Unfallchirurgie (Heidelberg, Germany)最新文献

The full clinical picture of a gas gangrene infection is an absolute rarity. The mechanism of development can be either traumatic or spontaneous (e.g., hematogenous seeding in occult colon carcinoma). In particular, the rare pathogen Clostridium septicum appears to be associated with spontaneously occurring gas gangrene. Diabetes mellitus is a significant risk factor. The mortality rate of the disease is around 50%, even with maximum therapeutic efforts, and the course of the disease is fulminant in the majority of cases. Initial symptoms are unspecific and make early diagnosis difficult. Treatment consists of high-dose antibiotics in combination with radical surgical debridement and, if necessary, supplementary hyperbaric oxygen therapy.

The question of the need for generalists and specialists in trauma surgery is controversially discussed concerning the challenges in the healthcare system, the interdisciplinary nature of the discipline, and the consequences of increasing specialization. The hospital reform as well as the availability of personnel and financing are discussed as central points. For high-quality patient care it is essential that the balancing act between generalists and specialists is successful. Effective interdisciplinary collaboration and holistic thinking are crucial to overcome the challenges in the healthcare system and to fulfil the needs of patients.

Background: The German hospital landscape is undergoing comprehensive changes due to the increasing aging population and staff shortages in the healthcare sector. These changes are driven by the current hospital reform and the guidelines of the Federal Joint Committee (G-BA) for the treatment of proximal femoral fractures.

Objective: To investigate the effects of the hospital reform and the implementation of the G‑BA guidelines for the treatment of proximal femoral fractures in Saxony.

Methods: Based on the number of proximal femoral fracture surgeries performed in all certified trauma centers in Saxony (East Saxony/West Saxony Trauma Network) in 2019 and 2022, a simulation was conducted to visualize the implementation of the G‑BA guidelines and the hospital reform.

Results: Applying the criteria of the G‑BA resolution results in a reduction of hospitals treating proximal femoral fractures in Saxony from 42 to 28 (-33%). The implementation of the planned hospital reform further reduces the number of such hospitals to 15 (-64%). This reduction leads to a significant increase in case numbers in the remaining hospitals (twofold to threefold) and up to a fourfold increase by 2030. This comes with an increased need for operating capacities (1.2 operating rooms per week) and about 7400 secondary transfers per year. In the districts of North Saxony, Bautzen, Central Saxony, and the Erzgebirge District, no hospital would be available to treat geriatric proximal femoral fractures.

Conclusion: The planned reform and the current implementation of the G‑BA resolution pose a high risk to create gaps in care in Saxony with a markedly reduced number of hospitals involved in treatment of proximal femoral fractures. The necessary operating resources and inpatient capacities in the remaining hospitals are insufficient to care for the expected number of patients given the personnel and capacity shortages.

For several years now, the question has been asked whether there is still any need for generalists in surgery. Those who still believe in generalists are often described as stuck in the past, because the only specialization is modern. There is no doubt that specialization is well underway and that patient care has certainly improved as a result. Nevertheless, the question remains whether providing care to the population across the board and in all situations for which we must be prepared is effective. If generalists are still needed then for what, for which situation, for which task and how must they be trained and educated? The following article addresses these questions and attempts to find an answer, supplemented by a brief look into the future.

Background: Individual mobility in road traffic is of high importance in Germany, both individually and socioeconomically; however, diseases and injuries of the musculoskeletal system in particular can lead to temporary impairments. The aim of this prospective patient survey was to record how patients assessed their driving capability during an injury and the associated immobilization and on what basis the decision on driving capability was made on the part of the patients.

Material and methods: A systematic questionnaire was used to analyze a total of 100 patients with a diagnosis in orthopedics/trauma surgery and associated joint immobilization. In addition to personal data and the injuries/illnesses, an analysis on risk tolerance was performed and patients were asked about their knowledge regarding driving capability. Finally, it was recorded which patients drove a motor vehicle and for what reasons despite immobilization.

Results: Overall, 40.2% reported knowledge of the applicable laws regarding driving capability and 55.6% considered the treating physician to be responsible regarding the decision on driving capability. The patients who drove a motor vehicle reported higher personal and professional dependence on the motor vehicle (personal: 60.6% vs. 45.7%; professional: 48.5% vs. 36.1%). In the group of patients who drove a motor vehicle during immobilization, overall a fracture was less likely to be the reason for immobilization (33.3% vs. 51.0%).

Conclusion: Overall, the patient population rated their knowledge of the law as low and viewed the treating physician as having the majority of the decision-making responsibility regarding driving capability. The patients who drove a motor vehicle during immobilization reported a higher personal as well as professional dependence on driving a motor vehicle. At the same time the injury severity had an influence on the decision, so that patients with fractures were more likely to avoid driving a motor vehicle. Further studies, particularly at the biomechanical level, are needed to ensure a better basis for the physician in making decisions with respect to the driving capability of orthopedic and trauma surgery patients.

Despite maximally motivated and professionally outstanding young talent, the particularly stressful surgical disciplines have recruitment concerns. In recent years various sections and subsidiary societies of the German Society for Orthopedics and Trauma Surgery (DGOU) have developed and distributed personnel and institution-related certificates. Organ-specific and procedure-specific certificates are very popular to confer increased visibility to individuals and institutions. Many specialists for orthopedics and trauma surgery specialized early in fields, such as foot, knee, shoulder, elbow or arthroscopic surgery. General traumatology, treatment of polytrauma and complex traumatology of the chest and abdomen are becoming more and more unattractive. Knife attacks and also the "truck attack" at the Breitscheidplatz in Berlin illustrate the smoldering terror situation in Germany. The Federal Criminal Police Office also recently announced that the incidence of domestic violence increased by 6.5% in 2023 alone. This cannot be mastered with specialization alone. The visibility and the attractiveness of specialized trauma surgery must be increased and structures for appropriate specialization must be achieved. The possible introduction of a qualification "specialized trauma surgery" is discussed. In current considerations of the German Society of Trauma Surgery (DGU), the Academy for Trauma Surgery (AUC) and the Working Group for Osteosynthesis Issues (AO) Trauma Germany, a stepwise acquisition of defined knowledge from the principles on basic contents up to specialization and expert knowledge, could lead to the acquisition of the qualification in "specialized trauma surgery".

Objective of surgery: The aim of this surgery is to safeguard the multifragmentary and nondisplaced talus fracture (body and neck) against secondary dislocation in a navigated and minimally invasive manner using screw osteosynthesis.

Indications: Due to the young age of the patient in the presented case and the risk of a possible secondary dislocation, the decision was made in favor of surgical treatment.

Contraindications: Soft tissue swelling, wound infections and allergies to the osteosynthesis material.

Surgical technique: The video is available online (in English) and shows the individual surgical steps in detail. Preoperative computed tomography (CT) imaging and screw planning. Attachment of the reference array. 1) Cone beam CT (CBCT) scan, image fusion and fusion control. Planning of the minimally invasive skin incisions. Skin incision, navigated drilling and insertion of the K‑wires. 2) CBCT scan and position check of the K‑wires, fine adjustment if necessary. Insertion of the screws. 3) CBCT scan with subsequent position check of the screws, retightening of the screws if necessary. Performed in the Robotic Suite (Brainlab, Munich, Germany) using the following elements: navigation unit curve navigation system, movable robotic 3D CBCT, "Loop-X" and wall monitor "BUZZ".

Follow-up: Postoperative X‑ray and CT to control the position of the implants. Partial weight-bearing of the foot with 10 kg sole contact for 6 weeks. Physiotherapy with active and passive joint mobilization. Thrombosis prophylaxis with enoxaparin sodium. Optional implant removal after approximately 1 year.

Evidence: Navigated operations are routine, so far mainly in the area of the spine. This article shows that navigated extremity surgery can be successfully performed in hybrid operating theaters.

Acute sprains and ruptures of the lateral ankle ligaments are the most common injuries of the ankle joint. They are often related to sporting activity and predominantly affect individuals under 40 years old. Lateral ligament injuries occur due to supination trauma. The anterior talofibular ligament is most commonly affected often in combination with the calcaneofibular ligament. In contrast, ruptures of all three lateral ankle ligaments (luxatio pedis supinatoria) or complete ruptures of the medial and lateral ligaments (luxatio pedis cum talo) are extremely rare. The clinical diagnostics have a high sensitivity and specificity and X-ray images are used to exclude fractures and other accompanying injuries. In cases of acute injuries conservative treatment in an orthosis for 5-6 weeks to prevent supination is the method of choice. Surgical treatment is reserved for exceptional indications. For both operative and conservative forms of treatment the functional treatment with initial movement exercises in a semi-rigid orthosis and the following proprioceptive training are crucial for the success of treatment and show superior results compared to immobilization in a surgical cast.