Unfallchirurgie (Heidelberg, Germany)最新文献

In-hospital disaster medicine demands a structured, pragmatic and resource-efficient approach in the surgical treatment of patients under extreme conditions. The Surgical Working Group for Military and Emergency Surgery (CAMIN) of the German Society of General and Visceral Surgery (DGAV) has developed guideline-based recommendations for making decisions, prioritization and management in disaster scenarios. The guidelines address the special challenges of atypical trauma patterns, as can be found in terrorist attacks or situations with mass casualties, such as gunshot or blast injuries. They highlight the use of damage control surgery (DCS), the differentiated application of laparotomy, open abdominal management and the triage of general and oncological procedures. The clinical assessment, focused diagnostics (e.g., extended focussed assessment with sonography in trauma, eFAST) and staged surgical algorithms are at the heart of this concept, aiming to ensure the highest level of patient safety and effectiveness despite critical resource limitations. The overriding principle is: "do the most for the most."

Hoffa fractures are coronal plane fractures of the femoral condyle and overall represent a rare fracture entity. These fractures are predominantly caused by high-energy trauma und usually involve the lateral femoral condyle. An axial load to the femoral condyle with the knee in 90° or more of flexion produces the typical fracture pattern. In the initial radiological diagnostics the fracture is often overlooked, therefore, a computed tomography (CT) examination is indicated for the diagnostics and planning of surgery (selection of the access and the implant). The operative treatment with an equivalent of the Herbert screw achieves a good functional result, which corresponds to the preferred osteosynthesis implant for simple Hoffa fractures without a debris zone. Meniscal, chondral and ligamentous lesions are frequent collateral injuries of Hoffa fractures and can impact on the functional outcome. Therefore, additional magnetic resonance imaging (MRI) diagnostics and intraoperative stability tests are recommended. Despite differentiated diagnostics and management the trajectory of Hoffa fractures is often associated with complications and therefore require a structured rehabilitation protocol and follow-up with radiological controls.

An emergency doctor became infected with group A streptococci during resuscitation and developed necrotizing fasciitis (NF) on his arm and thorax. The patient could be cured by antibiotic treatment and several operations. This case aims to increase the awareness for the risk of NF for medical personnel and makes an appeal to personnel involved in emergencies to consider the relevance of personal protective equipment.

Background: Although patellar fractures are one of the rarer entities in the routine clinical practice, the biomechanical functioning of the knee joint must be correctly addressed. The numerous biomechanical data are often not considered in routine clinical practice, which is reflected in avoidable follow-up interventions.

Aim of the work: The subject of this review article is the concise explanation of the recording of fracture morphology, the resulting conclusions about the fracture character, a summary of the international biomechanical key results and the resulting meaningful treatment procedures.

Conclusion: With this review article the Fracture Committee of the German Knee Society would like to propose a treatment recommendation for the surgical treatment of patellar fractures.

Simulators and immersive technologies, such as virtual reality and augmented reality are becoming increasingly more important for training in orthopedic and trauma surgery. They enable safe and standardized training of surgical skills and contribute to improving patient safety. This article provides an overview of various simulation techniques, their evaluation methods and the challenges of their integration into orthopedic and trauma surgery further education.

Background: The current guidelines of the German Federal Joint Committee on the treatment of proximal femoral fractures require that patients with a proximal femoral fracture receive surgical treatment as soon as possible and within 24 h of admission. This is intended to reduce perioperative complication rate and mortality.

Objective: The aim of this study was to analyze the hospital mortality as well as complication rates and types in relation to the preoperative waiting time.

Methodology: From 2010 to 2020, a total of 575 patients with femoral neck fractures treated with a bipolar prosthesis were retrospectively analyzed with respect to hospital mortality and the occurrence of complications. Patients with pathological fractures, femoral neck fractures more than 4 weeks old and those treated with osteosynthesis were excluded. Patient-specific data, hospital mortality and complication rates and types were recorded.

Results: During the study period, the implementation of the given guidelines resulted in a reduction in the preoperative waiting time from a median of 38 h in 2010 to 19 h in 2020. Surgical treatment was performed on average after 14.2 h in patients who had surgery within 24 h after admission and on average after 40.2 h for those who had surgery after 24 h. The average American Society of Anesthesiologists (ASA) score for all 575 patients was 2.76. The group of patients who had surgery after more than 24 h had a significantly higher ASA classification (p = 0.024). A total of 12 (4.2%) patients in the group surgically treated within 24 h died, compared to 24 (8.5%) deaths in the group surgically treated after 24 h (p = 0.035). The complication rate for the entire cohort was 15% (88 patients). There was no difference in the occurrence of complications and the overall complication rate with respect to the timing of surgery.

Conclusion: During the study period the preoperative waiting time was halved from 39h to 19 h. Patients who were surgically treated within 24 h had a significantly lower hospital mortality than those surgically treated after 24 h; however, the group surgically treated after 24 h simultaneously showed higher baseline comorbidities and in the adjusted analysis for age and ASA score, the 24‑h threshold no longer emerged as an independent risk factor for hospital mortality. Regarding complication rates, no significant differences were found between the groups based on the timing of surgery.

The integration of artificial intelligence (AI) into medical education and advanced training is gaining in importance. Especially in advanced surgical training AI offers potential to support both theoretical and practical learning processes. Applications include interactive chatbots, digital assistance systems and automated assessment of surgical skills using computer vision and machine learning. This article provides an overview of current developments, opportunities and challenges of AI in advanced surgical training.

Fractures of the talar head, lateral tubercle of the talus and posterior tubercle of the talus are summarized under the term peripheral talar fractures. These injuries are rare and are often overlooked on conventional X‑rays, which is why they are often diagnosed after a delay. When overlooked they are very likely to lead to poorer outcomes. In all cases where an injury is suspected computed tomography (CT) imaging should be carried out to detect or exclude a peripheral talar fracture and concomitant injuries and to understand the injury. Nonoperative treatment can be used for nondisplaced fractures, excision can be considered for small displaced fragments and open reduction and internal fixation should be considered for displaced fragments of sufficient size. The surgical approach is based on the morphological characteristics of the fracture and the localization. Due to the scarce evidence available treatment recommendations are based solely on expert opinions.

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.