BACKGROUND:The directives of the Federal Joint Committee (G-BA) define tiered emergency care structures, but their influence on patient decision-making has not been sufficiently studied. OBJECTIVE (RESEARCH QUESTION):This study examined patient-related determinants of utilising emergency departments (ED) of different emergency levels in Bavaria. MATERIALS AND METHODS:From September to November 2024, we carried out a standardised, cross-sectional survey in 18 ED at basic, extended and comprehensive care levels (n = 7527 participants). Data were analysed descriptively and with multinomial logistic regression. Subjective urgency, reason for visit, travel time and mode of arrival were included as influencing factors. RESULTS:15.4% of respondents who visited the ED independently (n = 5300) chose to do so because of the expected specialization. Patients in comprehensive EDs used emergency medical services significantly more often, rated their urgency higher and more frequently reported neurological, urological or ophthalmological complaints. They accepted longer travel times and were less likely to have sought outpatient care beforehand. DISCUSSION:The choice of emergency level is chiefly influenced by subjective urgency, specialty-related complaint types, mode of arrival and institutional structure. Even the existing heterogeneity among institutions exerts a steering effect. Future management concepts-such as integrated emergency centres-should incorporate these patient preferences and regional care realities to enable need-oriented direction without undersupply.
BACKGROUND:Conversion from laparoscopic to open cholecystectomy is associated with increased morbidity. A low conversion rate, together with a low complication rate, may serve as a surrogate marker of surgical quality. This study aimed to analyze the conversion rate at a secondary referral center in relation to bile duct injuries and to identify risk factors associated with conversion. METHODS:We performed a retrospective analysis of all laparoscopically initiated cholecystectomies between January 2013 and December 2022. Demographic and clinical data, surgical indication, timing, difficulty level (Nassar and Randhawa scores), conversion rates, and bile duct injuries (Neuhaus system) were evaluated. RESULTS:A total of 1534 laparoscopic cholecystectomies were performed. The overall conversion rate was 2.0% (n = 31), with 84% of conversions occurring in emergency cases. Converted patients showed a high prevalence of known risk factors. Most converted cholecystectomies (80.6%) were performed during daytime hours; only 6.5% of conversions occurred after midnight. The incidence of bile duct injuries was 0.26%, well below the average reported in the literature. CONCLUSION:A low conversion rate combined with a low rate of bile duct injuries can serve as a surgical quality indicator. Risk stratification using established scoring systems, laparoscopic skills such as intraoperative cholangiography, appropriate timing of surgery, and team composition may contribute to achieving a low conversion rate.
Background: Previous high tibial osteotomy (HTO) with extra-articular deformity can compromise subsequent knee arthroplasty by altering alignment and joint line orientation, making restoration of the coronal axis and ligamentous stability difficult. This may lead to poor outcomes and frequent use of constrained implants. UKA is generally discouraged, but a one-stage tibial reosteotomy with UKA may be an efficient alternative. Methods: A retrospective matched case-control study included 32 patients treated between 2013 and 2023. 16 underwent biplanar closed-wedge tibial reosteotomy with UKA for valgus malalignment (MPTA ≥90°) after failed open-wedge HTO (intervention group). 16 matched patients underwent isolated UKA (control group). Matching criteria were age, sex, body mass index (BMI), ASA, and surgery date. Radiographic evaluation (MPTA, mLDFA, aHKA) was based on weight-bearing long-leg radiographs, and knees were classified per CPAK. Functional outcomes were assessed at ≥12 months using the OKS, KOOS, LEFS, TAS, and FIPS. Equivalence testing (TOST) was performed at group level and confirmed within matched pairs. Results: No significant differences were observed between cohorts. Equivalence was confirmed for OKS (39.9 vs. 40.1), KOOS-Sport/Rec (51.9 vs. 52.2), and FIPS (1.8 vs. 1.6). LEFS (76.6 vs. 75.9), KOOS Pain (80.0 vs. 79.5), KOOS-ADL (83.3 vs. 82.2), KOOS-QoL (66.8 vs. 63.3), and ΔTAS (0.7 vs. 0.1) showed no clinically relevant differences. Matched-pair analyses confirmed equivalence across primary outcomes and further confirmed equivalence for LEFS and KOOS-ADL. CPAK patterns improved from IX preoperatively to predominantly I/II postoperatively, mirroring the control group. Postoperative MPTA in the intervention group (86.1°) aligned closely with the control group (84.6°). Conclusions: Simultaneous tibial reosteotomy and UKA effectively restore physiological alignment and achieve functional outcomes equivalent to isolated UKA. These findings challenge the prevailing two-stage paradigm and support the one-stage approach as a viable treatment option for patients with progressive anteromedial osteoarthritis and extra-articular deformity following HTO.
