Jan Theopold

Saisonale Verteilung von Diagnosen und DRG in der Unfallchirurgie

ZusammenfassungHintergrundDurch die Erfassung von „diagnosis related groups“ (DRG) und Diagnosen lässt sich deren Verteilung im Jahresverlauf ableiten. Ein gehäuftes Auftreten von Erkrankungen zu bestimmten Zeiten kann so identifiziert werden.Patienten und MethodeFür die Zeit von 2004–2010 erfassten wir 22.293 Hauptdiagnosen und DRG an der unfallchirurgischen Klinik. Verletzungen mit gleicher Lokalisation und Behandlung wurden zusammengefasst.ErgebnisseDie häufigsten Verletzungen waren das Schädel-Hirn-Trauma, Wirbelkörper- und Unterschenkelfrakturen. Für diese zeigte sich keine Häufung im Jahresverlauf. Proximale Humerusfrakturen traten im Winter etwa 25% häufiger auf als im Sommer, Frakturen des oberen Sprunggelenks etwa 33% häufiger. Die Gonarthrose ist im Winter doppelt so oft Behandlungsdiagnose wie im Sommer.SchlussfolgerungEs gilt zu prüfen, inwiefern logisitische Folgerungen aus diesen Ergebnissen eine Effizienzsteigerung bewirken können. Das zugrunde liegende Analyseverfahren ist generell für jedes Klinikum anwendbar und stellt ein valides Controlling-Instrument dar.AbstractBackgroundRecording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected.Patients and methodsFrom 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled.ResultsThe most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer.ConclusionIt has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.BACKGROUND Recording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected. PATIENTS AND METHODS From 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled. RESULTS The most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer. CONCLUSION It has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.

Lesser tuberosity avulsion in combination with multifragment fracture of the greater tuberosity. A rare entity at the proximal humerus

Isolated fractures of the greater tuberosity represent 14-21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.ZusammenfassungIsolierte Tuberculum-majus-Frakturen machen 14–21% der proximalen Humerusfrakturen aus. Tuberculum-minus-Frakturen finden sich hauptsächlich in Einzelfallbeschreibungen. Wir berichten von einem seltenen Fall einer Kombinationsfraktur von Tuberculum majus und Tuberculum minus ohne Einbeziehung des Collum anatomicum oder chirurgicum. Der Verletzungsmechanismus scheint auf einem komplexen Zusammenspiel zwischen Abduktion, Außenrotation mit Impaktion und Scherung gegen das Glenoid und Akromion zu beruhen.AbtractIsolated fractures of the greater tuberosity represent 14–21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.

Mittelfristige klinische und radiologische Ergebnisse nach autologer osteochondraler Transplantation unter Berücksichtigung der Lebensqualität

BACKGROUND Treatment of full-thickness cartilage defects remains a challenge in musculoskeletal surgery. Autologous osteochondral transplantation represents a possible solution for the repair of affected areas. However, some problems like degenerative changes of the transplanted cylinders and the surrounding cartilage or lack of cylinder integration to the surrounding cartilage arise with this method. Thus mid-term results respecting the quality of life are useful for assessment of the method. PATIENTS/MATERIAL AND METHODS We investigated 22 patients with a mean follow-up of 88 ± 14.5 months after autologous osteochondral transplantation due to a full-thickness cartilage defect of the medial femoral condyle. Beside clinical scores we assessed at follow-up the quality of life using the SF-36 health survey and the EQ-5D. Furthermore, radiological changes were detected and MRI was performed in 21 patients. A control group of 19 patients, treated with microfracture, was matched in terms of BMI, gender and age. Exclusion criteria for this group were tibial kissing lesion, ligament instability, arthrosis and malalignment. RESULTS In a longitudinal comparison with results 13.5 months after operation, no difference in Lysholm score was found. In plain radiographs higher degrees of arthritic changes in the medial compartment compared to the unaffected knee were observed. MRI revealed a mean modified MOCART score of 41.2 ± 7.7 for the OAT group and of 39.4 ± 16.1 for the microfracture group, without being significant. For OAT patients all cylinders showed an osseous integration. However, cylinder oedema was found in 9 patients. Those patients had a higher intensity of pain on a visual analogue scale. Quality of life was better for OAT patients in the physical scale of SF-36, but not in the mental scale. CONCLUSION Autologous osteochondral transplantation has an unaltered significance in treating full-thickness cartilage defects and leads to satisfying mid-term results. The development of early arthritic changes might not be preventable by this method. Oedema of the transplanted cylinders is attended by higher pain intensity and might be an indirect sign of cartilage degeneration.

Kombinierte Tuberculum-minus-Avulsion mit Mehrfragmentfraktur des Tuberculum majus

Isolated fractures of the greater tuberosity represent 14-21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.ZusammenfassungIsolierte Tuberculum-majus-Frakturen machen 14–21% der proximalen Humerusfrakturen aus. Tuberculum-minus-Frakturen finden sich hauptsächlich in Einzelfallbeschreibungen. Wir berichten von einem seltenen Fall einer Kombinationsfraktur von Tuberculum majus und Tuberculum minus ohne Einbeziehung des Collum anatomicum oder chirurgicum. Der Verletzungsmechanismus scheint auf einem komplexen Zusammenspiel zwischen Abduktion, Außenrotation mit Impaktion und Scherung gegen das Glenoid und Akromion zu beruhen.AbtractIsolated fractures of the greater tuberosity represent 14–21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.

Saisonale Verteilung klinischer Kennzahlen (DOC-Study)

ZusammenfassungHintergrundDas Diagnosis-related groups(DRG)-System wurde 2004 verpflichtend in Deutschland eingeführt. „Case mix“ (CM), „case mix index“ (CMI) und die Fallzahl sind grundlegende Kennzahlen. Sowohl deren saisonale Verteilung und auch die Verteilung von Hauptdiagnosen und DRGs könnten zu logistischen Konsequenzen im Krankenhaus führen.MethodikZwischen 2004 und 2013 wurden alle Hauptdiagnosen und DRGs der stationären Patienten der unfallchirurgischen Klinik des Universitätsklinikums Leipzig erfasst. Die monatliche und saisonale Verteilung wurde mittels ANOVA analysiert.ErgebnisseDie durchschnittliche monatliche Fallzahl betrug 265 ± 25, der durchschnittliche CM 388,50 ± 51,75, der CMI 1,46 ± 0,15 jeweils ohne signifikante saisonale Häufung (p > 0,1). Die Gehirnerschütterung war die häufigste Diagnose im beobachteten Zeitraum (3739 Fälle) gefolgt von proximalen Humerusfrakturen (699). Signifikante Verteilungsunterschiede konnten für Humeruskopffrakturen im monatlichen (p = 0,018) sowie jahreszeitlichen Vergleich (p = 0,006) mit einem Maximum im Winter gezeigt werden. Auch Radius- (p = 0,01) und Außenknöchelfrakturen (p ≤ 0,001) treten im Winter am häufigsten auf. Weichteilverletzungen der Schulter sind im Frühjahr am seltensten (p = 0,04). DRGs weisen keine saisonale Verteilungshäufung auf (p > 0,1).DiskussionDie signifikante Häufung von Verletzungen in bestimmten Monaten/Jahreszeiten sollte in Bezug auf logistische Konsequenzen in einer Klinik berücksichtigt werden (OP-Kapazität, Personalanforderung). Zur Erstellung einer Bedarfsanalyse ist die Betrachtung der Diagnosen besser geeignet als die von DRGs.AbstractObjectivesThe German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management.MethodsFrom 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA.ResultsThe average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1).ConclusionThe significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.OBJECTIVES The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management. METHODS From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA. RESULTS The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1). CONCLUSION The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

Detection of articular perforations of the proximal humerus fracture using a mobile 3D image intensifier – a cadaver study

BackgroundThe purpose of this study was to investigate the accuracy of perforation detection with multiplanar reconstructions using a mobile 3D image intensifier.MethodsIn 12 paired human humeri, K-wires perforating the subchondral bone and placed just below the cartilage level were directed toward five specific regions in the humeral head. Image acquisition was initiated by a fluoroscopy scan. Within a range of 90°, 45° external rotation (ER) and 45° internal rotation (IR). The number and percentage of detected perforating screws were grouped and analyzed. Furthermore, the fluoroscopic images were converted into multiplanar CT-like reconstructions. Each K-wire perforation was characterized as “detected” or “not detected”.ResultsIn the series of fluoroscopy images in the standard neutral position at 30° internal rotation, and 30° external rotation, the perforations of all K-wires (n = 56) were detected. Twenty-nine (51.8%) of them were detected in one AP view, 22 (39.3%) in two AP views, and five (8.9%) in three AP views. All K-wire perforations (100%, n = 56) were detected in multiplanar reconstructions.ConclusionIn order to reveal all of the intraoperative and postoperative screw perforations in a “five screw configuration”, conventional AP images should be established in both the neutral positions (0°), at 30° internal rotation and 30° external rotation. Alternatively, the intraoperative 3D scan with multiplanar reconstructions enables a 100% rate of detection of the screw perforations.

Verletzungen der oberen Halswirbelsäule

Rund 30% aller Halswirbelsäulenverletzungen entfallen auf die obere Halswirbelsäule, wobei mit steigendem Lebensalter die Frakturen des zweiten Halswirbelkörpers prozentual zunehmen: Bezogen auf alle Verletzungen der Halswirbelsäule finden sich bei den unter 60-Jährigen zu 21% Frakturen des zweiten Halswirbelkörpers, bei den 60- bis 75-Jährigen zu 28% und bei den über 75-Jährigen zu 54% [1]. Auch die Art der Verletzung ist altersabhängig: Bei jüngeren Patienten dominieren aufgrund der guten Knochenqualität die ligamentären Läsionen, bei älteren überwiegen die knöchernen Verletzungen.

Osteoid Osteoma of the Proximal Fibula: An Uncommon Location with the Indication for Open Surgery

Purpose. This is a case report of a patient with an osteoid osteoma of the proximal fibula. The objective is to illustrate a rare tumor location that requires open surgery due to closeness of neurological structures. Methods. Clinical and roentgenographic findings, treatment, and histological appearance are presented. Results. Local pain and swelling of the proximal fibula with improvement under salicylates led to the diagnosis of an osteoid osteoma, what was confirmed with an MRI scan. Due to proximity to the common peroneal nerve, we decided for open surgery. During the operation, the nerve was seen to cross the tumor site making it necessary to retract it to expose the entire tumor. Histologically, typical features of osteoid osteoma with a rather well-defined nidus surrounded by sclerotic bone were seen. A complete removal was performed. Conclusion. Osteoid osteomas of the proximal fibula are rare. When planning surgery, the common peroneal nerve must be identified, and its further distal course should be taken into account to avoid iatrogenic damage to the nerve.

Neue Repositionstechnik bei akuten posterioren Luxationen

Herr Lubojacký beschreibt eine interessante Repositionstechnik akuter posteriorer Luxationen. Die beschriebenen Fälle sprechen für eine erfolgreicheTechnik. Eine alleinige Abduktion des Armes birgt jedochunterUmständendieGefahr eines weiteren Verhakens des Humeruskopfes und demzufolge über den langen Hebel des Armes ebenso die Gefahr einer Fraktur des Humeruskopfes. Die in klassischer Weise weithin empfohlene Innenrotation des Armes dreht den Reverse-Hill-Sachs-Defekt aus der Gefahrenzone heraus und verhindert somit eine Abscherung des Kopfes.

Snapping knee syndrome caused by semitendinosus and semimembranosus tendons. A case report

We report the case of a 24-year-old female triathlon athlete with a snapping syndrome of both the distal semimembranosus and the semitendinosus tendon which has not been described so far. The semitendinosus tendon was harvested whereupon snapping has diminished. Tenoscopy and digital palpation showed the semimembranosus tendon to cause the snapping, as well. A careful step-by-step release of the anterior insertion of the tendon was performed with the result of a snapping-free range of motion of the patients knee.