Unfallchirurgie (Heidelberg, Germany)最新文献

Background: The global COVID-19 pandemic led to excess mortality, especially for vulnerable older patients with simultaneous comorbidities. Patients with proximal femoral fractures already have a high mortality risk of up to 30% during the first postoperative year. The purpose of this study was not only to investigate the impact of COVID-19 on the mortality of patients tested positive but also of negatively tested patients with proximal femoral fractures.

Methods: A single center cohort study of 2186 patients (mean age 79.8 years) who were surgically treated for a proximal femoral fracture at a level I trauma center was retrospectively carried out. The mortality and complication rates before the COVID-19 pandemic (January 2016-February 2020) and during the pandemic (March 2020-October 2021) were compared. A standardized treatment protocol was carried out during the total observational period. Orthogeriatric co-management was negatively impaired by the pandemic. Patient data, COVID-19 infections, surgical procedure, time from admission to surgery, postoperative complications and mortality were analyzed.

Results: The pandemic group included 596 patients with an average age of 79.7 years. During the pandemic 26 patients were tested positive for COVID-19 (18 women, 8 men, average age 81.4 years, minimum 63 years, maximum 99 years, SD 9 years). Patients who tested positive for COVID-19 had more comorbidities than COVID-19 negative patients during the same period (Charlson comorbidity index, CCI 6.26 vs.5.25 points p < 0.037). The prepandemic control group consisted of 1590 patients with an average age of 79.9 years and a mean CCI of 5.86 points. Patients tested positive had a much longer hospitalization and a longer duration on the intensive care unit (p < 0.001) and a complication rate of 62.5%, especially due to the occurrence of pneumonia (p < 0.001). The mortality rate during the pandemic did not differ between patients tested positive or patients tested negative but was significantly higher for both groups in comparison to the period before the pandemic (pandemic 14% vs. 15.4%, before the pandemic 3.1%).

Conclusion: Patients suffering from COVID-19 infection and proximal femoral fractures have a high risk of complications and a high mortality. The total increase in mortality for all patients with critical injuries, such as hip fractures during the pandemic emphasizes the importance of early mobilization and orthogeriatric co-management, which was discontinued during the pandemic and the lockdown.

The integration of large language models (LLM) into the care of trauma surgery patients offers an exciting opportunity with immense potential to enhance the efficiency and quality of care. The LLM can serve as supportive tools for diagnosis, decision making and patient communication by efficiently providing medical knowledge and generating personalized treatment recommendations; however, there are also substantial challenges that must be addressed. The lack of transparency in the decision-making processes of LLM as well as currently unresolved legal and ethical issues, necessitate careful implementation and examination by medical professionals to ensure the safety and effectiveness of these technologies.

Objectives of the surgery: The aim of this operation technique is to bridge the pathological fracture of a vertebral body by a dorsal spondylodesis, to stabilize the spine, reduce the pain and regain mobility.

Indications: Due to the vertebral body fracture (OF 2) of the third lumbar vertebral body (L3) and the associated pain and immobility and due to the modified score of the AO Spine-DGOU osteoporotic fracture (OF) classification system.

Contraindications: No specific contraindications.

Surgical technique: Technical set-up: Robotic Suite (Brainlab, Munich, Germany) with navigation unit "curve navigation system", robotic 3D cone beam computed tomography (CBCT) "Loop-X", robotic arm "Cirq Arm System" and wall-mounted monitor "BUZZ". Operation steps are shown in the video (English): Planning of the screws based on preoperative CT imaging. Placement of the reference array. First imaging, image fusion and fusion control. Registration of instruments. Robotically assisted skin incision planning. Robotically assisted drilling. K-wire insertion. Second imaging and wire position check. Screw placement. Cement augmentation of the screws. Insertion of the connecting rods. Wound closure.

Follow-up: Full weight bearing, pain medication if required. Physiotherapeutic treatment to learn strengthening exercises and restoration of mobility. Medication with vitamin D3 and calcium. Metal removal is not intended.

Evidence: Operations on the lumbar spine are now routine clinical practice in orthopedics and trauma surgery. They can be performed without any problems and with very good accuracy in terms of precise screw placement.

Background: Due to the demographic changes, including the need for more orthogeriatric co-management, addressing the healthcare of geriatric patients is an important issue.

Objective: The aim of this study was to create an overview of the fundamental characteristics of centers for geriatric trauma ATZ-DGU including the distribution of departments and cooperations as well as the level of trauma care. The distribution of sites across Germany was compared to hospital and population data.

Methods: Certified German ATZ-DGU were assigned to Trauma Center DGU^® (TC) certification data (levels III-I) via institutional numbers. They were evaluated descriptively and correlations with several parameters at the federal states level were added.

Results: Due to cooperations 188 institutions formed 147 ATZ-DGU and 152 provided orthogeriatric co-management in domo. Of the facilities with trauma surgery departments 86% (n = 168) were certified as TCs (level II = 33% > III = 30% > I = 22%). The number of ATZ-DGU per German state was correlated with the number of hospitals (r_s = 0.88), inhabitants (r_s = 0.92) and cases in total (r_s = 0.92, p < 0.001 each) but not with the proportion of people older than 65 years (p > 0.05). With only 14 facilities, the new federal states of Germany seemed to be disadvantaged and also showed great disparities compared to each other.

Conclusion: The levels of trauma care revealed a distribution referring to the different focus of the two certificates: treatment of the severely injured vs. geriatric co-treatment. On average, the population in the new German states was older, while there were less ATZ-DGU; however, there seemed to be a slight tendency towards improvement.

Due to demographic changes, proximal humeral fractures (PHF) are becoming increasingly more frequent in routine clinical practice. At the same time, surgical treatment is more frequently indicated and more demanding due to increasingly more complex fracture morphology and declining bone quality. Osteosynthesis using locking plate fixation remains the mainstay of surgical treatment alongside reverse fracture arthroplasty. The treatment concept is individually dependent on the characteristics of the fracture morphology, the patient-specific risk profile and the expertise of the surgeon. In younger patients fracture fixation is preferable, when feasible. In recent years, combinations of different surgical techniques have been increasingly used to achieve humeral head preservation and sufficient stability. The risk of complications, such as secondary dislocation and screw cut-out has significantly decreased in recent years due to improved evaluation of the indications and surgical techniques. As one of these combined procedures, double plate fixation offers promising options for complex fractures due to an additional plate applied ventrally. This technique is increasingly becoming established in routine clinical practice. Cement augmentation of screws and different bone grafts are additional options to supplement locking plate osteosynthesis so that a good reconstruction result can also be achieved in osteoporotic bone.

Background: Subtalar dislocations (simultaneous dislocations of the talocalcaneal and talonavicular joints) without concomitant fracture are rare and account for 1-2% of all dislocations. The treatment has been described in several case reports and consists primarily of closed reduction with the patient under anesthesia followed by immobilization.

Case: A 30-year-old male patient sustained a multidimensional nonfractured dislocation of the ankle joint with a predominantly subtalar component (luxatio subtalolateralis) while climbing. As it turned out later, a closed reduction was not possible due to interposition of the tendons of the posterior tibialis muscle and the flexor digitorum pedis longus muscle, so that an open reduction had to be performed. The full extent of the injury could only be assessed during the surgical exploration. The patient was treated in an external fixator for 12 weeks. Subsequently, physiotherapy was initiated. After only 6 months postoperatively the patient showed good mobility, functionality and resilience in the affected ankle joint. After 30 months the patient was free of symptoms. The prolonged immobilization after subtalar dislocation using an external fixator over a total period of 12 weeks, as performed in this case report, demonstrated good long-term functional outcomes.

Objective of surgery: The aim of this operation is to stabilize the anterior pelvic ring fractures on both sides and the sacral fracture on the right using robotically assisted screw osteosynthesis and to restore the mobility of the patient.

Indications: The indications arise from the patient's very severe pain, resulting immobility under conservative treatment measures and a fragility fracture of the pelvis grade II (FFP II).

Contraindications: Typical contraindications for this type of operation are the same as for conventional techniques (mainly infection and swelling).

Surgical technique: Performed in the 3D navigation hybrid operating theatre Robotic Suite with the following components: navigation unit "Curve Navigation System", movable robotic 3D cone beam computed tomography (CBCT) "Loop‑X", robotic arm "Cirq Arm System" and wall monitor "BUZZ" (Brainlab, Munich, Germany). The individual surgical steps are explained in the video online (English).

Follow-up treatment: Full weight bearing, pain medication according to the World Health Organization (WHO) stage scheme, physiotherapy after the first postoperative day.

Evidence: Navigated and robotically assisted techniques are mainly used on the spine. These techniques are also increasingly being used on the pelvis, whereby very high levels of accuracy can also be achieved.

The rising incidence of proximal humeral fractures has made this an important topic in the treatment reality of trauma surgery. Given the variety of treatment options available, the question arises as to what extent patient age influences the choice of treatment and, consequently, the functional outcome. In our approach the morphological features of the fracture and individual patient characteristics form the foundation for determining whether surgical or conservative treatment should be pursued. Whenever possible, joint-preserving reconstruction should be the goal in younger patients. In older patients, the implantation of reverse shoulder arthroplasty is the treatment of choice. Joint replacement enables early mobilization of older patients, facilitating a swift return to daily life. Looking ahead, a further increase in the fracture incidence and a corresponding rise in the rate of necessary surgical interventions are anticipated.

The shoulder joint combines three main joints and two auxiliary joints, which enable a unique freedom of movement. Stability is primarily ensured by muscles and ligaments, making injuries, overuse or degenerative processes common causes of complaints. A systematic examination includes the anamnesis, inspection, palpation, range of motion assessment and functional tests. During the inspection the pattern of movement, muscle atrophy and malalignments are assessed. Bone and soft tissue structures are tested by palpation. Functional tests help to differentiate pathological alterations. A structured examination enables an accurate diagnosis with the option of supplementary imaging examinations.