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Background A different utilization of health care services due to socioeconomic status on the same health plan contradicts the principle of equal treatment. We investigated the presence and magnitude of socioeconomic differences in utilization of diagnostic imaging and non-pharmaceutical conservative therapies for patients with spinal diseases. Methods The cohort study based on routine healthcare data from Germany with 11.7 million patient-years between 2012 and 2016 for patients with physician-confirmed spinal diseases (ICD-10: M40-M54), occupation and age 20 to 64 years. A Poisson model estimated the effects of the socioeconomic status (school education, professional education and occupational position) for the risk ratio of receiving diagnostic imaging (radiography, computed tomography, magnetic resonance imaging) and non-pharmaceutical conservative therapies (physical therapy including exercise therapy, manual therapy and massage, spinal manipulative therapy, acupuncture). Results Patients received diagnostic imaging in 26%, physical therapy in 32%, spinal manipulative therapy in 25%, and acupuncture in 4% of all patient-years. Similar to previous survey-based studies higher rates of utilization were associated with higher socioeconomic status. These differences were most pronounced for manual therapy, exercise therapy, and magnetic resonance imaging. Conclusions The observed differences in health care utilization were highly related to socioeconomic status. Socioeconomic differences were higher for more expensive health services. Further research is necessary to identify barriers to equitable access to health services and to take appropriate action to decrease existing social disparities.

Background There are different procedures for both, the diagnosis and the therapy of a periprosthetic joint infection (PJI), however, national or international guidelines for a standardised treatment regime are still lacking. The present paper evaluates the use of the predominant treatment protocols for PJI in certified total joint replacement centres (EPZ) in Germany based on an EndoCert questionnaire. Materials and methods The questionnaire was developed in cooperation with the EndoCert Certification Commission to survey the treatment protocols for septic revision arthroplasties in EPZ. Questions targeted the various treatment options including prosthesis preserving procedures (DAIR - Debridement, antibiotics, irrigation, and retention of the prosthesis), one-stage revision, two-stage revision, removal of the endoprosthesis and diagnostic sampling prior to re-implantation. All certified EPZ participated ( n  = 504) and the results from the current survey in 2020 were compared to data from a previous analysis in 2015. Results The number of centres that performed DAIR up to a maximum of 4 weeks and more than 10 weeks after index surgery decreased since 2015, while the number of centres that provided a one-stage revision as a treatment option increased (hip: + 6.3%; knee: + 6.6%). The majority of the centres (73.2%) indicated a 4–8 week period as the preferred interval between prosthesis removal and re-implantation in two-stage revision in hip as well as knee revisions. Centres with a higher number of revision surgeries (> 200 revisions/year), opted even more often for the 4–8 week period (92.3%). In two-stage revision the use of metal-based spacers with/without reinforcement with antibiotic-containing cement as an interim placeholder was significantly reduced in 2020 compared to 2015. There was also a clear preference for cemented anchoring in two-stage revision arthroplasty in the knee in 2020, whereas the majority of hip replacements was cementless. Additionally, in 2020 the number of samples for microbiological testing during the removal of the infected endoprosthesis increased and 72% of the centres took five or more samples. Overall, the number of EPZ with a standardised protocol for the procedure expanded from 2015 to 2020. Conclusion While there was a trend towards standardised therapeutic algorithms for PJI with more uniform choices among the centres in 2020 compared to 2015, the treatment often remains an individual decision. However, since a consistent treatment regime is of vital importance with an expected rise of total numbers of revision arthroplasties, uniform definitions with regard to comparability and standardisation are necessary for the further development of the EndoCert system.

Background The periprosthetic joint infection (PJI) is a severe complication in the field of arthroplasty. Despite the rising number of primary joint replacements, no unified therapeutic standard has been established for the treatment of PJI yet. Methods A survey on the principles of treatment of PJI in Germany was conducted. A total of 515 EndoProthetikZentren (EPZ) were included, resulting in a response rate of 100%. Results For early infections 97.6% of the centers use prosthesis-preserving procedures (DAIR). A one-stage exchange was implemented by less than 50% of the centers. If implemented, this treatment entails a prior selection of patients for a successful treatment. The two-stage exchange is performed in all centers, and most centers proceed with the implantation of a cemented spacer between stages. 75% of the centers proceed with a center-based concept for the treatment of PJI. Conclusion The aim of a uniform PJI standard at the centers has not yet been fully achieved. Further improvements within the certification were initiated. The most relevant treatment options in Germany are displayed. The two-stage revision with a cemented spacer is the most widely implemented treatment. This exposition of principles could help for the further development of standardized treatment guidelines and definitions.

Background Rising surgery rates have raised questions about the indications for spinal surgery. The study investigated patient-level and regional factors associated with spinal surgery for patients with spinal diseases. Methods We undertook a cohort study based on routine healthcare data from Germany of 18.4 million patients within 60.9 million episodes of two patient-years before a possible spinal surgery in the time period 2008 to 2016. Using a Poisson model, the effects of a broad range of patient-related (sociodemographic, morbidity, social status), disease- and healthcare-related (physicians’ specialty, conservative treatments) and regional variables were analyzed. Results There was substantial regional heterogeneity in the occurrence of spinal surgery which decreased by only one quarter when controlling for the various determinants assessed. Previous musculoskeletal and mental health disorders as well as physical therapy were associated with a lower probability of surgery in the fully-adjusted model. Prescriptions for pain medication and consultations of specialists were associated with a higher probability of surgery. However, the specific severity of the vertebral diseases could not be taken into account in the analysis. Furthermore, a substantial proportion of patients with surgery did not receive a consultation with an outpatient specialist (29.5%), preoperative diagnostics (37.0%) or physical therapy (48.3%) before hospital admission. Conclusion This large study on spinal diseases in Germany highlights important patterns in medical care of spinal diseases and their association with the probability of spinal surgery. However, only a relatively small proportion of the regional heterogeneity in spinal surgery could be explained by the extensive consideration of confounders, which suggests the relevance of other unmeasured factors like physicians’ preferences.

Shifting surgeries from the stationary to the outpatient setting is seen as a suitable way to increase efficiency in the health care system. A substantial increase in outpatient procedures can therefore be observed internationally-particularly in the field of orthopedics. However, the interests and needs of patients are often insufficiently taken into account in this process. The \"Power-AOP\" research project was initiated to identify the associated challenges in the area of patient empowerment and to develop solutions. Using the field of orthopedics as an example, the Power-AOP project investigates how patient empowerment can be strengthened in the context of outpatient surgery. Using a mixed methods approach, health policy recommendations will be developed that aim to strengthen patient empowerment in the context of outpatient surgery. The project is scheduled to run for 3 years and comprises 6 work packages, with a total of 10 modules. In the first step, a scoping review was carried out to map the existing literature. This is followed by focus groups and interviews with patients and health care providers to gain deeper insights into their experiences and perspectives. The results will be quantified using a questionnaire-based survey. In order to identify a suitable patient population for this survey, an analysis of claims data will be conducted beforehand. The results will then be discussed and refined in 2 stakeholder workshops with key players in the health care system. In the final phase, a concept will be developed that contains actionable recommendations for strengthening patient empowerment in the context of outpatient care. The project began in April 2025. The claims data analysis and the scoping review have been completed, and a manuscript for the review is currently being prepared. The focus groups and interviews were conducted with 19 health care providers and 26 patients. Data analysis is in progress. The quantitative survey is planned for May 2026 to March 2027. The workshops are scheduled for the second and fourth quarters of 2027. The project will conclude with the final results in March 2028. This project will help to improve patient empowerment in the context of outpatient surgery. This allows patients to take a more active role in the process. On the one hand, this can lead to greater satisfaction with the process, particularly among patients. On the other hand, more active participation by patients can improve outcomes and prevent unnecessary readmissions or additional treatments.

HintergrundDie Implantation einer Totalendoprothese im Bereich des Kniegelenkes erfordert eine Nachbehandlung. Diese kann ambulant im Rahmen einer physiotherapeutischen Behandlung auf Rezeptbasis erfolgen, aber auch als ambulante oder stationäre Rehabilitation.RehabilitationsformenDie ambulante Rehabilitation liefert vergleichbare Resultate wie die stationäre Rehabilitation, allerdings nur bei den Patienten, die für eine ambulante Rehabilitation geeignet sind. Eine stationäre Rehabilitation ist in Abhängigkeit von generellem Gesundheitszustand, der allgemeinen körperlichen Leistungsfähigkeit, der Wohnsituation, der Erreichbarkeit von Rehabilitationseinrichtungen und den Möglichkeiten der sozialen Unterstützung in der häuslichen Umgebung sowie dem Alter und Komorbiditäten zu indizieren. Bei den physiotherapeutischen Verfahren ist der Schwerpunkt im Bereich der Bewegungstherapie zu setzen. Passiv reaktive Maßnahmen ergänzen die Therapie. Bei Patienten im erwerbsfähigen Alter ist im Rahmen der Rehabilitation das Tätigkeitsprofil zu berücksichtigen. Die Patientenschulung stellt mit Informationen über prothesengerechtes Verhalten einen wichtigen Baustein in der Nachbehandlung dar.AusblickDer demographische Wandel erfordert die zunehmende Berücksichtigung orthogeriatrischer Aspekte. Fast-Track-Programme werden eine Nachbehandlung nicht erübrigen, stellen bei beschleunigten Abläufen aber eine neue Herausforderung für die sektorale Zusammenarbeit dar.

In contrast to postmenopausal women, evidence for a favorable effect of exercise on Bone Mineral Density (BMD) is still limited for men. This might be due to the paucity of studies, but also to the great variety of participants and study characteristics that may dilute study results. The aim of the present systematic review and meta-analysis was to evaluate the effect of exercise on BMD changes with rational eligibility criteria. A comprehensive search of six electronic databases up to 15 March 2021 was conducted. Briefly, controlled trials ≥6 months that determined changes in areal BMD in men >18 years old, with no apparent diseases or pharmacological therapy that relevantly affect bone metabolism, were included. BMD changes (standardized mean differences: SMD) of the lumbar spine (LS) and femoral neck (FN) were considered as outcomes. Twelve studies with 16 exercise and 12 control groups were identified. The pooled estimate of random-effect analysis was SMD = 0.38, 95%-CI: 0.14–0.61 and SMD = 0.25, 95%-CI: 0.00–0.49, for LS and FN, respectively. Heterogeneity between the trials was low–moderate. Funnel plots and rank and regression correlation tests indicate evidence for small study publication bias for LS but not FN-BMD. Subgroup analyses that focus on study length, type of exercise and methodologic quality revealed no significant difference between each of the three categories. In summary, we provided further evidence for a low but significant effect of exercise on BMD in men. However, we are currently unable to give even rough exercise recommendations for male cohorts.

Since its foundation in 2010 by the German Society for Orthopaedics and Orthopaedic Surgery (DGOOC) and its establishment together with industry representatives (Bundesverband Medizintechnologie e. V.-BVMed) and the health insurance companies (AOK-Bundesverband eGbR, Verband der Ersatzkassen e. V. (vdek)), the German Arthroplasty Registry (EPRD) has developed rapidly in terms of size and quality of results. With over 3 million data records of hip and knee prostheses, it is now the world's third largest registry for arthroplasty. The product database of the EPRD and National Joint Registry (NJR) is becoming the global standard. 2023 was a record year in terms of recorded operations and scientific publications. The results of the EPRD are increasingly analysing and influencing everyday clinical practice in hip and knee arthroplasty in Germany. From 2025, all EPRD clinics will be able to use the Oxford Hip and Oxford Knee Score free of charge for their patients as Patient Reported Outcome Measures (PROMs). In 2025, the recording parameters will be expanded to include surgical approaches to the hip, navigation and robotics on the knee joint, as well as an optional infection module. In 2026, voluntary registration of the surgeon with surgeon level reporting will be possible. The EPRD and the Implantateregister Deutschland (IRD) are expected to exist in parallel from 2025, and cooperation is still being sought. Data collection should be as streamlined as possible without duplicate data entries. However, the EPRD will continue to work independently of the IRD with its more than 12 years of experience and over 3 million data sets and will continue to provide clinics and specialists with its analyses and publications in the future.

To improve arthroplasty care quality, the EndoCert initiative focuses on structural, processual, and surgeon-related quality assurance. The aim of this study was to assess the impact of a surgeon’s case load in certified centers on quality of care, distinguished by different types of surgeons. Data from the annual reports of EndoCert certified centers for the years 2017 to 2021 were analyzed. The study revealed reduced numbers of cases, while the number of surgeons remained constant. Since 2020, the decrease in the average case load per surgeons has become more pronounced. There were also differences between senior (sECrs) and EndoCert-registered surgeons (ECrs). Before the 2020 pandemic, over half of surgeons exceeded minimum annual case requirements, while, afterwards, this number declined, especially for the ECrs. Affiliated surgeons, who are also sECrs or ECrs, performed predominantly lower numbers of arthroplasties. However, a higher percentage of affiliated surgeons in a center correlated with faster surgeries and lower mortality rates. High numbers of arthroplasties per center or surgeon were not necessarily associated with better quality indicators, especially in the knee. While the comprehensive quality standards may offset volume effects, EndoCert should reconsider minimum volume regulations based on surgeon, but also on each joint.