T. Tiling

Does the mode of data collection change results in a subjective knee score? Self-administration versus interview.

Our objective was to compare the effect of two meth ods of data collection on results in a functional knee score. Two Lysholm scores were obtained for 61 pa tients 1 year after anterior cruciate ligament surgery at the same clinic visit. First, the patients completed a self-administered questionnaire, and second, the Ly sholm score form was completed by the investigator in the course of a patient interview. A comparison of the scores revealed that the mean score was significantly lower with self-administration (self, 89.3 ± 10.6; inter viewer, 92.2 ± 7.4) (P = 0.0035, Wilcoxon rank sum test). The assignment to one of four categories (excel lent, good, fair, poor) was also significantly altered by the manner of data collection. Nineteen patients (31 %) were assigned to different categories based on the mode of data collection. We believe that the major reason for a better score result with an interview was the presence of interview bias. The more the investi gator is involved in the treatment of the patient, the greater the influence of this bias may be. To avoid such potential bias we suggest that a standardized self- administered questionnaire be used as the method of choice for obtaining subjective data in clinical settings.

Trauma score systems: Cologne Validation Study

BACKGROUND Most standard trauma score systems have been developed and validated in the United States. However, trauma differs between the United States and Germany. This prospective study tested the validity of eight current trauma scoring systems (Glasgow Coma Scale, Trauma Score, Revised Trauma Score, Injury Severity Score, TRISSTS, TRISSRTS, Prehospital Index, Polytraumaschluessel) in 612 patients in Cologne. METHODS Between January 1, 1987, and December 31, 1987, 2,136 trauma related emergencies were seen by emergency physicians in the field. All trauma patients with a Trauma Score below 16 and a random sample of 10% of patients with a Trauma Score of 16 were included in the study (n = 625). Follow-up was successfully completed for 612 patients (97%). Their hospital outcome was correlated with their individual score result. RESULTS All trauma score systems under study showed high accuracy rates. TRISSRTS and TRISSTS performed best with values of above 0.97 for the area under the receiver operating characteristics curve. CONCLUSION We conclude that the standard trauma score systems are valid tools for patient classification and support TRISSRTS as the international reference score system for the assessment of injury severity. This validation will allow comparisons between different trauma care systems.

Functional treatment and early weightbearing after an ankle fracture : A prospective study

Objective: Postoperative care for ankle fractures is generally 1 of 2 regimens: 1) functional treatment combined with early weightbearing (EWB), or 2) immobilization in a cast/orthosis for 6 weeks without weightbearing (6WC). The objective of this study was 2-fold: 1) to follow a prospective group treated with EWB as to long-term subjective and objective outcomes, and 2) to compare a subset of this group with a matched group of historic controls treated with 6WC. Design: Prospective, clinical, cohort observation, and retrospective matched pair analysis. Setting: University hospital, level 1 trauma center. Patients: Forty-three patients (20 males; mean age, 49 ± 14 years) with operated Weber B/C fractures underwent EWB. For comparison, 23 patients of this group were matched to a same number of historic controls with respect to age, gender, body mass index, and fracture type. Intervention: Open reduction and internal fixation (ORIF) using a 1/3-tubular-fibula-plate for the fibula, and malleolar screws for the medial malleolus fracture (in cases with a bimalleolar ankle fracture) followed by EWB or 6WC. Main Outcome Measurements: Olerud and Tegner scores at follow-up (at least 12 months after surgery), time to full weightbearing, return to work, pain intensity (numerical rating scale (NRS)), and hospital stay. Statistical comparisons were performed by using the Mann-Whitney U test or Fisher exact test (P < 0.05). Results: Patients with EWB were full weightbearing at 7 ± 3 weeks and returned to work at 8 ± 5 weeks after surgery. At follow-up (mean, 20 ± 11 months after surgery), all EWB patients showed good results in the Olerud score (90 ± 13 points). Matched-pair analysis in 23 patients in each group revealed differences between EWB and 6WC groups for hospital stay (mean, 10.8 ± 4.7 vs. 13.6 ± 6 days; P = 0.12), time to full weightbearing (mean, 7.7 ± 3.1 vs. 13.5 ± 9.4 weeks; P = 0.01), and time until return to work (mean 9.2 ± 5.5 vs. 10.8 ± 7 weeks; P = 0.63). No differences concerning pain intensities were observed (EWB vs. 6WC: NRS = 1.9 vs. 1.7; P = 0.12). At follow-up, Olerud scores were generally considered good for both groups; however, mean values in EWB patients were slightly higher (87 ± 14 vs. 79 ± 19 points; P = 0.25). In both groups, the majority of patients reached their preinjury level of activity as demonstrated by Tegner scores. Conclusions: EWB patients tolerated earlier full weightbearing compared with 6WC patients, and there were no disadvantages with EWB compared with 6WC concerning hospital stay, pain intensities, time until return to work, and Olerud/Tegner Scores. Potential candidates for EWB are patients with a stable osteosynthesis of their fractured ankles as judged by the responsible surgeon, compliance, and high motivation.

Constant-Score und Neer-Score : Ein Vergleich von Scoreergebnis und subjektiver Patientenzufriedenheit

ZusammenfassungEinleitung. Der Constant- und Neer-Score sind 2 weitverbreitete Scores zur Beurteilung der Schulterfunktion nach verschiedenartigen Erkrankungen oder Verletzungen.Ziel der vorliegenden Arbeit ist ein Vergleich von subjektiver und Score-basierter Bewertung der Schulterfunktion unter der Hypothese einer deutlichen Diskrepanz zwischen Scoreergebnis und subjektiver Patienteneinschätzung insbesondere für selektionierte Patientenkollektive. Methodik. Die Schulterfunktion von 51 Patienten wurde, 1–6 Jahre nach operativ versorgter proximaler Humerusfraktur, unter Verwendung des Neer- und Constant-Score analysiert. Gleichzeitig erfolgte eine subjektive Bewertung durch die Patienten in den Kategorien “sehr gut” bis “schlecht”. Ergebnisse. Beide Scoresysteme zeigten eine gute Übereinstimmung mit einer linearen Korrelation von r=97. In der subjektiven Bewertung beurteilten 57% der Patienten ihre Schulterfunktion als “sehr gut” oder “gut”, in der Score-basierten Bewertung erreichen nur 37% (Constant) bzw. 43% (Neer) der Patienten ein entsprechendes Ergebnis. Bezogen auf die Einteilung in Ergebnisgruppen (sehr gut/gut/befriedigend/schlecht) stimmen die Ergebnisse von Neer-Score und subjektiver Einschätzung in 20 Fällen und von Constant-Score und subjektiver Einschätzung in 15 Fällen überein. Die Spearman-Rangkorrelation zwischen der subjektiven und der Score-basierten Einschätzung ist mit 0,50 (Constant) und 0,55 (Neer) nur mäßig. Bei älteren Patienten (>60 Jahre) war die subjektive Beurteilung insgesamt positiver als die Score-Bewertung. Von 20 älteren Patienten kamen 14 (Neer-Score) bzw. 16 (Constant-Score) subjektiv zu einer besseren Einschätzung ihrer Funktion als der Score. Schlussfolgerungen. Die aufgestellte Hypothese einer Diskrepanz zwischen subjektiver und Score-basierter Einschätzung wird durch unsere Ergebnisse insbesondere für ältere Patienten bestätigt. Für die Klinik bedeutet dieses, dass das “Outcome” des Patienten nicht zwangsläufig mit seinem Scoreergebnis korrelieren muss. Therapieempfehlungen und Aussagen wissenschaftlicher Arbeiten, die ausschließlich auf einer Scorebewertung basieren, können deshalb für bestimmte Patientenkollektive nicht uneingeschränkt übernommen werden.AbstractIntroduction. The Constant- and the Neer-Score are widely used to assess shoulder function after trauma or shoulder diseases.The objective of this study was to compare the correlation of score result with the patient subjective assessment. We hypothesized that there is a clinically relevant difference between the score result and the patient assessment, especially for highly selective patient groups. Methods. 51 patients were followed up after the surgical treatment of a proximal humeral fracture. For each patient the Constant- and the Neer-Score was calculated. Further, the patients were asked for a subjective assessment of their shoulder function (“excellent”, “good”, “fair”, “poor”). Results. For both score-systems a good linear correlation (r=0,97) is shown. 57% of the patients assessed their shoulder function as “excellent” or “good”, but only 37% (Constant) vs. 43% (Neer) of the patients were classified as “excellent” or “good” based on their score results. The Spearman correlation of subjective and score-based assessment was just fair with r=0,50 (Constant) and r=0,55 (Neer). When comparing the score results with the patient subjective assessment for the groups: “excellent”, “good”, “fair” and “poor”, there was a positive correlation for the Neer-Score in 20 cases and for the Constant-Score in 15 cases. Of all elderly patients (>60 years, n=20), 14 (Neer-Score) vs. 16 (Constant-Score) assessed their shoulder function as better than the score did. Conclusion. The hypothesis of a clinically relevant difference between the subjective and the score-based assessment of shoulder function can be confirmed. Our results suggest that for clinical practice, statements and therapy strategies recommended in the literature, that are just based on score results might not be valid for all patient-groups (e.g. elderly patients).

Stand der Therapie der Schultereckgelenkverletzung Ergebnisse einer Umfrage an Unfallchirurgischen Kliniken in Deutschland

ZusammenfassungDie Therapie der Schultereckgelenkverletzung, insbesondere der Typ-III-Verletzung nach Rockwood/Tossy wird kontrovers diskutiert. In der Literatur werden gute Ergebnisse für verschiedene operative Behandlungsmethoden sowie für eine rein konservative Therapie beschrieben. Das Ziel der vorliegenden Erhebung ist es, die reale Praxis der Versorgung von Schultereckgelenkverletzungen in deutschen unfallchirurgischen Kliniken darzustellen und zu analysieren.In einer anonymen schriftlichen Umfrage wurden 210 unfallchirurgische Abteilungen in Deutschland nach ihrem diagnostischen und therapeutischen Vorgehen bei Schultereckgelenkverletzungen befragt. Entsprechend einer Rücklaufquote von 49% konnten 104 Bögen ausgewertet werden.Für eine Tossy-I/II-Verletzung gaben 99 bzw. 87% der Klinken eine konservative Therapie an. Die überwiegende Mehrheit (84%) der befragten Kliniken sprachen sich für eine operative Therapie bei der Verletzung Typ Tossy III aus. Nahezu alle befürworten ein operatives Vorgehen bei Überkopfarbeitern und Leistungssportlern. Die hochgradigen Verletzungen (Rockwood IV–VI) werden fast ausschließlich operativ stabilisiert.Als operative Methode bevorzugen 37% eine temporäre Kirschner-Drahtfixierung und 32% eine coraco-claviculäre Cerclage, die in 73% der Fälle mit resorbierbaren Materialien durchgeführt wird. Übrige Operationsverfahren zeigen einen niedrigeren Stellenwert.AbstractThe therapy of acromioclavicular dislocations remains controversial. In particular, for injuries classified as Rockwood/Tossy Type III good results have been reported with different operative techniques as well as with conservative treatment. The objective of this study was to obtain data about the current treatment for Rockwood/Tossy III injuries in German trauma departments.In a countrywide anonymous survey 210 German trauma departments were asked about their diagnostic procedures and their treatment strategies for acromioclavicular injuries. 104 questionaires (49%) were returned and evaluated.In Rockwood/Tossy I/II injuries most clinics recommend conservative treatment (Rockwood/Tossy I/II: 99% / 87%). On the other hand, 84% of the clinics would operate on Type III acromioclavicular injuries – especially in athletes or overhead workers. Although 38 percent of the clinics believe that conservative treatment is equal or better than operative treatment, only 13 percent manage Type III injuries conservatively. For more severe acromioclavicular injuries (Rockwood IV to VI) all clinics recommend an operative treatment.The operative techniques of choice for acromioclavicular injuries are K-wire fixation (37%) or a coraco-clavicular cerclage (32%). Of the latter, 73% use a resorbable material, while the remainder use wires.

Welche Prognosefaktoren korrelieren mit der Alltagsaktivität (Barthel-Index) ein Jahr nach hüftgelenksnaher Fraktur? Eine prospektive Beobachtungsstudie

ZusammenfassungZiel dieser prospektiven Studie war es, aus-sagekräftige Prognosefaktoren für das Outcome bei Patienten ein Jahr nach hüftgelenksnaher Fraktur zu finden. Methodik. Vom 01.10.1996–30.09.1997 wurden alle hüftgelenksnahen Frakturen (n=98) in unserer Klinik prospektiv erfasst und im Rahmen einer systematischen “Follow-up”-Untersuchung nach 3, 6 und 12 Monaten untersucht. Hauptzielkriterium waren die Aktivitäten des täglichen Lebens gemessen am Barthel-Index. Es wurden die Variablen – Lebensalter, Geschlecht, ASA-Klassifikation, Frakturart, Art der Osteosynthese, Liegedauer und Rehabilitation – univariat untersucht und mit dem Barthel-Index korreliert. Weiterhin wurde in einer schrittweisen logistischen Regressionsanalyse mit multivariatem Ansatz versucht prädiktive Einflussvariablen für das postoperative Outcome zu identifizieren. Ergebnisse. Die Letalität 12 Monate nach dem Unfall betrug 33%. Alle überlebenden Patienten mit einem Alter <75 Jahren hatten nach einem Jahr ihr präoperatives Aktivitätsniveau wieder erreicht. Die Patienten ab 75 Jahre büßten 20% ihres Aktivitätsniveaus ein. Die ADL-Unterschiede beider <<0,001). Die ADL-Durchschnittswerte der Patientengruppe mit einer Rehabilitationsmaßnahme zeigten ein Jahr nach der Operation höhere Werte, als die Gruppe ohne durchgeführte Rehabilitationsmaßnahme (nicht signifikant). Die multivariate Analyse zeigte, dass der präoperativ gemessene Barthel-Index der beste Prognosefaktor für das Aktivitätsniveau bis zu einem Jahr nach dem Unfall war. Schlussfolgerung. Das präoperative Aktivitätsniveau, gemessen mit dem Barthel-Index, sollte stärker bei Therapieentscheidungen bei Patienten mit hüftgelenksnahen Frakturen berücksichtigt werden.AbstractThe aim of this prospective study was to identify prognostic factors predicting postoperative outcome in patients one year after their hip fracture. Methods. From October 1996 until September 1997 all patients (n=98) treated for a hip fracture in our hospital were prospectively included into the study. Follow up was performed at three, six and twelve months after the injury. The main outcome variable was the activity of daily living measured by the Barthel-Index. An univariate analysis of the variables age, gender, ASA-classification, type of fracture and treatment, length of stay and rehabilitation was performed and all these variables were correlated with the Barthel-Index. A multiple logistic regression was performed for identification of prognostic factors predicting outcome. Results. The one year letality was 33% (n=31). All patients younger than 75 years reached their preoperative activity level at one year follow up. Patients with age of 75 years or more experienced a reduction of their activities of daily living of 20%. The ADL-differences of both groups at the follow up after 3, 6 and 12 months showed a significant p-value (p <0,001). The ADL-differences between the group of patients with or without a transfer to a specialized rehabilitation center were not significant. The multivariate analysis showed that the preoperative use of the Barthel-Index was the best prognostic factor for outcome until one year after the injury. Conclusion. The preoperative Barthel-Index should be seriously considered for therapeutic decision making in patients with hip fractures.

Local and intra-articular infiltration of bupivacaine before surgery : Effect on postoperative pain after anterior cruciate ligament reconstruction

In a double-blind, randomized trial, 40 patients undergoing open anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft were randomly allocated to two groups: group A (n = 20) received an intra-articular instillation of 20 mL bupivacaine (0.25%) and a local infiltration of 20 mL bupivacaine (0.5%) 15 minutes before surgery. Group B (n = 20) received an injection of saline solution in the same manner. Patient-controlled on-demand analgesia (PCA) with intravenous piritramid was used for postoperative pain control. A significant decrease in pain scores on a visual analog scale (VAS scale, 0 to 10) was found in the bupivacaine group (group A) at bedrest on the day of surgery only (pain score, 5.5 v 7.3 (scale, 0 to 10), P < .05). At all other times, no significant differences were found. The overall supplemental opioid requirements were not different between the study groups (63.9 v 62.6 mg piritramid/72 hours). A long-lasting, clinically relevant, pain-reducing effect with infiltration of bupivacaine before surgery could not be shown with this study.

Prehospital detection of uncontrolled haemorrhage in blunt trauma.

The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n = 353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et al., 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

The Prognostic Value of Prothrombin Time in Predicting Survival after Major Trauma: a Prospective Analysis of 1,351 Patients from the German Trauma Registry

Background: Early assessment of the individual trauma load in major trauma patients is difficult. A simple and reliable prognostic factor already available in the emergency room would help the emergency physician to make appropriate therapeutic decisions, e. g., when and how to operate on major fractures. The aim of the study was to evaluate the prognostic value of prothrombin time (PT). Patients and Methods: The German Trauma Registry is a prospective, standardized and anonymous documentation of severely injured patients. 3,814 patients were included in the registry. 1,351 patients with an Injury Severity Score (ISS) ≤ 16 and complete data for specific variables (PT, Trauma Score + Injury Severity Score [TRISS], survival until discharge) were included in the study. The PT was measured on the patients arrival in the emergeny room. Three different analyses were performed. 1. According to clinical judgment, three groups of patients were compared (PT ≥ 60%, PT 40–59%, PT < 40%). A univariate analysis compared therapeutic interventions and outcome variables between the three groups. 2. A receiver-operator-characteristic (ROC) curve analysis compared the performance of PT with the prognostic standard TRISS. 3. A multivariate logistic regression was performed in order to evaluate PT as an independent prognostic variable. Results: PT values showed a good inverse correlation with the severity of injury and the level of therapeutic interventions. The ROC analysis as well as the regression revealed PT as a significant prognostic factor although it showed a slightly worse performance compared to TRISS. Conclusions: As PT, in contrast to TRISS, is readily available already in the emergency room, it can be used as a screening variable for the assessment of a patients trauma load and thereby help in the decision-making for further operative treatment of major trauma patients.

Die operative Therapie der traumatischen Schulterluxation Gibt es evidenzbasierte Indikationen für die arthroskopische Bankart-Operation?

ZusammenfassungEinleitung. Für jüngere Patienten (<30 Jahre) mit einer traumatischen vorderen Schulterluxation wird eine frühzeitige operative Therapie befürwortet. Als operatives Verfahren der Wahl gilt die Bankart-Operation. Kontrovers diskutiert wird, ob diese Operation in offener oder arthroskopischer Technik erfolgen soll. Fragestellung. Gibt es evidenzbasierte Indikationen für die arthroskopische Bankart-Operation? Methodik. Nach den Kriterien der Cochrane Collaboration erfolgte eine systematische Literaturanalyse in der Medline (1966 bis 12/2000). Zu den Stichworten “shoulder dislocation” und “Bankart” wurden 172 Arbeiten ermittelt. Die relevanten Arbeiten wurden nach den Kriterien der evidenzbasierten Medizin klassifiziert und ausgewertet. Ergebnisse. 12 Originalarbeiten basierten auf einer prospektiven Datenerfassung (Evidenzklasse (Ib/IIa)), in weiteren 28 Arbeiten erfolgte eine retrospektive Datenerhebung (Evidenzklasse III). Die Rezidivrate nach offener Bankart-Operation beträgt 0–8% (prospektive/retrospektive Arbeiten). In 19 von 40 Arbeiten bzw. in 8 von 12 prospektiven Studien wird für die arthroskopische Bankart-Operation eine Rezidivrate von <10% beschrieben. In den übrigen Studien (prospektiv/retrospektiv) liegt die Rezidivrate zwischen 11–38%. Die Gründe für diese Unterschiede sind aus den angegebenen Daten nicht erkennbar. Bezüglich der postoperativen Schulterbeweglichkeit scheinen sich gewisse Vorteile für die arthroskopische Bankart-Operation zu ergeben (Einschränkung der Außenrotation: arthroskopisch: 5–12°, offen: 5–25°), wobei die klinische Relevanz dieser Unterschiede zu diskutieren ist. Keine Vorteile bestehen in Bezug auf die postoperative Wiedererlangung einer uneingeschränkten Sportfähigkeit (arthroskopisch: 42–100%, offen 72–94% d. Patienten). Schlussfolgerung. Die offene Bankart-Rekonstruktion stellt weiterhin den “golden standard” in der Versorgung der traumatischen Schulterluxation dar. Die Studien zur arthroskopischen Bankart-Operation können nach den Kriterien der “evidence-based medicine” nicht den Nachweis erbringen, dass die arthroskopische Technik gleichwertig oder besser als die offene Bankart-Operation ist.AbstractIntroduction. For young athletic patients with a primary traumatic shoulder dislocation a surgical treatment is recommended. The operation of choice is the Bankart-Repair. Question. Are there evidence-based indications for an arthroscopic Bankart repair. Methods. Based on the criteria of the “Cochrane Collaboration” a systematic literature search was performed using medline (1966 to 9/2000). 172 publications were found with the key words “shoulder dislocation” and “Bankart”. All relevant articles were ranked and analysed by the criteria of “evidence-based medicine”. Results. There are 12 prospective studies (evidence grade Ib/IIa) and another 28 retrospective studies (evidence grade III). For open Bankart-Repair a recurrence rate of 0 to 8% is reported (prospective/retrospective studies). For arthroscopic Bankart-Repair, 19 of 40 studies and 8 of 12 prospective studies, show a recurrence rate of <10%; however in other studies (prospective/retrospective) an atraumatic recurrence rate of up to 38% is reported. The reasons for these differences in the recurrence rate are not obvious from the given data. In particular, there seems to be no correlation between the type of arthroscopic fixation technique and the recurrence rate. Concerning the postoperative range of shoulder motion, the reported data suggest that external rotation is less limited after arthroscopic than after open Bankart-Repair (arthroscopic: 5–12°, open: 5–25°). However, there is no evidence that patients are more likely to return to their previous level of sporting activities when operated on in an arthroscopic technique than in an open technique (arthroscopic: 42–100%, open: 72–94%). Conclusion. In the surgical treatment of a traumatic shoulder dislocation, the open Bankart-Repair remains the “gold standard”. In reviewing the literature, arthroscopic Bankart-Repair has not been shown to be equal or superior to the open technique.