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Hintergrund
Die Symphysensprengung mit entsprechender Diastase kann durch eine Symphysenplatte stabilisiert werden.
Fragestellung
Welche Beckenverletzungen werden mit einer Symphysenplatte stabilisiert und wie ist das Outcome?
Material und Methoden
Retrospektive Auswertung von 64 Patienten über einen Untersuchungszeitraum von 24 Monaten.
Ergebnisse
Es waren 56 Patienten männlich, 8 weiblich und das mittlere Alter betrug 44 Jahre (SD ± 17). Unfälle im Straßenverkehr waren der führende Grund für die Beckenverletzung. Die Verteilung nach AO-Klassifikation zeigte sich wie folgt: 14-mal B1-, 10-mal B2-, 5‑mal B3-, 23-mal C1-, 9‑mal C2- und 3‑mal C3-Verletzungen. Die Verteilung nach Young und Burgess ergab: 9‑mal APC-I-, 18-mal APC-II-, 13-mal APC-III-, 9‑mal LC-I-, 3‑mal LC-II-, 2‑mal LC-III- und 10-mal VS-Verletzungen. Der mittlere Injury Severity Score (ISS) betrug 32 und die mittlere stationäre Verweildauer 29 Tage (pos. Korrelation p ≤ 0,001). Im Verlauf war eine radiologische Implantatlockerung bei 52 Patienten nachweisbar. Therapierelevante Komplikationen gab es in 14 Fällen. Hierbei war das Implantatversagen (n = 8) der Hauptgrund für eine operative Revision.
Diskussion
Obwohl die radiologische Implantatlockerung häufig beobachtet wird, ist sie nur selten Grund für einen Revisionseingriff. Kommt es hingegen zum vollständigen Implantatversagen, tritt dies meist innerhalb der ersten postoperativen Wochen auf und ist revisionsbedürftig. Eine frühzeitige Abklärung durch Röntgenbildgebung sollte bei Verdacht erfolgen.
Hintergrund
Die Fotodokumentation von offenen Frakturen, Wunden, Dekubitalulzera, Tumoren oder Infektionen ist ein wichtiger Bestandteil der digitalen Patientenakte. Bisher ist unklar, welchen Stellenwert diese Fotodokumentation bei der Abrechnungsprüfung durch den Medizinischen Dienst der Krankenkassen (MDK) hat.
Fragestellung
Kann eine Smartphone-basierte Fotodokumentation die Verteidigung von erlösrelevanten Diagnosen und Prozeduren sowie der Verweildauer verbessern?
Material und Methoden
Ausstattung der Mitarbeiter mit digitalen Endgeräten (Smartphone/Tablet) in den Bereichen Notaufnahme, Schockraum, OP, Sprechstunden sowie auf den Stationen. Retrospektive Auswertung der Abrechnungsprüfung im Jahr 2019 und Identifikation aller Fallbesprechungen, in denen die Fotodokumentation eine Erlösveränderung bewirkt hat.
Ergebnisse
Von insgesamt 372 Fallbesprechungen half die Fotodokumentation in 27 Fällen (7,2 %) zur Bestätigung eines Operationen- und Prozedurenschlüssels (OPS) (n = 5; 1,3 %), einer Hauptdiagnose (n = 10; 2,7 %), einer Nebendiagnose (n = 3; 0,8 %) oder der Krankenhausverweildauer (n = 9; 2,4 %). Pro oben genanntem Fall mit Fotodokumentation ergab sich eine durchschnittliche Erlössteigerung von 2119 €. Inklusive Aufwandpauschale für die Verhandlungen wurde somit ein Gesamtbetrag von 65.328 € verteidigt.
Diskussion
Der Einsatz einer Smartphone-basierten Fotodokumentation kann die Qualität der Dokumentation verbessern und Erlöseinbußen bei der Abrechnungsprüfung verhindern. Die Implementierung digitaler Endgeräte mit entsprechender Software ist ein wichtiger Teil des digitalen Strukturwandels in Kliniken.
Background
The role of cement-augmented screw fixation for calcaneal fracture treatment remains unclear. Therefore, this study was performed to biomechanically analyze screw osteosynthesis by reinforcement with either a calcium phosphate (CP)-based or polymethylmethacrylate (PMMA)-based injectable bone cement.
Methods
A calcaneal fracture (Sanders type IIA) including a central cancellous bone defect was generated in 27 synthetic bones, and the specimens were assigned to 3 groups. The first group was fixed with four screws (3.5 mm and 6.5 mm), the second group with screws and CP-based cement (Graftys (R) QuickSet; Graftys, Aix-en-Provence, France), and the third group with screws and PMMA-based cement (Traumacem (TM) V+; DePuy Synthes, Warsaw, IN, USA). Biomechanical testing was conducted to analyze peak-to-peak displacement, total displacement, and stiffness in following a standardized protocol.
Results
The peak-to-peak displacement under a 200-N load was not significantly different among the groups; however, peak-to-peak displacement under a 600- and 1000-N load as well as total displacement exhibited better stability in PMMA-augmented screw osteosynthesis compared to screw fixation without augmentation. The stiffness of the construct was increased by both CP- and PMMA-based cements.
Conclusion
Addition of an injectable bone cement to screw osteosynthesis is able to increase fixation strength in a biomechanical calcaneal fracture model with synthetic bones. In such cases, PMMA-based cements are more effective than CP-based cements because of their inherently higher compressive strength. However, whether this high strength is required in the clinical setting for early weight-bearing remains controversial, and the non-degradable properties of PMMA might cause difficulties during subsequent interventions in younger patients.
Background
Tibial head depression fractures demand a high level of fracture stabilization to prevent a secondary loss of reduction after surgery. Elderly individuals are at an increased risk of developing these fractures, and biomechanical investigations of the fractures are rare. Therefore, the aim of this study was to systematically analyze different types of osteosyntheses in combination with two commonly used bone substitutes.
Methods
Lateral tibial head depression fractures were created in synthetic bones. After reduction, the fractures were stabilized with eight different treatment options of osteosynthesis alone or in combination with a bone substitute. Two screws, 4 screws and a lateral buttress plate were investigated. As a bone substitute, two common clinically used calcium phosphate cements, Norian® Drillable and ChronOS™ Inject, were applied. Displacement of the articular fracture fragment (mm) during cyclic loading, stiffness (N/mm) and maximum load (N) in Load-to-Failure tests were measured.
Results
The three different osteosyntheses (Group 1: 2 screws, group 2: 4 screws, group 3: plate) alone revealed a significantly higher displacement compared to the control group (Group 7: ChronOS™ Inject only) (Group 1, 7 [p < 0.01]; group 2, 7 [p = 0.04]; group 3, 7 [p < 0.01]). However, the osteosyntheses in combination with bone substitute exhibited no differences in displacement compared to the control group. The buttress plate demonstrated a higher normalized maximum load than the 2 and 4 screw osteosynthesis. Comparing the two different bone substitutes to each other, ChronOS™ inject had a significantly higher stiffness and lower displacement than Norian® Drillable.
Conclusions
The highest biomechanical stability under maximal loading was provided by a buttress plate osteosynthesis. A bone substitute, such as the biomechanically favorable ChronOS™ Inject, is essential to reduce the displacement under lower loading.
The coronal unicondylar fracture of the distal femur (AO 33-B3) is a rare intraarticular injury within the weight bearing area of the knee, initially described by Albert Hoffa in 1904. We report an unusual combination of a Hoffa fracture with lateral patellar dislocation in a young adult. Our patient sustained the injury by a sudden twist of his leg during sports. He presented clinically with knee swelling, dislocation of the patella, and localized tenderness; unable to bare weight. After plane radiograph confirmed the injury, manual reduction of the patella was done by hyperextension of the knee and medialward pressure. Afterwards, a CT scan and MRI were conducted. The injury was surgically treated with lag-screws, locking-plate and MPFL-reconstruction.
Background
Suture pretension during tendon repair is supposed to increase the resistance to gap formation. However, its effects on the Bunnell suture technique are unknown. The purpose of this study was to determine the biomechanical effects of suture pretension on the Bunnell and cross-lock Bunnell techniques for tendon repair.
Methods
Eighty porcine hindlimb tendons were randomly assigned to four different tendon repair groups: those repaired with or without suture pretension using either a simple Bunnell or cross-lock Bunnell technique. Pretension was applied as a 10 % shortening of the sutured tendon. After measuring the cross-sectional diameter at the repair site, static and cyclic biomechanical tests were conducted to evaluate the initial and 5-mm gap formation forces, elongation during cyclic loading, maximum tensile strength, and mode of failure. The suture failure mechanism was also separately assessed fluoroscopically in two tendons that were repaired with steel wire.
Results
Suture pretension was accompanied by a 10 to 15 % increase in the tendon diameter at the repair site. Therefore, suture pretension with the Bunnell and cross-lock Bunnell repair techniques noticeably increased the resistance to initial gap formation and 5-mm gap formation. The tension-free cross-lock Bunnell repair demonstrated more resistance to initial and 5-mm gap formation, less elongation, and higher maximum tensile strength than the tension-free Bunnell repair technique. The only difference between the tensioned cross-lock Bunnell and tensioned Bunnell techniques was a larger resistance to 5-mm gap formation with the cross-lock Bunnell technique. Use of the simple instead of cross-lock suture configuration led to failure by suture cut out, as demonstrated fluoroscopically.
Conclusion
Based on these results, suture pretension decreases gapping and elongation after tendon repair, and those effects are stronger when using a cross-lock, rather than a regular Bunnell suture. However, pretension causes an unfavorable increase in the tendon diameter at the repair site, which may adversely affect wound healing.
Background
Barbed suture material offers the possibility of knotless flexor tendon repair, as suggested in an increasing number of biomechanical studies. There are currently two different absorbable barbed suture products available, V-Loc™ and Stratafix™, and both have not been compared to each other with regard to flexor tendon repair. The purpose of this study was to evaluate both suture materials for primary stability under static and cyclic loading in a biomechanical ex vivo model.
Methods
Forty fresh porcine flexor digitorum profundus tendons were randomized in two groups. A four-strand modified Kessler suture technique was used to repair the tendon either with a 3–0 V-Loc™ or 3–0 Stratafix™ without a knot. Parameters of interest were mode of failure, 2-mm gap formation force, displacement, stiffness and maximum load under static and cyclic testing.
Results
The maximum load was 42.3 ± 7.2 for the Stratafix™ group and 50.7 ± 8.8 N for the V-Loc™ group. Thus, the ultimate tensile strength was significantly higher for V-Loc™ (p < 0.05). The 2-mm gap occurred at 24.8 ± 2.04 N in the Stratafix™ group in comparison to 26.5 ± 2.12 N in the V-Loc™ group (n.s.). Displacement was 2.65 ± 0.56 mm in the V-Loc™ group and 2.71 ± 0.59 mm in the Stratafix™ group (n.s.). Stiffness was 4.24 ± 0.68 (N/mm) in the V-Loc™ group and 3.85 ± 0.55 (N/mm) the Stratafix™ group (n.s.). Those measured differences were not significant.
Conclusion
V-Loc™ demonstrates a higher maximum load in tendon reconstruction. The differences in 2-mm gap formation force, displacement and stiffness were not significant. Hereby, the V-Loc™ has an advantage when used as unidirectional barbed suture for knotless flexor tendon repair.