Zeitschrift für Orthopädie und Unfallchirurgie
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The incidence of fractures among epileptics is frequent and mostly occurs by direct trauma due to falls caused by seizures. The risk of fractures is estimated to be 50 % higher in epileptics than in the general population. Most of the fractures affect the proximal femora and the hip joint. ⋯ If they occur bilaterally, this is pathognomonic for seizuring. Besides this, shoulder dislocation and bilateral dislocation fractures of the humeral head, however, are far more rare even among epileptics but pathognomonic for seizure. In this case report we present a female patient with bilateral dislocation fracture of the humeral head due to first clinical manifestation of a tonic-clonic seizure without direct trauma.
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As the need for joint replacements will continue to rise, the outcome of primary total hip replacement (THR) must be improved and stabilised at a high level. In this study, we investigated whether pre-operative risk factors, such as gender, age and body weight at the time of the surgery or a restricted physical status (ASA-Status > 2 or Kellgren and Lawrence grade > 2) have a negative influence on the post-operative results or on patient satisfaction. ⋯ The quality of results after primary THR depends on preoperative factors. Existing comorbidities have a significant influence on the duration of surgery and therefore on the perioperative rate of complications and the postoperative outcome. Despite improvements in the functional and subjective outcome after primary THR, an adverse preoperative symptomatic status is associated with less favourable postoperative results.
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In the two stage revision of periprosthetic joint infection (PJI), the prosthesis-free interval may be reduced to 2-3 weeks (fast-track). This is an innovative approach with clear advantages for both the patient and health insurance stakeholders. The prosthesis-free interval with conventional two-stage PJI slow-track procedures lasts 6-12 weeks. In Germany, the patient spends this time either at home or in a geriatric hospital. This period is mainly used to manage infections. The patient is then readmitted for implantation of the revision prosthesis. This readmission then leads to additional reimbursement, as this is formally a new insurance case. Despite this double payment, the costs for the treatment of such complex diseases are not covered by the German DRG system. If hospitals are to implement the proven fast-track concept, they need to invest in a multidisciplinary medical team. This would be responsible for defining infections, selecting patients, and improving diagnosis and antimicrobial therapy and should thus improve the rates of cure of infections. However, the G-DRG reimbursement system treats the two surgeries as a single case, providing that less than 30 days lies between the two interventions; as a result, the reimbursement is inadequate for patients with the fast-track interval. We analysed the theoretical financial deficit for a hospital and describe the cost-saving potential for payers applying the fast-track interval rather than the slow-track approach in selected PJI patients, using a comprehensive and individualised treatment concept. ⋯ The current G-DRG reimbursement system paradoxically rewards slow-track intervals for two-stage revisions and jeopardizes the implementation of beneficial fast-track intervals in clinical routine. Patients treated with slow-track therapy experience longer and more debilitating treatment, accompanied by greater healthcare costs for both payers and hospitals. New treatment concepts which offer better care at lower cost should attract the attention of policy makers, clinicians, and the public.
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In geriatric patients the management of odontoid type II fractures is complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2) with an increased lever arm. Furthermore, a few of the odontoid fractures are accompanied by an atlas fracture resulting in the "atlantoaxial unhappy triad". Posterior C1/C2 spondylodesis with bilateral Magerl screws and C1 hooks is a strong biomechanical construct, however, the posterior approach is associated with several drawbacks such as increased risk of infection and increased blood loss. In contrast, the anterior bilateral C1/C2 transarticular screw fixation with additional odontoid screw fixation is also a known technique. Advantages of the anterior approach are shorter surgery time, lower intraoperative blood loss and lower risk of infection. ⋯ This study included 16 patients who underwent surgery for C1-C2 lesions. There were 9 females and 7 males. Median age at the time of operation was 76 years. At the time of surgery, fractures were classified as follows: 8 patients showed an "atlantoaxial unhappy triad", 8 patients had a type II odontoid fracture complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2). Average time for operative treatment was 100 ± 36.35 minutes with a median intraoperative fluoroscopy time of 161 seconds. The intraoperative blood loss was minimal (45 ± 22.80 ml). Length of stay was documented with 10 (± 4.60) days whereby the patients spent on average 0.8 days in the intensive care unit postoperatively. No serious morbidities, such as esophageal perforation, carotid artery laceration, neurological deterioration, and airway obstruction were reported. All cases of transient dysphagia resolved gradually and spontaneously without therapy. In 4 cases (25 %) we detected a penetration of the atlantooccipital joint without functional impairment. In one case we have seen an implant failure. The technique of anterior screw fixation of odontoid and bilateral transarticular C1-C2 anterior screw fixation provides a fast surgery without higher morbidity. Based on our findings, this technique and its feasibility is an alternative to known posterior C1/C2 spondylodesis in the elderly.