Pericapsular Nerve Group Block Leads to Small but Consistent Reductions in Pain Between 18 and 24 Hours Postoperatively in Hip Arthroscopy for Femoroacetabular Impingement Surgery: A Prospective, Randomized Controlled Clinical Trial.

PURPOSE: To investigate whether the use of a pericapsular nerve group (PENG) block would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine opioid requirements and occurrence of postoperative nausea and vomiting (PONV). METHODS: Between May 2022 and October 2022, patients (N = 68) undergoing arthroscopic surgery for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided PENG preoperatively with 20 mL of 0.375% ropivacaine and standardized postoperative oral medication. The second group received a sham block preoperatively with 20 mL of 0.9% saline and standardized postoperative oral medication. The primary end point was pain scores (visual analog score [VAS], 0-10) during the first 24 hours postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the minimal clinically important difference (MCID) was calculated using the half standard deviation method. The incidence of PONV as well as opioid usage (converted to morphine equivalent) within the first 24 hours were secondary outcomes. RESULTS: Randomization and permission were successfully obtained from 68 participants. From the fifteenth postoperative hour, the PENG group reported significantly less postoperative pain than the control group (24th postoperative hour: VAS pain PENG group 1.3 ± 0.9 [0-3]; 95% confidence interval {CI} 0.4-1.2 vs the VAS pain control group 2.4 ± 1.6 [0-5]; 95% CI 1.4-4.7; P = .009). The VAS pain score threshold for achieving the MCID at 24 hours postoperative was defined as a decrease of 1.1. 27 patients (79%) in the PENG group and 22 patients (65%) in the control group were able to achieve MCID (P = .009). Opioid dosage and postoperative nausea did not differ significantly between groups (P = .987 and P = .655, respectively). Concomitant complications such as falls, hematomas, or weakened muscles did not occur in either group. CONCLUSIONS: According to this study, a PENG block minimally reduced pain after arthroscopic treatment for FAIS between the 18th and 24th postoperative hours. The PENG group achieved significantly more often the pain VAS MCID. However, there was no proof that the PENG group consumed fewer opioids than the control group. Overall, PONV was found at a low and comparable rate. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G).

BACKGROUND: The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation. METHODS: Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation. RESULTS: The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (KPABAK = 0.55 -0.81). Validity for the sum score (r = 0.52-0.65) and the dimensions pain (r = 0.53-0.62), range of motion (r = 0.7) and stability (r = - 0.61) was verified. The function subscale reached insufficient validity (r = 0.15-0.39). CONCLUSION: The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability After Failed Common Extensor Origin Release: Outcomes at Minimum 2-Year Follow-up.

BACKGROUND: In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI). PURPOSE: To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction. RESULTS: The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5). CONCLUSION: LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI.

The Erector Spinae Plane Block in the Setting of Hip Arthroscopy: A Prospective Randomized Controlled Clinical Trial.

PURPOSE: To investigate whether the use of an erector spinae plane block (ESPB) would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine the amount of additional opioids and postoperative nausea and vomiting (PONV). METHODS: From October 2019 to October 2020, 68 patients undergoing arthroscopic therapy for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided ESPB preoperatively with 30 mL of 0.375% ropivacaine and standard postoperative oral medication. The second group received a sham block preoperatively with 30 mL of 0.9% saline and standard postoperative oral medication. The primary endpoint was pain scores (numeric pain score out of 10) during the first 24 hours postoperatively. Secondary outcomes were opioid consumption during the first 24 hours (converted to morphine equivalents) and the incidence of PONV. Demographic and clinical characteristics were recorded for all patients. Categorial data were compared with chi-squared and Fisher's exact tests. Continuous data were compared with 2-sided t tests and Wilcoxon rank-sum tests. RESULTS: Sixty-eight subjects consented and were successfully randomized. Reported postoperative pain was significantly lower in the ESPB group than in the control group during the first 24 hours. The opioid amount (P = .865) and postoperative nausea (P = .642) did not differ significantly between groups. No associated complications such as falls, hematomas, or muscular weakness occurred in either group. CONCLUSION: This study demonstrates that ESPB significantly decreases pain in the first 24 hours after arthroscopic therapy for FAIS. However, there was no evidence of lower opioid consumption compared with the control group. Overall, a low and comparable rate of PONV was present. Therefore, the ESPB seems to complement a multimodal approach to perioperative pain management in hip arthroscopy. LEVEL OF EVIDENCE: 1, randomized controlled trial.

17-Year Results following Transepiphyseal Anterior Cruciate Ligament Reconstruction in Children and Adolescents. / 17-Jahres-Ergebnisse nach transepiphysärer Plastik des vorderen Kreuzbandes im Kindes- und Jugendalter.

OBJECTIVE: Rupture of the anterior cruciate ligament (ACL) in childhood and adolescence is a serious injury. It is now known that conservative therapy of an unstable knee joint in childhood or adolescence under can lead to poor subjective and objective results. The aim of this study is to record long-term results after transepiphyseal ACL reconstruction using autologous hamstring tendons and extracortical fixation in childhood and adolescence with open physes - at least 15 years after surgery. METHODS: Our internal registry was used to identify all patients who received surgical treatment of an acl tear during childhood and adolescence by transepiphyseal acl reconstruction more than 15 years previously. In these patients, the International Knee Documentation Committee for Subjective Knee Form (IKDCsubj.), Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Score (TAS) and Lysholm Score were collected, and clinical and magnetic resonance imaging (MRI) examinations were performed. RESULTS: A total of 22 patients were identified, 5 of whom could not be contacted. The mean age at the time of surgery was 13.1 years, and the mean follow-up time was 17.4 years. In 3 patients, a traumatic tear was observed with subsequent reconstruction of the ACL. None of the included patients showed a growth disorder during the course of the study. The IKDCsubj. was 92.4 ± 14.7 (48 - 100), the Lysholm score was 87.9 ± 16.9 (34 - 100), the TAS was 5.7 ± 2.3 (3 - 9) and the pain level based on VAS was 3.5 ± 2.6 (1 - 8) points. The values showed subjective and objective deterioration compared to the 10-year results, with no statistical significance. The following subscores were reported for the KOOS: KOOSpain 90.9 ± 17.6 (28 - 100); KOOSsymptom 82.9 ± 22.6 (11 - 100); KOOOSADL 94.3 ± 13.7 (44 - 100); KOOSSport 80.3 ± 26.4 (15 - 100); KOOSQOL 80.9 ± 25.8 (0 - 100). 13 of the 17 patients could also be clinically and radiologically examined. In 92% of patients, an intact acl reconstruction was found without evidence of cartilage or meniscus damage. The mean lateral difference in the KT-1000 measurement was 1.5 mm. CONCLUSION: ACL reconstruction in childhood and adolescence provides good functionality and stability of the knee joint over the long term. Secondary signs of osteoarthritis can only be detected in isolated cases by MRI. ACL reconstruction using the transepiphyseal technique can be considered the method of choice for open growth plate knee joints.

Is Hip Arthroscopy an Adequate Therapy for the Borderline Dysplastic Hip? Correlation Between Radiologic Findings and Clinical Outcomes.

BACKGROUND: Recent studies have shown that assessment of the lateral center-edge angle (LCEA) between 18° and 25° is not sufficient to adequately classify mildly dysplastic hips and that further radiological features should be considered. However, no correlation between different morphologic features and clinical outcomes has been investigated so far. PURPOSE: To analyze the clinical outcomes of patients with different subtypes of borderline dysplastic hips who underwent arthroscopic surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We examined patients with an LCEA between 18° and 25° who underwent arthroscopic treatment for femoroacetabular impingement syndrome between January 2015 and December 2016. A hierarchical cluster analysis was performed to identify hip morphologic subtypes according to radiographic parameters, including the LCEA, femoro-epiphyseal acetabular roof (FEAR) index, anterior and posterior wall indices (AWI and PWI), Tönnis angle, alpha angle, and femoral neck-shaft angle. In addition, the International Hip Outcome Tool 12 (iHOT-12) and a visual analog scale (VAS) for pain were applied preoperatively and at follow-up, and the results were compared among the different clusters. Previously reported minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values were used to determine clinically significant improvements. RESULTS: A total of 40 patients were identified. Of these, 36 patients were available for evaluation at a mean follow-up of 43.8 months. In total, 4 sex-independent clusters with different morphologic patterns of the hip were identified: cluster 1, unstable anterolateral deficiency (FEAR index >2°, AWI <0.35); cluster 2, stable anterolateral deficiency (FEAR index <2°, AWI <0.35); cluster 3, stable lateral deficiency (FEAR index >2°, normal AWI and PWI); and cluster 4, stable posterolateral deficiency (FEAR index <2°, PWI <0.85). At follow-up, clusters 1, 2, and 3 showed significantly improved iHOT-12 (P < .0001) and VAS pain (P < .0001) scores, and cluster 4 showed no significant improvements. The MCID of 15.2 points was achieved by all patients in clusters 2 and 3, by 63% of patients in cluster 1, and by 23% of patients in cluster 4. Clusters 2 and 3 differed significantly from clusters 1 and 4 (P = .02). A postoperative PASS score of 60 was achieved by all patients in cluster 3, by 86% of patients in cluster 2, by 63% of patients in cluster 1, and by 20% of patients in cluster 4. The differences between the groups were statistically significant (P = .01). CONCLUSION: Arthroscopic surgery yielded good results in the treatment of stable borderline hip dysplasia with anterolateral and lateral deficiency. In contrast, borderline hip dysplasia with acetabular retroversion showed no improvements after arthroscopic therapy. This study underlines the need for an accurate analysis of all possible radiological signs to adequately classify borderline dysplastic hips.

Translation of the Mayo Elbow Performance Score (MEPS) into German (MEPS-G). / Die Übertragung des Mayo Elbow Performance Score (MEPS) ins Deutsche (MEPS-G).

BACKGROUND: The Mayo Elbow Performance Score is a clinical assessment to rate the performance of the elbow from a medical and/or therapeutic perspective. It is simple and efficient to operate and therefore frequently used in research as well as in clinics. However, an adequate translation of the MEPS into the German language and a verification of the quality criteria for the use in the German health system are currently lacking. GOAL OF THE STUDY: The aim of this study is to translate the MEPS and to review the applicability of the German version (MEPS-G) in Germany. MATERIALS AND METHODS: The translation was undertaken on the basis of a guideline for cultural adaptation. Two independent translations were created, combined and translated back into English by two native speakers. The back translations were reviewed and the German version was amended accordingly. The suitability of the final questionnaire was verified in a pretest with 73 participants. RESULTS: The MEPS was converted into the German version MEPS-G and was tested. Apart from minor adjustments, the questionnaire was translated into German without difficulty. The time to complete the assessment was on average 2.5 min (± 1.6). CONCLUSION: First analyses of the psychometric properties of the German MEPS showed identical values as the English version. The detailed quality criteria will be reviewed in a subsequent study.

Functional improvement is sustained following anatomical and reverse shoulder arthroplasty for fracture sequelae: a registry-based analysis.

INTRODUCTION: Shoulder arthroplasty for proximal humerus fracture sequelae is known to provide significant patient improvement, yet this outcome varies with time, prosthesis type, and fracture sequelae. We outline the expected course of postoperative shoulder pain and function in patients with anatomical (ASA) or reverse (RSA) shoulder arthroplasty following different fracture sequelae. MATERIALS AND METHODS: Of 111 consecutive patients from our local shoulder arthroplasty registry, 32 underwent ASA for Boileau type 1 sequelae and 77 RSA patients were identified with Boileau types I, III, and IV. By 5 year post-surgery, there were 72 patients available. All patients underwent standardised ASA or RSA procedures with anatomical (Promos Standard; Lima SMR™; Arthrex Eclipse™; Univers™ II) or reverse prostheses (Promos Reverse®; Lima SMR™ Reverse; Univers Revers™; Aequalis® Reversed). Range of motion, Constant-Murley, Disability of the Arm, Shoulder and Hand (DASH), and Shoulder Pain and Disability Index (SPADI) scores were compared at 6, 12, 24, and 60 months postoperatively. We used generalised linear mixed models or random-effects ordered logistic regression to investigate postoperative changes of outcome parameters from baseline to follow-up time points for each group as well as for group comparisons. RESULTS: Range of motion and clinical scores improved until 24 months postoperatively and did not deteriorate thereafter, except for internal rotation of Boileau type III and IV patients and external rotation of RSA patients with type I and IV sequelae. At all follow-ups, ASA patients with Boileau type I sequelae had significantly better internal and external rotation versus patients with RSA and/or other Boileau types (p < 0.001), while Constant, DASH, and SPADI scores were not significantly different between groups. CONCLUSION: In humeral fracture sequelae, ASA and RSA lead to sustained clinical improvements. Surgeons may primarily consider implantation of ASA in type I sequelae.

Limited reliability of grading scapular notching according to Nerot-Sirveaux on anteroposterior radiographs.

INTRODUCTION: Incidences of scapular notching (SN) in reverse shoulder arthroplasty (RSA) range between 0% and 96%, and controversy remain as to its relevance for patient outcome. We assessed the reliability of scapular notching (SN) grading based on the Sirveaux classification system using anteroposterior radiographs. MATERIALS AND METHODS: 206 RSA procedures with 5-year postoperative anteroposterior shoulder radiographs were classified independently by seven assessors according to Sirveaux (session 1). After a review meeting, three assessors re-classified the radiographs along with quality criteria (session 2). SN grading by the majority of assessors was taken as the reference. Classification interobserver reliability was analyzed using Kappa statistics. RESULTS: The incidence of SN was estimated at 53% and 37% at the first and second sessions, respectively. Interobserver reliability Kappa coefficients resulting from the first and second sessions were 0.27 and 0.43, respectively. Case selection based on radiographic quality criteria did not improve SN grading reliability in the second session. CONCLUSION: Agreement between individual surgeons was low when grading SN in RSA according to Sirveaux using anteroposterior radiographs. Consensus among several assessors may increase reliability in research settings.

Porcine Dermis Patch Augmentation of Supraspinatus Tendon Repairs: A Pilot Study Assessing Tendon Integrity and Shoulder Function 2 Years After Arthroscopic Repair in Patients Aged 60 Years or Older.

PURPOSE: To investigate the 2-year postoperative clinical and subjective outcomes after arthroscopic rotator cuff repair (ARCR) with xenologous porcine dermal patch augmentation compared with ARCR alone. METHODS: Patients aged 60 years or older with a complete supraspinatus (SSP) tendon tear underwent primary ARCR with a transosseous-equivalent technique. By use of a matched-pair comparative trial design, a consecutive series of 20 patients receiving additional xenologous porcine dermal patch augmentation (patch group) was matched by tear location with 20 patients who received ARCR only (control group). Prior conservative treatment failed in all patients. Patients with concomitant pathologies precluding accurate repair assessment, partial or open reconstruction, or a latissimus dorsi and/or pectoralis major muscle transfer were excluded. Patients reported daily pain levels for 10 days after surgery. Clinical parameters and various patient-reported outcome scores were documented preoperatively and at 3, 6, and 24 months after surgery. Repair integrity was determined by magnetic resonance imaging or ultrasound at 24 months. Adverse events were recorded. Group outcome differences were analyzed with t tests, Fisher exact tests, and mixed models. RESULTS: Patients in both groups were aged 67 years on average (range, 60-74 years), and 70% of patients were men. Patients in the patch group had slightly more SSP fatty infiltration preoperatively. Patch surgical procedures were on average 22 minutes longer than control interventions (P = .003). At 24 months, 4 patients and 9 patients were diagnosed with a recurrent SSP tendon defect in the control group (n = 20) and patch group (n = 19), respectively (relative risk, 2.4; P = .096). Of 11 defects (85%) identified as medial cuff failure, 8 occurred in the patch group. Pain rated by all patients decreased from postoperative day 1 to day 10 without any significant group difference (P = .348). No significant group differences were noted for other outcome parameters, and recurrent defects had no relevant effect on functional outcomes. Local complications (including recurrent defects) occurred in 8 patients in the control group and 12 in the patch group (P = .343). CONCLUSIONS: Our pilot study supports the view that an SSP tear repair with porcine dermal xenograft augmentation does not benefit patients in terms of reducing the risk of a recurrent tendon defect or improving shoulder function up to 24 months after surgical repair. LEVEL OF EVIDENCE: Level III, therapeutic study, retrospective comparative trial.

Reliable Alignment in Total Knee Arthroplasty by the Use of an iPod-Based Navigation System.

Axial alignment is one of the main objectives in total knee arthroplasty (TKA). Computer-assisted surgery (CAS) is more accurate regarding limb alignment reconstruction compared to the conventional technique. The aim of this study was to analyse the precision of the innovative navigation system DASH® by Brainlab and to evaluate the reliability of intraoperatively acquired data. A retrospective analysis of 40 patients was performed, who underwent CAS TKA using the iPod-based navigation system DASH. Pre- and postoperative axial alignment were measured on standardized radiographs by two independent observers. These data were compared with the navigation data. Furthermore, interobserver reliability was measured. The duration of surgery was monitored. The mean difference between the preoperative mechanical axis by X-ray and the first intraoperatively measured limb axis by the navigation system was 2.4°. The postoperative X-rays showed a mean difference of 1.3° compared to the final navigation measurement. According to radiographic measurements, 88% of arthroplasties had a postoperative limb axis within ±3°. The mean additional time needed for navigation was 5 minutes. We could prove very good precision for the DASH system, which is comparable to established navigation devices with only negligible expenditure of time compared to conventional TKA.

Does Pure Platelet-Rich Plasma Affect Postoperative Clinical Outcomes After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: The exact role of platelet-rich plasma (PRP) in rotator cuff tendon reconstruction remains unclear. PURPOSE/HYPOTHESIS: This study investigated whether an intraoperative pure PRP injection, compared with a local anesthetic injection, improves patient-reported outcomes at 3 and 6 months after arthroscopic rotator cuff repair. The hypothesis was that pure PRP improves patient-reported outcomes (Oxford Shoulder Score [OSS]) at 3 and 6 months after surgery and has the same pain-reducing effect compared with a postoperative subacromial local anesthetic (ropivacaine) injection. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Between January 2011 and November 2012, a total of 120 patients who underwent arthroscopic double-row repair of a supraspinatus tendon rupture were randomized to receive either pure PRP by an injection at the footprint (PRP group; n = 60) or ropivacaine injected in the subacromial region (control group; n = 60). Seventy-eight percent of patients had other concomitant tears. All patients, surgeons, and follow-up investigators were blinded. Clinical parameters and various outcome scores (Constant-Murley shoulder score; OSS; patient American Shoulder and Elbow Surgeons score; quick Disabilities of the Arm, Shoulder and Hand score; EuroQol 5 dimensions) were documented preoperatively and at 3, 6, and 24 months postoperatively. The repair integrity was assessed by magnetic resonance imaging or ultrasound at 24 months. Furthermore, a pain diary was completed within the first 10 postoperative days, and adverse events were recorded. Group outcome differences were analyzed using t tests, Fisher exact tests, and mixed models. RESULTS: The final follow-up rate was 91%. An associated tear of the subscapularis tendon was diagnosed in 23% of PRP-treated patients and 36% of control patients. Three months after surgery, the mean (±SD) OSS was 32.9 ± 8.6 in PRP-treated patients and 30.7 ± 10.0 in control patients (P = .221). No significant differences were noted for other outcome parameters as well as at 6 and 24 months postoperatively. Smoking was a significant effect modifier. Pain for both groups decreased from postoperative day 1 to 10 without any significant group difference (P = .864). Six (12.2%) and 11 (20.8%) patients were diagnosed with a recurrent supraspinatus tendon defect in the PRP and control groups, respectively (P = .295). Twenty-two (40.7%) and 18 (30.5%) PRP-treated and control patients, respectively, experienced a local adverse event within 24 months (P = .325). CONCLUSION: Patients treated with pure PRP showed no significantly improved function at 3, 6, and 24 months after arthroscopic repair compared with control patients receiving ropivacaine; however, a similar pain reduction was documented in both groups. The negative influence of smoking on the effect of pure PRP requires further investigation. REGISTRATION: NCT01266226 (ClinicalTrials.gov).

Direct comparison of different surgical approaches in a woman with bilateral osteochondrosis dissecans of her knees: a case report.

BACKGROUND: Osteochondrosis dissecans is a disorder of the subchondral bone potentially affecting the adjacent articular cartilage. There remains disunity with regard to treatment methods. CASE PRESENTATION: We present the case of a 21-year-old Swiss woman who presented with clinically symptomatic bilateral osteochondrosis dissecans lesions at both medial femoral condyles. She underwent sequential surgical intervention and was prospectively monitored using clinical scores and magnetic resonance imaging. Her left knee was treated with an open refixation of the osteochondrosis dissecans lesion with two 2.0 mm screws in combination with a cancellous bone graft and subchondral drilling since the cartilage of the osteochondrosis dissecans lesion was intact. On her right knee, she underwent open removal of the defective bone and cartilage, cancellous bone graft with subchondral drilling and coverage with a bilayered collagenous membrane (autologous matrix-induced chondrogenesis technique) since the cartilage of the osteochondrosis dissecans lesion was not intact. At final follow-up 12 months after surgery her Lysholm score had improved from 79 to 95 on her left side and from 74 to 78 on her right. Magnetic resonance imaging displayed good integration of the cancellous bone graft with a slight irregularity at the articular surface on her left side (magnetic resonance observation of cartilage repair tissue (MOCART) 75). The magnetic resonance imaging of her right knee depicted satisfying bony reconstitution with yet more irregularity at the joint surface (magnetic resonance observation of cartilage repair tissue 65) in comparison to her left femoral condyle. CONCLUSIONS: In cases of failed conservative treatment of osteochondrosis dissecans lesions of the knee joint surgery should be taken into consideration. Considering this case, we believe that the focus should be the preservation of the cartilaginous layer whenever possible or at least replacement with high quality replacement tissue, such as autologous chondrocyte implantation.

Metal implant removal: benefits and drawbacks--a patient survey.

BACKGROUND: Hardware removals are among the most commonly performed surgical procedures worldwide. Current literature offers little data concerning postoperative patient satisfaction. The purpose of our study was to evaluate the patients' point of view on implant removal. METHODS: We surveyed patients of a German level one trauma center, who underwent hardware removal in 2009 and 2010, with regard to their personal experiences on implant removal. Exclusively, data obtained out of the survey were analyzed. RESULTS: In 332 patients surveyed, most hardware removals were performed at the ankle joint (21%) followed by the wrist (15%). The most frequent indication was a doctor's recommendation (68%), followed by pain (31%) and impaired function (31%). Patient reported complication rate of implant removal was 10%. Importantly, after implant removal because of pain or impaired function patients reported an improvement in function (72%) as well as decreased pain (96%). 96% of all responding patients and 66% of the patients who suffered from subsequent complications would opt for surgical implant removal again. CONCLUSION: In summary, despite the challenging and frequently troublesome nature of surgical hardware removal our data contradicts the widely held view that implant removal is often without a positive effect on the patients. These findings may influence the surgeons' attitude towards implant removal and their day-to-day routine in patient counseling.

Current state of treatment of acute acromioclavicular joint injuries in Germany: is there a difference between specialists and non-specialists? A survey of German trauma and orthopaedic departments.

PURPOSE: The purpose of this study was to evaluate currently preferred treatment strategies as well as the acceptance of new arthroscopic techniques among German orthopaedic surgeons. We assumed that surgeons specialized in shoulder surgery and arthroscopy would treat acute acromioclavicular joint dislocations different to non-specialized surgeons. METHODS: Seven hundred and ninety-six orthopaedic and/or trauma departments were found through the German hospital directory of 2012. Corresponding websites were searched for the email address of the chair of shoulder surgery (if applicable) or the department. Seven hundred forty-six emails with the request for study participation including a link to an online survey of 36 questions were sent. In 60 emails, the recipient was unknown. RESULTS: Two hundred and three (30 %) surgeons participated in the survey. one hundred and one were members of the AGA (German-speaking Society for Arthroscopy and Joint-Surgery) and/or of the DVSE (German Association of Shoulder and Elbow Surgery) and regarded as specialists, while 102 were non-members and regarded as non-specialists. According to the treatment of Rockwood I/II and IV-VI injuries, no significant differences were found. Seventy-four % of non-specialists and 67 % of specialists preferred surgical treatment for Rockwood III injuries (P = 0.046). Non-specialists would use the hook plate in 56 % followed by the TightRope in 16 %; specialists would use the TightRope in 38 % followed by the hook plate in 32 % (P = 0.004). CONCLUSIONS: The majority of German orthopaedic and trauma surgeons advise surgical treatment for Rockwood III injuries. Specialists recommend surgery less often. Non-specialists prefer the hook plate, whereas specialists prefer the arthroscopic TightRope technique. LEVEL OF EVIDENCE: Observational survey, Level IV.

How do we face patients' expectations in joint arthroplasty?

INTRODUCTION: Patients' expectations have become increasingly important over the last decade, as the fulfilment of preoperative expectations has been shown to be associated with postoperative satisfaction. Understanding the pattern of patients' expectations is necessary to provide a better basis for recommendations to patients opting for arthroplasty. The aim of this study was to show patients' expectations of joint replacement surgery in Germany and to elucidate factors, which might have an influence. MATERIALS AND METHODS: A retrospective analysis of anonymously collected data was performed on people participating in a patient information event for joint replacement surgery. They were asked to complete a survey, which consisted of five questions requesting demographic data and three questions regarding preoperative expectations. The latter were taken from the New Knee Society Score. An expectation score (0-12 points) was generated by adding the single point values of the three questions. RESULTS: 180 attendees were included in this study. The distribution of patients' expectations was remarkably skewed towards high expectations, the mean expectation score was 10.17. 87.2 % of participants had high and very high expectations and only 12.8 % had low and moderate expectations. Patients' expectations were independent of age and previous participation in a patient information event. Female gender and a history of arthroplasty led to a slightly higher expectation score. Patients with isolated knee pain had significantly lower expectations than patients suffering from isolated hip pain. CONCLUSIONS: This study shows that the majority of patients have high expectations regarding joint replacement surgery. To improve postoperative patients' satisfaction a straightforward physician-patient communication is necessary to prevent patients from potentially unrealistic expectations and therefore dissatisfaction with surgery.

Epidemiology and risk factors of multiple-organ failure after multiple trauma: an analysis of 31,154 patients from the TraumaRegister DGU.

BACKGROUND: In the severely injured who survive the early posttraumatic phase, multiple-organ failure (MOF) is the main cause of morbidity and mortality. An enhanced prediction of MOF might influence individual monitoring and therapy of severely injured patients. METHODS: We performed a retrospective analysis of a nationwide prospective database, the TraumaRegister DGU of the German Trauma Society. Patients with complete data sets (2002-2011) and a relevant trauma load (Injury Severity Score [ISS] ≥ 16), who were admitted to an intensive care unit, were included. RESULTS: Of a total of 31,154 patients enclosed in this study, 10,201 (32.7%) developed an MOF according to the Sequential Organ Failure Assessment score. During the study period, mortality of all patients decreased from 18.1% in 2002 to 15.3% in 2011 (p < 0.001). Meanwhile, MOF occurred significantly more often (24.6% in 2002 vs. 31.5% in 2011, p < 0.001), but mortality of MOF patients decreased (42.6% vs. 33.3%, p < 0.001). MOF patients who died survived 2 days less (11 days in 2002 vs. 8.9 days in 2011, p < 0.001). Independent risk factors for the development of MOF following severe trauma were age, ISS, head Abbreviated Injury Scale (AIS) score of 3 or higher, thoracic AIS score of 3 or higher, male sex, Glasgow Coma Scale (GCS) score of 8 or less, mass transfusion, base excess of less than -3, systolic blood pressure less than 90 mm Hg at admission, and coagulopathy. CONCLUSION: Over one decade, we observed an ongoing decrease of mortality after multiple trauma, accompanied by decreasing mortality in the subgroup with MOF. However, incidence of MOF in the severely injured increased significantly. Thus, MOF after multiple trauma remains a challenge in intensive care. The risk factors from multivariate analysis could be instrumental in anticipating the early development of MOF. Furthermore, a reliable prediction model might be supportive for patient enrolment in trauma studies, in which MOF marks the primary end point. LEVEL OF EVIDENCE: Epidemiologic study, level III.