Frakturen der Brust- und Lendenwirbelsäule im Wachstumsalter

Background

Only 1.5-2% of all fractures in children and adolescents are fractures of the thoracic and lumbar spine. Treatment is most often conservative. This study compares the own experience with the recent literature.

Material and methods

Over a 48 month period all patients with fractures of the thoracic and lumbar spine, younger than 16 years were included prospectively. Of the patients 67 underwent follow-up investigations after 3-36 months.

Results

The average age of the patients was 11.9 years. Sports (53%) and traffic (28%) accidents were most frequent. Fractures most often appeared in the mid-thoracic (47%) and thoracolumbar spine (41%). Operative treatment was performed in 9 cases (10.4%). Secondary loss of alignment was not observed neither after conservative nor operative treatment. Neurological deficits (n=2) did not completely improve.

Conclusions

Most fractures of the thoracic and lumbar spine heal fast and without any sequelae. Unstable fractures of type B and C (exclusively occurring as a result of traffic accidents) need operative stabilization as in adults.     

Konservative und operative Behandlung der Hiatushernie im Säuglingsalter

Ohne ZusammenfassungVortragender:A. Flach-Tübingen.     

Stress und Berufszufriedenheit im Fachgebiet der stationären Anästhesiologie

Background

How do physicians in the specialty of anesthesiology perceive the working conditions regarding stress and job satisfaction? The health system in Germany has been confronted with a rapidly changing framework over the last 20 years: For example, an increased influence of economic patterns on the workflow and the medical decision of physicians has been established forcing them to always take the economic aspects into account. Moreover, a new generation (generation Y) of physicians with other requirements of the work place, meaning mainly a demand for a better work-life balance, has gained a foothold in hospitals. These changes make it very important to investigate the status quo of current working conditions.

Aim

Working conditions in hospitals in the specialty of anesthesiology is the main issue investigated in this study.

Methods

For this study 1,321 completed online-questionnaires from physicians in hospitals with the specialty of anesthesiology were analyzed. The questionnaire was based on the stress theory, the effort-reward-imbalance model (ERI) and the job-demand-control model (JDC).The items used in the questionnaire were taken from the ERI questionnaire and the short questionnaire on work analysis (KFZA). By calculating a certain ratio of several items (according to the stress theory), the prevalence of distress could be measured. In addition the overall job satisfaction in the field of anesthesiology was measured and analyzed.

Results

In this study 47.0?% (95?%-CI: 44.3–49.7?%) of all respondents showed signs of distress. Simultaneously, 61.8?% (95?%-CI: 59.2–64.5 %) were very satisfied with the job situation. Regarding gender, female physicians perceived a lower control of the work situation whereas male physicians perceived a much higher decision level. This led to a higher prevalence of distress in the group of female physicians regarding the JDC model (odds ratio, OR: 1.54, 95?%-CI: 1.19–2.01). Regarding age, the prevalence of distress increased from 36.5?% in the respondents under 35 years old to 50.7?% in those 35–59 years old (OR: 1.79, 95?%-CI: 1.38–2.32). Looking at the different functional positions in the hospital, senior doctors showed a much higher prevalence of distress (52.8?%) than junior doctors (OR: 1.57, 95?%-CI: 1.21–2.05). Analyzing job satisfaction with respect to the functional position, the highest significant proportion was shown by senior doctors (65.8?%).

Consequences

This study revealed a high prevalence of unfavorable working conditions for anesthetists in hospitals. Taking the forthcoming shortage of qualified physicians in German hospitals into account, these results have to be considered as a cause for concern. Constant unfavorable working conditions have a negative effect on the mental and physical health of employees. Sooner or later a migration of qualified physicians abroad could be the consequence. To prevent a future shortage of qualified physicians and to make the hospital work place more appealing, working conditions have to be adapted to current needs and expectations of employees. The focus should be put on balanced working conditions according to stress models shown in this study.     

Finanzierung der stationären Orthopädie und Unfallchirurgie im G-DRG-System 2010

Background

The German DRG (diagnosis-related groups) system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also additional and innovation payments. This paper analyzes and evaluates the relevant developments of the G-DRG System 2010 for orthopedics and traumatology from the medical and classification perspectives.

Methods

Analyses of relevant diagnoses, medical procedures and G-DRGs in the versions 2009 and 2010 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI) were carried out.

Results

The DRG catalog is has grown from 8 to 1,200 G-DRGs. A number of codes for surgical measures have been newly established or modified. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopedics and traumatology has been changed, especially in the areas of spinal surgery and surgery of the upper and lower extremities. The actual impact of the changes may vary depending on the individual hospital services.

Conclusion

For the first time since the introduction of the G-DRG system, the pure numerical changes at the level of DRGs themselves are so marginal that only part of the DRG users in the hospitals will register them. The changes implemented not only a high selectivity between complex and less complex scenarios, but partly also unintended and unjustified revaluation of less complex measures. The G-DRG system has gained complexity again. Especially the G-DRG allocation of spinal surgery and multiple surgical interventions of the upper and/or lower extremities have reached such a complexity that only a few DRG users can follow them.     

63. Dauer und Wandel im ärztlichen Ethos

Zusammenfassung Der Vortrag entwickelt zuerst einen allgemeinen Begriff des Ethos [1] und Kategorien zur Erfassung seiner Strukturen [2]. Das klassische hippokratische Ethos zeigt sich dann als Entwurf, welcher ärztliches Handeln als Sache eines, durch praktisch Wissenschaft orientierten Standes im Dienst des privaten Wohls des Patienten normiert [3]. Der Wille, im Wandel der Bedingungen ärztlicher Praxis die Substanz dieses Ethos auf Dauer zu stellen, erfordert a) gegen das Mißverständnis der Medizin als theoretischer Naturwissenschaft die Besinnung aufihren praktischen Charakter, b) gegen die Ausweitung einer bloß sozialen Zielsetzung die Anerkenntnis der Maßstäblichkeit des privaten Verhältnisses zum Patienten, c) gegen die technologisch bedingte Entpersönlichung eine Orientierung am Gesamt der Bedürfnisse des Patienten.     

Konzept zur Lungen- und Herz-Lungen-Präservation im Rahmen der Multiorganentnahme

Zusammenfassung Die Lungenpraservation ist ein noch weitgehend ungelöstes Problem, das die Ischämie-/Transportzeit und somit die Ausschöpfung von Spenderresourcen limitiert. Das derzeit am häufigsten angewendete Verfahren beruht auf Flush-Perfusion des pulmonalen Funktionskreislaufes. Weitere Verfahren sind autolog arbeitende Herz-Lungenpräparation oder tiefe Spenderganzkörperhypothermie. Die vorgestellte Konzeption verbindet Ganzkörperhypothermie mit Aquilibrierung des Extrazellularraumes mit dem Ziel intrazellulärer Adaptation und ist modifiziert auf die Anforderungen der Multiorganentnahme. Durch Anschluß des Spenders an eine für these Zwecke entwickelte transportable Herz-Lungenmaschine wird das Kühlverfahren eingeleitet und parallel zur Temperaturabsenkung eine Hämodilution durch Inkorporation der protektiven HTK-Lösung nach Bretschneider induziert. Die schrittweise Äquilibrierung zielt auf eine extrazelluläre Senkung des Na⁺-Gehaltes, Anhebung des K⁺-Gehaltes and Ca⁺⁺-Absenkung. Gleichzeitig wird die Kapazität der bluteigenen Puffersysteme durch das inkorporierte Histidin-Puffersystem verstärkt. Zur Vermeidung von Ödembildung wird eine möglichst kurze Phase der extrakorporalen Zirkulation angestrebt; die tiefe Hypothermie his unter 10°C Organtemperatur wird durch parallelgeschaltete Wärmeaustauscher mit Hochdrucküberflutung eines Tieftemperaturcisblockes in weniger als 30 min erreicht. Zusätzlich wird zur weiteren Oberflächenorgankühlung arterielle Blutüberströmung der Lungen eingesetzt. Die Vorteile erstrecken sich nicht allein auf die Lungenpräservation, sondern auch auf die Vorbehandlung aller weiteren zur Multiorganentnahme vorgesehenen Organe.

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Concept for lung and heart-lung preservation in multi-organ-procurement

Summary Preservation of the lung is still one of the most challenging problems, because due to limited procurement time not all organs available can be used. The most common procurement technique is flush perfusion of the pulmonary artery system. Alternative methods in clinical use are either the autologous working heart-lung preparation or donor core-cooling (DCC). The own concept presented here, modified to the special demands of multiorgan-procurement, combines DCC and interstitial equilibration adapted to intracellular ion concentration. DCC is induced by extracorporeal circulation (ECC) using a transportable heart lung machine including a highly effective cooling system: cooling circuit based on two parallel heat exchangers with ice-water cooling produced by an high-pressure overflow of an low-temperatured ice block (–40°C). While cooling by ECC stepwise hemodilution is achieved by priming volume and incorporation of the cardioplegic solution (Bretschneider-HTK). The aim of equilibration is to lower the extracellular levels of sodium and calcium, and to increase the level of potassium. Additionally, the buffer capacity of donor blood is increased by the incorporated histidine-buffer system (-stat). To avoid donor organ edema the time of ECC should be as short as possible. Using our system donor organ temperatures below 10°C are reached within less than 30 min. In addition to ECC, lung surface cooling is achieved by external overflow with cold arterial blood (internal mammary artery). Besides lung preservation the main advantage of this concept is the profound precooling of all visceral organs before their individual flush perfusion.

In Auszügen vorgetragen auf dem 1. Symposium der Chirurgischen Arbeitsgemeinschaft für Transplantationschirurgie (CAT) der Deutschen Gesellschaft für Chirurgie, Berlin, 7. 9. 1989     

Konservative und operative Therapie der suprakondylären Humerusfraktur im Kindesalter

Aim

The supracondylar fracture of the humerus is a common fracture in children. The aim of this study was to record complications and to evaluate functional outcome of the children with dislocated fractures who had been operated on in the Catholic Children’s Hospital Wilhelmstift in Hamburg.

Patients and methods

A total of 191 patients with 194 dislocated supracondylar fractures of the humerus underwent operation between July 1, 2004 and June 30, 2009. All children were operated on promptly, and the fractures were stabilized the day of the accident. An open surgical reduction was needed in 17 patients (9%). In 92%, the fractures were stabilized by crossed Kirschner wires. After 4 weeks, the wires and splint were removed. A follow-up of 185 patients between 3 months and 3 years after the fracture was possible; the axis, function, mobility, and nerve alteration were evaluated.

Results

In 8 cases (4.3%), a deviation between 11° and 15° in the frontal and sagittal plane persisted. No correction osteotomy was performed. According to the Mayo performance score, 182 patients (98.4%) achieved the maximum number of points. Traumatic nerve injuries were recorded in 15 cases (8%), iatrogenic injuries in 6 cases (3%). Vascular operations were necessary in 5 cases (2.5%).

Conclusions

Dislocated supracondylar fractures of the humerus have to be treated as an emergency by closed reduction and stabilization. Good results have been achieved using the well-established percutaneous Kirschner wire fixation. In comminuted fractures, residual deviations may occur. Iatrogenic ulnar nerve lesions may be reduced by the use of a small medial incision. Alternative treatment methods, e. g., applying elastic intramedullary nailing or external fixators, may reduce the complication rate even further.

     

Navigation von Tumoren und Metastasen im Bereich der thorakolumbalen Wirbelsäule

In this clinical feasibility study, CT-based verification of the efficacy of navigated decompression and pedicle screw placement in patients who had tumor-related posterior surgery was demonstrated. Eighty-six percent of the pedicle screws were positioned centrally in the bone without perforation; in all patients accurate decompression was seen. The accuracy of transpedicle screw implantation postoperatively was investigated with CT. In contrast to other published studies, no postoperative neurologic deterioration was seen in the patients as a result of using computer-aided surgical procedures. At the same time we were able to achieve complete decompression of the neural structures for radiologic and neurologic findings. Because of inaccurate registration, it was not possible to use computer-aided implantation surgery for 15% of the pedicles and, therefore, a conventional fluoroscopic approach was used. Our initial results indicate that computer-aided frameless navigation of tumor surgery of the spine is a safe technique which improves surgical performance during posterior decompression and transpedicle stabilization. In addition, CAS surgery improved the intraoperative information about the tumor and the current surgical intervention during decompression. Nevertheless the technique should be used only by experienced surgeons who can, if required, continue the operation using conventional techniques. Furthermore, the surgeon should have a complete theoretical understanding of the navigation system to minimize possible misinterpretation of computer guidance information.     

1. Chirurgie im Spannungsfeld technischer Perfektion und Humanität

Zusammenfassung Zu keiner Zeit hat die Frage, ob in der Chirurgie alles gemacht werden darf, was technisch machbar ist, die Menschen und vor allem verantwortungsbewußte Ärzte so bewegt wie heute. Die Spezialisierung und Technisierung in der Medizin ist aber die Voraussetzung für die Fortschritte in Diagnostik und Therapie. Dennoch darf der Arzt die Einheit des Patienten als Körper und Seele nicht außer acht lassen. So muß der Chirurg die Technik in seinem Bereich humanisieren und sie nur dort einsetzen, wo sie Humanes zu leisten vermag. Die technischen Möglichkeiten in der Chirurgie bedeuten, wenn man sie mit jenen früheren Zeiten vergleicht, einen solchen Fortschritt, daß die Bezeichnung perfekte Chirurgie keineswegs abwegig ist. Technik und Humanität verbunden mit medizinischnaturwissenschaftlichem Wissen und Denken sind die Grundpfeiler einer optimalen Chirurgie.     

Chirurgie der Weichteilsarkome im Bereich der Extremitäten

Treatment of soft tissue sarcomas requires an individual plan which considers interdisciplinary recommendations and the various clinical situations. Anatomical region, histological grading and typing, and tumor size necessitate adjusted methods of reconstruction. The biopsy should be performed at the institution where the patient is treated. In general surgical resection of the tumor will be the treatment of choice. Adjuvant therapies are applied according to anatomical region and size and grading of the tumor. Surgery alone is recommended only in small (<5 cm), superficial, low-grade sarcomas. Sarcomas larger than 5 cm in diameter should be treated by surgery and radiotherapy, achieving excellent results, although in high-grade sarcomas more than 50% of patients still will experience metastatic disease. In case of locally recurrent disease, surgical revision with tumor-free resection margins followed by radiotherapy should be the aim. This applies even for patients who had had radiotherapy after the first excision. In this case brachytherapy is a good modality of tissue-sparing treatment.     

Arterielle und venöse Durchblutungsänderungen im Verlaufe der Frakturheilung an Extremitäten

Ohne Zusammenfassung     

Brust- und Lendenwirbelsäulenverletzungen im Kindes- und Jugendalter

Spinal injuries are generally very rare in childhood. Fractures of the thoracic and lumbar spine occur mainly in older children and adolescents. Exact knowledge of the anatomy is essential for accurate diagnosis in still incomplete ossification. With increasing age the classification can be performed by using the AO classification over the age of 8 years. Neurological symptoms in the thoracic and lumbar spine occur mainly in adolescence. Conventional radiography is the standard diagnostic tool for thoracic and lumbar spinal injuries. With the appearance of abnormal neurological deficits magnetic resonance imaging (MRI) diagnostics should also be performed and for operative cases computed tomography (CT) scans are mandatory. The most common fractures of the thoracic and lumbar spine are compression fractures (type A) which can generally be treated conservatively due to the stable situation but unstable fractures of the thoracic and lumbar spine (types B and C) are stabilized dorsally (internal fixation). Ventral stabilization with vertebral body replacement is occasionally necessary in adolescents. Spinal injuries in children have a good overall prognosis.     

Die Transplantation von homologen und heterologen Spänen der Wachstumsfuge im Tierversuch

Zusammenfassung Es wird eine Methode zur Testung der Knochenneubildung angegeben. Mit Hilfe dieser Methode wurden an 36 Kaninchen homologe, an fünf Hunden heterologe Transplantationen von Wachstumsfugengewebe vorgenommen. Bei den Homoiotransplantaten konnte neben einem Überleben der Epiphysenzellen gelegentlich eine Regeneration der hyalinen Knorpelzellen festgestellt werden. Die Knochenneubildung führte hierbei in erster Linie zu spongiösem Knochen. Ob die Knochenneubildung allerdings allein vom Transplantatbett ausging oder ob die weiterlebenden homologen Epiphysenfugenzellen in der Lage sind, vorübergehend auch aus sich heraushomologen Knochen zu bilden, läßt sich aus den Versuchen nicht entscheiden.Bei den heterologen Transplantaten starben die Epiphysenknorpelzellen ab. Es setzte ein rascher Abbau der Knorpelgrundsubstanz neben einer Bildung vorwiegend kompakten Knochens ein. Transplantate beider Qualitäten lösten bereits nach 14 Tagen Knochenneubildung im Transplantatbett aus.Mit 6 Textabbildungen     

13. Bedeutung der präoperativen cyto- und histopathologischen Tumordiagnostik

Zusammenfassung Eine Biopsie oder Punktion ist immer dann erforderlich, wenn der Verdacht auf einen bösartigen Tumor nicht auf andere Weise ausgeschlossen werden kann. Eine Gefährdung des Patienten durch Steigerung der Metastasenquote besteht nach heute vorliegendem Schrifttum nicht. Im Idealfall soll der gesamte Tumor entfernt werden. Zu den Aufgaben des Pathologen gehört die subtile Untersuchung insbesondere der Abtragungsstellen einschließlich der Metastasen. Der intraoperative Schnellschnitt erleichtert das operative Vorgehen und liefert in ca. 90% der Fälle klare Diagnosen. Das grading gibt Hinweise auf die Prognose und bestimmt damit das Vorgehen in der postoperativen Nachsorge.     

Zur Erkennung und Begutachtung der Schädelgrundbrüche.

Ohne Zusammenfassung