Injury, Int. J. Care Injured 44 (2013) 1423–1427

Evaluation of the current treatment concepts in Germany, Austria and Switzerlandfor acute traumatic lesions to the prepatellar and olecranon bursa

Sebastian F. Baumbach a,*, Florian Domaszewski b, Hendrick Wyen c,d, Klaudius Kalcher e,Wolf Mutschler a, Karl-Georg Kanz a

a Department of Trauma Surgery - Campus Innenstadt, Ludwig-Maximilians-University Munich, Nussbaumstrasse 20, 80336 Munich, Germanyb Department of Trauma Surgery, Medical University of Vienna, Wahringer Gurtel 18-20, 1090 Vienna, Austriac Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC),

Ostmerheimer Str. 200, Building 38, D-50670 Cologne, Germanyd Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germanye Department of Statistics and Probability Theory, Vienna University of Technology, Wiedner Hauptstrasse 8-10/107, 1040 Vienna, Austria

A R T I C L E I N F O

Article history:

Accepted 31 July 2012

Keywords:

Injury

Trauma

Laceration

Bursa

Olecranon

Prepatellar

A B S T R A C T

Background: Although traumatic lacerations of the olecranon (OB) and praepatellar bursae (PB) are

common entities often associated with complications, no study could be found on this injury. The aim of

this study was to survey the current treatment concepts for acute traumatic laceration of the OB and PB in

Germany, Austria and Switzerland.

Materials and methods: An international online survey was conducted among orthopaedic and trauma

surgeons in Germany (TraumaNetwork DGU), Austria (Austrian Society of Trauma (OGU) and

Orthopaedic (OGO) Surgeons) and Switzerland (Swiss Orthopaedic Surgeons and Swiss Society of

Infectious Disease (CH)) (n = 1967). The survey comprised of five demographical questions, the current

treatment concepts were evaluated using a case study.

Results: The overall-response-rate was 16% (12–46%). 88% of the responding physicians were male, aged

47.5 � 10.2 years with a mean working experience of 20.1 � 10.6 years. 54% of the surveyed physicians were

either senior or chief physicians. Treatment concepts varied significantly between DGU and OGO/CH

(p = 0.02/p = 0.006), no significant differences could be found between DGU and OGU. Generally, German and

Austrian trauma surgeons favoured bursectomy (86.7%/90.9%) and immobilisation (68.3%/77.3%). Austrian

orthopaedic surgeons performed fewer bursectomies (69.3%) but had the highest proportion for

administering antibiotics (73.9%). Less than 50% of Swiss physicians indicated bursectomy as a treatment

option.

Conclusion: Overall, this survey revealed a significant heterogeneity in treatment approaches in Central

Europe. Further evidence is needed to identify the best treatment concepts for traumatic lacerations of

the OB and PB.

� 2012 Elsevier Ltd. All rights reserved.

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Injury

jo ur n al ho m epag e: ww w.els evier . c om / lo cat e/ in ju r y

Introduction

Bursae are closed cavities lined by a synovial membrane whichform after birth and serve to reduce friction between adjacenttissues during motion. Commonly diseased bursae are theolecranon (OB) and prepatellar bursae (PB). In general, one hasto differentiate between acute septic/non-septic bursitis, chronic/recurrent bursitis and traumatic lacerations of the OB and PB.Whereas several studies report on diagnosis and treatment ofacute/chronic olecranon and prepatellar bursitis,1–6 the authors

* Corresponding author. Tel.: +49 089 51602511.

E-mail address: Sebastian.Baumbach@yahoo.com (S.F. Baumbach).

0020–1383/$ – see front matter � 2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.injury.2012.08.008

are not aware of any study focusing on the treatment oftraumatically lacerated OB and PB.

However, due to the bursaes’ exposed and superficial location,traumatic laceration of OB and PB has to be considered a commoninjury. With no epidemiological data published, the authors (FD,SFB) reviewed the records of the Department of Traumatology ofthe Medical University of Vienna in 2010 and identified 105patients who were treated for a traumatic laceration of theOB or PB.

Whereas the diagnosis of a traumatic OB/PB laceration is notchallenging, clinicians have to think of several potentialtreatment approaches, including one- or two-stage bursectomy,open drainage, simple suture of the wound or reconstruction ofthe bursa. With no literature available, the authors searchedtextbooks for guidance in this field and found very little

S.F. Baumbach et al. / Injury, Int. J. Care Injured 44 (2013) 1423–14271424

documentation dealing with the treatment of traumatic OB andPB laceration, most often recommending bursectomy andimmobilisation.7,8

Due to lacking evidence and several possible treatmentstrategies, the aim of this study was to survey the currenttreatment concepts for traumatic laceration of the OB and PB inGermany, Austria and Switzerland, in order to collect explor-atory data on the treatment approaches for this common injuryand to evaluate possible treatment differences within CentralEurope.

Materials and methods

In the course of a large anonymous online survey oforthopaedic surgeons in Germany, Austria and Switzerland onthe treatment of olecranon and prepatellar bursitis, weevaluated the current treatment concepts for traumatic lacera-tions of the PB. The questionnaire’s flowchart is presented inFig. 1. Following 5 demographic questions, the currenttreatment concepts were evaluated using a case study and acombination of multiple-choice answers and developmentanswers. The survey was designed to be distributed via e-mailusing Interview (Interview 123 5.5.b.e ND3, 15 rue GeorgesPerec, 38400 Saint Martin, d’Heres, France). Each survey wasonline for approximately one month and reminders were sentout two weeks after the initial distribution.

German survey

The questionnaire was mailed to certified clinics of theTraumaNetwork DGU1 of the German Society of Trauma Surgeryrevealing their contact information online (n = 233, as of June 22nd2011). At that time data was available for 39 Level I, 80 Level II, and

Independent

Questions

1) Please choose the type of ho(Basic care / Tertiary care / Adcare / University)

2) Please enter your age: (Free-text)

3) Please enter your sex: (Mann/Frau)

4) Please enter years of workin(Free-text)

5) Please enter your position: (Head of department / Senior pResident)

17) How do you treat a TRAUMATIC LACERATION of the prepatellar bursa?(Debridement / Excision / Suture / Subcutaneous adaptation of the bursa / Bursectomy in local anest. / Bursectomy in regional anest. / Bursectomy in general anest. / NSARD / Antibiotics / Immobilization) [Multiple choice]

18) Do you perform further therapies?(yes/no)

20) Please enter any comments you might have.

Nei

n

Fig. 1. Questionnair

114 Level III trauma centres (as defined in Table 1) throughoutGermany.

Austrian survey

The Austrian survey was conducted in cooperation with theAustrian society of orthopaedic surgeons (Osterreichischen Ge-sellschaft fur Orthopadie und orthopadische Chirurgie; OGO) andthe Austrian society of trauma surgery (Osterreichische Gesell-schaft fur Unfallchirurgie; OGU). Orthopaedic and trauma surgerywere traditionally two separate specialties in German-speakingcountries. The survey was mailed to all current members of theOGO (n = 838), which, according to the OGO, includes approxi-mately 90% of all Austrian orthopaedic surgeons (average age48.7 � 12.6 years, 14.9% female). The OGU surveyed all heads oftrauma surgery departments in Austria who were members of thesociety (n = 69).

Swiss survey

All members of the Swiss Society of Infectious Disease(infectiologists; n = 242) and orthopaedic surgeons listed in theFoederatio Medicorum Helvetorum (n = 585, according to theirhomepage 95% of all Swiss physicians) were contacted viae-mail. E-mails contained a cover letter and a link to the survey,which was available in German and French. No reminderwas sent.

Statistics

Statistical calculations were performed using the free softwareR (version 2.13.0), for inferential statistics p-values of p < 0.05were deemed significant. Differences between samples for thevariables of interest were established using x2 tests post hoc tests

Demographics

spital you are working at. vance care / Maximum

g experience:

hysician / Consultant /

19) Which further therapies do you perform in case of a traumatic laceration of the prepatellar bursa?[free-text]

Dependent

Questions

Ja

e’s flow chart.

Table 1Demographic details and statistics.

Germany Austria Switzerland p-Value

DGU OGU OGO Ortho/infect

Number contacted 233 69 838 827

Response rateTotal 28% 46% 12% 14%

Included 26% 32% 10% 11%

Level of care <0.001

Level IV 10.0% 14% 40% 19%

Level III 50.0% 27% 9% 16%

Level II 23.8% 45% 39% 0%*

Level I 6.7% 4% 7% 26%

Level I (university) 5.0% 9% 6% 39%

Age [years; mean � SD] 48 � 8 54 � 8 47 � 11 46 � 10 0.01

Sex [%male] 97% 91% 82% 81% ns

Working experience [years; mean � SD] 21.1 � 9.0 28 � 9 19 � 11 18 � 10 0.002

Position <0.001

Resident 10.0% – 15% 10%

Attending 1.7% – 37% 25%

Senior physician 23.3% 27% 32% 42%

Chief physician 65.0% 73% 16% 24%

Level I: centre of maximum care; Level II: hospital with specialised medical services; Level III: Hospital of regular care; Level IV: hospital of basic care/including private

practice.

In Switzerland physicians indicating to work at a ‘Regionalspital’ were considered Level III, physicians indicating to work at a state hospital (‘Kantonspital’) were considered

Level I; ns: not significant.

S.F. Baumbach et al. / Injury, Int. J. Care Injured 44 (2013) 1423–1427 1425

for two centres were calculated using Student’s t-test forcardinally scaled variables and x2 tests for nominally scaledvariables.

Results

A total of 1967 physicians were contacted with an overallresponse-rate of 16%. 31% of the surveyed physicians indicatedworking at a Level I hospital, 24% at a Level II, 22.4% at a Level IIIand 24% at a hospital of basic care/private practice. An overall x2

test revealed significant difference between societies for hospitallevels, with a higher percentage of replies from Level I hospitals inSwitzerland than from the other samples (p < 0.001). 88% weremale, aged 47.5 � 10.2 years with a mean working experience of20.1 � 10.6 years. 54% were either senior or chief physicians, 35%attendings and 11% residents. Country and society specific responserates as well as comparative statistics are listed in Table 1.

Fig. 2 summarises the treatment options as indicated by thesurveyed physicians for each sample separately and showssignificant differences within each group. An overall x2 testshowed a significant difference for the distribution of treatment

Fig. 2. Results on the surveyed treatment concepts for traumatic OB and PB lacerations

Society of Trauma Surgery; OGU: Austrian Society of Trauma Surgery; OGO: Austria

Orthopaedic Surgeons. *p < 0.05; **p < 0.001.

approaches. In general, significant differences were found betweenDGU and OGO/CH (p = 0.02/p = 0.006). No significant differencescould be found between DGU and OGU. Neither experience(resident/attending vs. senior/chief physician) nor the level of care(Level III/IV hospitals vs. Level I/II hospitals) had a significantinfluence on the treatment regimes.

Discussion

Acute traumatic OB and PB lacerations are supposedly commoninjuries but a review of the existing literature shows that they havenot found their way into literature; only marginalia have beenmentioned in German and English textbooks. Not surprisingly, thissurvey revealed significant heterogeneity in treatment approachesacross Central European countries and different medical special-ties.

Bursectomy

In general, trauma surgeons (DGU, OGU) favoured a much moresurgical treatment approach compared to orthopaedic surgeons

in Germany, Austria and Switzerland. DGU: TraumaNetwork DGU1 of the German

n Society of Orthopaedic Surgeons; CH: Swiss Society of Infectious Disease and

S.F. Baumbach et al. / Injury, Int. J. Care Injured 44 (2013) 1423–14271426

(OGO, CH), consisting of bursectomy, immobilisation and woundexcision. A surgical intervention is consistent with the recommen-dations found in textbooks.7,8 Interestingly, only 49% of the surveyedSwiss physicians chose bursectomy as the standard therapeuticprocedure, which was significantly lower than in any other sample.This might be due to the inclusion of Swiss infectiologists in thestudy sample, who presumably favour a conservative treatmentapproach due to their background. With no evidence on treatmentoutcomes or complications available, interpretation of the hereinsurveyed treatment concepts is limited. From the authors’ experi-ence bursectomy in patients with acute traumatic laceration of theOB and PB is associated with complications such as healingproblems, wound infections, scar pain and recurrent bursitis.Although not directly comparable, bursectomy in cases of bursitishas been reported to show similar complications.3,6,9–15

Minor-surgical treatment (wound closure, debridement and bursal

reconstruction)

Taking into consideration the gap in existing literature and theconsiderable complication rates for bursectomy in case of bursitis,bursal conserving treatment consisting of bursal adaptation,wound excision and suture might be another treatment option,at least for non-heavily contaminated lacerations. On average, lessthan 10% of the surveyed physicians indicated bursal adaptation asa viable treatment option, and less than 50% indicated suture assuch, with no significant differences between the societies.Another half of the interviewed physicians performed a wounddebridement, with no conclusive differences between the samples.Wound excision was more frequently performed by traumasurgeons (DGU, OGU) than orthopaedic surgeons. Bearing in mindthe high rates of bursectomy, the low implementation of woundclosure and the neglectable values for bursal adaptation for traumasurgeons, bursectomy could be considered the primary treatmentapproach. An inconclusive treatment approach can be summarisedfor the surveyed Swiss surgeons.

Antibiotics

One possible explanation for the primarily surgical approachused by members of the DGU, OGU and OGO could be the fear ofhigh infection rates in case of traumatic OB and PB laceration. Fromthis perspective, the less frequent administration of antibiotics bytrauma surgeons seems inconclusive. A significantly higherantibiotic prescription rate by Austrian orthopaedic surgeonscompared to CH members could be explained by a presumablymore cautious application of antibiotics among infectiologists.

Immobilisation and NSAID

More than 70% of all surveyed physicians implementedimmobilisation, approximately 40% NSAIDs in their treatmentconcepts, with no significant differences between the societies.The high rate of immobilisation could be associated to a fear ofinfection or wound healing complications. Austrian orthopaedicsurgeons integrated NSAID most often into their treatment concept,which, in combination with lower bursectomy rates, might beindicative of a less invasive treatment approach compared to thetrauma surgeons interviewed. Significantly lower rates of NSAIDprescriptions were reported from the CH members, which againmight be explained by the infectiologists included in the sample.

Limitations/strengths

Several limitations must be addressed. First of all, demo-graphics did vary significantly between the samples interviewed,

which might bias the comparison between samples. To someextent this can be explained by varying target populations (DGU,OGU: addressed to department heads; OGO, CH: all members).Although the overall response rate was somewhat lower than inprevious studies,16,17 the high proportion of opinion leaders in thesample (senior/chief physicians: 48–100%) and their high workingexperience might compensate for that. A further consideration thatmay have limited the comparison between samples was themissing differentiation between Swiss orthopaedic surgeons andinfectiologists. This might explain varying results betweenAustrian orthopaedic surgeons and Swiss surgeons/infectiologists.

The previously mentioned high proportion of senior/chiefphysicians, who can be seen as opinion leaders, was a strength ofthis study. Moreover, this study was the first to publish data on thecurrent treatment concepts of traumatic OB and PB lacerations,surveying physicians from three different Central Europeancountries.

Conclusion

The aim of this study was to survey the current treatmentconcepts for traumatic OB and PB lacerations in Germany, Austriaand Switzerland. Although the results do not allow us to postulateof a best treatment approach, a first insight into the currenttreatment concepts of this common injury could be gained. Thestudy found rather heterogeneous treatment concepts, withtrauma surgeons (DGU and OGU) favouring bursectomy andimmobilisation. Austrian orthopaedic surgeons were found toperform bursectomy less often but had the highest rate ofantibiotic prescription. The treatment concept of Swiss orthopae-dic surgeons and infectiologists was the least invasive, with lessthan 50% indicating bursectomy as a treatment option. Furtherevidence needs to be generated on the different treatmentconcepts and their outcomes.

Conflict of interest

No author has financial or personal relationship with otherpeople or organisation, which could possibly have an influence onthis work.

Acknowledgement

The authors would like to thank Ms. J. Ebner-Daigle, MO, MA forproofreading.

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