Zeitschrift für Orthopädie und Unfallchirurgie
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Optimal treatment of injuries to the thoracolumbar spine is based on a detailed analysis of instability, as indicated by injury morphology and neurological status, together with significant modifying factors. A classification system helps to structure this analysis and should also provide guidance for treatment. Existing classification systems, such as the Magerl classification, are complex and do not include the neurological status, while the TLICS system has been accused of over-simplifying the influence of fracture morphology and instability. ⋯ The neurological damage is graded in 5 steps, ranging from a transient neurological deficit to complete spinal cord injury. Additional modifiers describe disorders which affect treatment strategy, such as osteoporosis or ankylosing diseases. Evaluations of intra- and inter-observer reliability have been very promising and encourage the introduction of this AOSpine classification of thoracolumbar injuries to the German speaking community.
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The ideal treatment for massive rotator cuff tears is influenced by the morphology and chronicity of the tear, tissue quality, the degree of concomitant osteoarthritis, and patient-specific factors. Traditionally, massive rotator cuff tears have wrongly been equated with irreparable tears. ⋯ This study provides an overview of the current treatment options for large and massive rotator cuff tears, including their expected outcomes. Finally, a possible treatment algorithm is suggested.
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Carpal fractures in children are rare, but can be missed, as their clinical symptoms are unspecific and discrete. Even X-ray diagnosis is difficult. Timely diagnosis and consistent therapy are especially important for scaphoid fractures, as they can help to avoid complications such as non-union or avascular necrosis. A diagnostic approach to paediatric carpal fractures will be discussed on the basis of the following group of patients. ⋯ In children with clinical and radiographic carpal fracture, diagnosis is difficult and often unsuccessful at first. Even in discrete clinical complaints, generous cast immobilization is essential and clinical follow up is recommended not later then 14 days. In patients with persistent clinical symptoms, MRI is the imaging method of choice, as it is capable of detecting carpal fractures and even bone bruise lesions with high sensitivity, thereby avoiding unnecessary diagnostic or therapeutic stress for the patients.
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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.