standard.

CONCLUSION

The external validation showed a high sensitivity and also specificity of a new criterion to identify a responder compared to the gold standard method. It is simple and has no uncertainties due to a single classification criterion.

Burden of postmenopausal osteoporosis in Germany: estimations from a disease model

This article describes the adaptation of a model assessing the incidence of osteoporotic fractures and prevalence of postmenopausal osteoporosis (PMO) in Germany.

PURPOSE

The purpose of this paper is to estimate the epidemiological burden of PMO in Germany from 2010 to 2020.

METHODS

For each year of the study, the 'incident cohort' (women experiencing a first osteoporotic fracture) was identified and run through a Markov model using 1-year cycles until 2020. Health states were based on the number of fractures (1, 2 or ≥3) and deaths. Although the fracture site was not explicitly accounted for in the model structure, the site (hip, vertebral, non-hip non-vertebral) was tracked for each health state. Transition probabilities reflected the site-specific risk of death and of subsequent fractures. Model inputs included population size and life tables from 1970 to 2020, incidence of fracture and BMD by age in the general population (mean and standard deviation).

RESULTS

In 2010, the number of osteoporotic fractures was estimated at 349,560 in women aged 50 years or more, including 80,177 hip and 48,550 vertebral fractures. By 2020, the population is expected to grow by 13.1 %. As a result, the number of fractures is predicted to increase by 15.2 %. The improvement in life expectancy is predicted to lead to a relatively smaller increase in the number of deaths attributable to fractures (+12.8 %), but also to an increase in the prevalence of women with multiple prior fractures (+25.5 %).

CONCLUSION

The PMO disease model, first developed for Sweden, was adapted to Germany. Due to the ageing of the population, the number of osteoporotic fractures is expected to increase markedly by +15.2 % by 2020.

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[Sports and osteoarthrosis]

Many risk factors for developing osteoarthrosis exist. Osteoarthrosis is the most common cause of chronic disability in middle-aged and older people. On the one hand, physical exercise can lead to arthrosis; on the other hand, physical exercise is commonly used in preventing and treating it. Experimental and clinical studies have shown that increased high-impact running or competitive sports result in a higher risk for osteoarthrosis than moderate low-impact running. In particular, sudden-impact loading and twisting movements of the joints can result in premature osteoarthrosis. Also, sports with a high risk for injuries can lead to secondary osteoarthrosis. Preventive exercises to strengthen the skeletal muscles seem to have a pivotal role. There are different therapeutic approaches to osteoarthrosis, which will be more important in the future. Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity, or disability. Exercise should include local muscle strengthening and general aerobic fitness.

EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee

Objectives:

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of variation in diagnostic and therapeutic performance across disciplines, have found consensus in starting task forces aiming at achieving diagnostic and therapeutic uniformity, and have identified medical conditions with which representatives of both organisations will frequently be confronted in common clinical practice. The aim of the present work was to establish recommendations for the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Methods:

The EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations were followed.

Results:

In all, 11 rheumatologists from 11 countries and 12 orthopaedic surgeons from 7 countries met twice under the leadership of 2 conveners, a clinical epidemiologist and a research fellow. After carefully defining the content and procedures of the task force, research questions were developed, a comprehensive literature search was performed and the results were presented to the entire committee. Subsequently, a set of 10 recommendations was formulated based on evidence from the literature if available, and after discussion and consensus building.

Conclusions:

This is the first combined interdisciplinary project of rheumatologists and orthopaedic surgeons, successfully aiming at achieving consensus in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

[Injury prevention as the physician's challenge]

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

[Significance of a coding engaged orthopaedic surgeon for the illustration quality and compensation of an orthopaedic university department in the German DRG System 2005]

AIM

In the year 2005 the German DRG system underwent further differentiation in many areas compared to previous years. The effects of an improved coding quality by a specifically trained orthopaedic surgeon (KBFA) at an orthopaedic university department are analysed.

METHODS

In a closed sample of 1 277 cases the following parameters were documented after primary coding at discharge and after the final coding by the KBFA: main diagnosis, number of additional diagnoses and procedures, the resulting G-DRG, PCCL, cost weight and revenues. These data were analysed for statistically significant differences and correlations.

RESULTS

The final coding by the KBFA caused a significant (p<0.001) increase in the number of diagnoses and procedures. The intervention of the KBFA changed the DRG grouping in 34 % of the cases. The cost weight increased significantly and the case mix index raised by 0.26 in the complete sample, corresponding to an increased revenue of euro 62 per case and day.

CONCLUSIONS

The establishment of a KBFA in an orthopaedic department improved the quality of revenue-relevant DRG coding and the reflection of the economic complexity level of the cases. Compared to other reports, an above-average increase of cost weight as well as specification depth for diagnoses and procedures was achieved.

[Differentiation of coding quality in orthopaedics by special, illustration-oriented case group analysis in the G-DRG System 2005]

AIM

We introduce a grouping system for clinical practice which allows the separation of DRG coding in specific orthopaedic groups based on anatomic regions, operative procedures, therapeutic interventions and morbidity equivalent diagnosis groups. With this, a differentiated aim-oriented analysis of illustrated internal DRG data becomes possible.

METHODS

The group-specific difference of the coding quality between the DRG groups following primary coding by the orthopaedic surgeon and final coding by the medical controlling is analysed. In a consecutive series of 1600 patients parallel documentation and group-specific comparison of the relevant DRG parameters were carried out in every case after primary and final coding.

RESULTS

Analysing the group-specific share in the additional CaseMix coding, the group "spine surgery" dominated, closely followed by the groups "arthroplasty" and "surgery due to infection, tumours, diabetes". Altogether, additional cost-weight-relevant coding was necessary most frequently in the latter group (84%), followed by group "spine surgery" (65%). In DRGs representing conservative orthopaedic treatment documented procedures had nearly no influence on the cost weight.

CONCLUSIONS

The introduced system of case group analysis in internal DRG documentation can lead to the detection of specific problems in primary coding and cost-weight relevant changes of the case mix. As an instrument for internal process control in the orthopaedic field, it can serve as a communicative interface between an economically oriented classification of the hospital performance and a specific problem solution of the medical staff involved in the department management.

Differences in the views of orthopaedic surgeons and referring practitioners on the determinants of outcome after total hip replacement

In order to assess current opinions on the long-term outcome after primary total hip replacement, we performed a multicentre, cross-sectional survey in 22 centres from 12 European countries. Different patient characteristics were categorised into 'decreases chances', 'does not affect chances', and 'increases chances' of a favourable long-term outcome, by 304 orthopaedic surgeons and 314 referring practitioners. The latter were less likely to associate age older than 80 years and obesity with a favourable outcome than orthopaedic surgeons (p < 0.001 and p = 0.006, respectively) and more likely to associate age younger than 50 years with a favourable outcome (p = 0.006). Comorbidity, rheumatoid arthritis, and poor bone quality were thought to be associated with a decreased chance of a favourable outcome. We found important differences in the opinions regarding long-term outcome after total hip replacement within and between referring practitioners and orthopaedic surgeons. These are likely to affect access to and the provision of total hip replacement.

A new dorsal modular fixation device allows a modified approach in cervical and cervico-thoracic neoplastic lesions

INTRODUCTION

The aim of this study was to improve the management of cervical tumor osteolysis. A new modular rod-screw implant system for the posterior instrumentation of the occipito-cervical, cervical and cervico-thoracic spine (neon occipito cervical system, Ulrich, Germany) is available since 2000. K-wire guided pedicle screws are used, CT-guided instrumentation is possible. Previous studies have demonstrated increased biomechanical stability compared to established posterior cervical systems.

METHODS

The cervical and cervico-thoracic spine of 8 patients (6 males, 2 females, mean age 62 years, range 48-77 years) with osteolysis due to plasmocytoma (n=2), bronchial (n=2), mammary (n=2), esophageal (n=1) and pancreatic (n=1) carcinoma were instrumentated since June 2001.

RESULTS

A stable fixation without loosening or failure of the fixation system was achieved in all cases. No impairment of the neurogical status was observed.

CONCLUSION

Posterior instrumentation of the cervical spine including the occipito-cervical and the cervico-thoracic region with a new modular angle-stable rod-screw implant system offers good stabilization and allows simultaneous decompression. Since tumor masses are predominantly located in the anterior portion of the spine blood loss can be reduced.

International variation in hip replacement rates

OBJECTIVES

To summarise epidemiological data on the frequency of hip replacements in the countries of the developed world, especially in countries of the Organisation for Economic Cooperation and Development (OECD), and to investigate whether missing consensus criteria for the indication for total hip replacement (THR) result in different replacement rates.

METHODS

Country-specific hip replacement rates were collected using the available literature, different data sources of national authorities, and estimates of leading hip replacement manufacturers.

RESULTS

According to administrative and literature data sources the reported crude primary THR rate varied between 50 and 130 procedures/100000 inhabitants in OECD countries in the 1990s. The crude overall hip implantation rate, summarising THR, partial hip replacement, and hip revision procedures, was reported to range from 60 to 200 procedures/100000 inhabitants in the late 1990s. Moreover, large national differences were seen in the relationship between total and partial hip replacement procedures.

CONCLUSION

The reported differences in hip replacement rates in OECD countries are substantial. They may be due to various causes, including different coding systems, country-specific differences in the healthcare system, in total expenditure on health per capita, in the population age structure, and in different indication criteria for THR.

Cytogenetic studies on fine-needle aspiration samples from osteosarcoma and Ewing's sarcoma

The preoperative multidrug chemotherapy of osteosarcoma and Ewing's sarcoma patients requires a reliable diagnosis. There are several advantages with obtaining the diagnosis by fine-needle aspiration (FNA) and cytologic examination. Although cytologic criteria have been defined, adjunctive methods such as cytogenetic analysis are valuable to support the diagnosis. We have cytogenetically analyzed FNAs from 18 primary bone sarcomas (six osteosarcomas and 12 Ewing's sarcomas). Two of the osteosarcomas showed abnormal, complex karyotypes seen in most highly-malignant osteosarcomas. Seven Ewing's sarcoma aspirates displayed abnormal karyotypes; five of these had the characteristic 11;22 translocation, and in one of these cases molecular genetic analysis revealed the hybrid EWS/FLI1 transcript. Since only two of six osteosarcomas showed clonal changes, chromosomal analysis of FNAs from suspected osteosarcoma seems to be of limited value, but may in some cases support the diagnosis of high-grade malignancy. In Ewing's sarcomas, however, the finding of an 11;22 translocation was valuable and strongly supported the cytologic diagnosis. As shown in one case, the material obtained by FNA is sufficient for cytologic, cytogenetic, and molecular genetic analysis.

[Acute posttraumatic lung failure. Its treatment through pressure-limited respiration and continuous postural change]

Nine patients (4 women and 5 men; mean age 31 [20-48] years) with severe posttraumatic adult respiratory distress syndrome (ARDS) were treated with continuous postural change (kinetic bed) and pressure-limited ventilation. Seven patients survived; only one patient died as a result of pulmonary insufficiency. As compliance was markedly reduced (less than 20 ml/cm H2O), low stroke volumes (up to 380 ml) and high respiratory rate (up to 45/min) were employed to keep airway peak pressure below 40 mmHg. Kinetic treatment lasted for a mean of 14 (2-28) days; artificial ventilation was maintained for 31 (9-49) days. Practical problems of the method are the intensive nursing care required for the kinetic bed and the risk of decubitus ulcers, as well as disconnection of infusion tubing. The results indicate that kinetic treatment with pressure-limited ventilation constitutes a low-risk and, in many cases, effective treatment of severe ARDS.

[Arthrolysis of the hip joint in para-articular calcification and ankylosis]

Para-articular ossification of the hip joint represents a severe complication after hip surgery for joint replacement or various forms of trauma. It is always accompanied by tremendous loss of function and is therefore disabling for the patient. The results of past years have drastically reduced this complication in high-risk groups-recurrent joint replacement, acetabular fractures, severe head injuries-by means of hip irradiation and non-steroidal anti-inflammatory medication. In cases, in which significant functional disability results from heterotopic bone formation, it is possible to restore function of the hip joint through surgery. The diagnostics, preoperative planning, surgical therapy, and postoperative treatment protocol are presented.