Correction: The Effect of an App-Based Home Exercise Program on Self-reported Pain Intensity in Unspecific and Degenerative Back Pain: Pragmatic Open-label Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/41899.].

The Effect of an App-Based Home Exercise Program on Self-reported Pain Intensity in Unspecific and Degenerative Back Pain: Pragmatic Open-label Randomized Controlled Trial.

BACKGROUND: The recommended first-line treatment for unspecific and degenerative back pain consists of movement exercises and patient education. OBJECTIVE: Using a pragmatic, randomized controlled trial, we evaluated the effectiveness of a digital home exercise program on self-reported pain intensity compared with the standard of care for physiotherapy. METHODS: Participant recruitment was based on newspaper advertisements and a consecutive on-site assessment for eligibility and enrollment. Participants with unspecific and degenerative back pain aged ≥18 years were randomly assigned in a 1:1 ratio to receive a 12-week stand-alone digital home exercise program or physiotherapy. The digital home exercise program included 4 exercises daily, while physiotherapy included 6 to 12 sessions, depending on the severity of symptoms. The primary outcome was pain, which was assessed using a verbal numerical rating scale. The clinical relevance of pain reduction was assessed using the following thresholds: improvement of at least 1.4 points on the verbal numerical rating scale and a pain reduction of at least 30%. RESULTS: During the study period, 108 participants were assigned to the intervention group and 105 participants to the control group. The mean difference in pain scores between the 2 groups at 12 weeks was -2.44 (95% CI -2.92 to -1.95; P<.01) in favor of the intervention group. The group receiving the digital therapeutic achieved a clinically relevant reduction in pain over the course of the study (baseline vs 12 weeks), with a mean change of -3.35 (SD 2.05) score points or -53.1% (SD 29.5). By contrast, this change did not reach clinical relevance in the control group (mean -0.91, SD 1.5; -14.6%, SD 25.3). Retention rates of 89.9% in the intervention group and 97.3% in the control group were maintained throughout the study. CONCLUSIONS: The use of the app-based home exercise program led to a significant and clinically relevant reduction in pain intensity throughout the 12-week duration of the program. The intervention studied showed superior improvement in self-reported pain intensity when compared with the standard of care. Given the great demand for standard physiotherapy for unspecific and degenerative back pain, digital therapeutics are evolving into a suitable therapeutic option that can overcome the limitations of access and availability of conventional modes of health care delivery into this spectrum of indications. However, further independent evaluations are required to support the growing body of evidence on the effectiveness of digital therapeutics in real-world care settings. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022781; https://tinyurl.com/hpdraa89.

Long-term results using the straight tapered femoral cementless hip stem in total hip arthroplasty: a minimum of twenty-year follow-up.

We report the first long-term results of a prospective cohort study after total hip arthroplasty using the cementless Bicontact hip stem. Between 1987 and 1990, 250 total hip arthroplasties in 236 patients were performed using the cementless Bicontact hip stem. The average follow-up was 22.8 years (20.4-24.8) and average age at index surgery was 58.1 years. Eighty-one patients died and 9 were lost to follow-up. We noted 11 stem revisions revealing an overall Kaplan Meier survival rate of 95.0% (CI 95%: 91.1-97.2%). The average Harris Hip Score revealed 81 points (range 24-93). The Bicontact hip stem demonstrated high survival rates despite high ages and osteopenic changes, which are equivalent to other long-term reports of cementless stem fixation.

Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009.

BACKGROUND: The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. METHODS: The databases (PubMed/EMBASE) were searched for the time period (01/1970-09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey's-test. Complication rates among methods were compared by using Pearson's-chi-square-test and pairwise comparisons using Fisher's-two-tailed-exact-test. RESULTS: Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)].The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. DISCUSSION: Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.

The complexity of proximal humeral fractures is age and gender specific.

BACKGROUND: Studies that investigated possible associations between the complexity of proximal humeral fractures and patient characteristics are rare. We hypothesized that the grade of fracture complexity may correlate with age and gender of hospitalized, adult patients. METHODS: Based on the Neer classification, we defined four radiological grades of fracture complexity. The data of adult patients that were treated during a 9-year period at a German hospital serving a town of 80,000 inhabitants was reviewed. RESULTS: Seven hundred and eighty fractures were evaluated [518 female/262 male (66.41/33.59 %), average age 64.2 years (range 17.4-99.2)]. During the study period, the number of fractures increased to 167 %. Almost two-thirds of the patients were females and older than 60 years. Of all fractures, 86 % were displaced fractures. In patients younger than 60 years, 1.99-fold more complex fractures occurred in males (32.4 %) than in females (16.2 %). In contrast, in patients older than 60 years, 1.72-fold more complex fractures occurred in females (54.1 %) than in males (31.5 %). There was a significant association between low-energy trauma and female gender older than 60 years. CONCLUSIONS: Our study demonstrated an overall increase of displaced proximal fractures. The vast majority of patients with more complex fractures consisted of female patients older than 60 years.

High success rate for augmentation compression plating leaving the nail in situ for aseptic diaphyseal tibial nonunions.

OBJECTIVES: To evaluate adjunctive compression plating leaving the previously unreamed inserted intramedullary nail (URIMN) in situ for treating a resultant diaphyseal tibial nonunion. DESIGN: Retrospective study. SETTING: Level 1 trauma center (University Hospital). PATIENTS/PARTICIPANTS: Patients treated by URIMN for diaphyseal tibial fractures that developed an aseptic hypertrophic nonunion. INTERVENTION: Dynamization of the nail and compression plating leaving the URIMN in situ. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical parameters. RESULTS: The mean follow-up was 3.8 years (range 2-7 years). Mean time for healing was 15 weeks with a mean operation time of 63 minutes. Union occurred in 27/28 (96.4%). There were no infections. CONCLUSIONS: This simple technique seems to have a high success rate and should be considered when a nonunion occurs after URIMN. The need for an additional incision and removal of symptomatic implants remains a disadvantage. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland.

BACKGROUND: The therapeutic spectrum for the treatment of displaced proximal humeral fractures ranges from conservative therapy to head-preserving surgical interventions and joint replacement. This study initiated a survey on the current treatment options with regard to diagnostics, choice of therapy, and complications that are encountered at trauma surgeries and orthopedic hospitals in Germany, Austria, and Switzerland. MATERIALS AND METHODS: The survey included 743 hospitals. The questionnaire covered information on demographics, diagnostics, classification, therapy, and complications of proximal humeral fractures. RESULTS: The questionnaire was completed by 348 hospitals. Five of 6 hospitals treat more than 40% of the fractures surgically. The percentage distribution of the available implants is at 63.4% for angular stable plates, 30.9% for intramedullary nails, and 10.1% for fracture prostheses. The 5 complications reported most frequently were nonanatomic reduction (83%), implant perforation (73%), secondary displacement of the fracture (71%), avascular necrosis (67%), and implant-related impingement (59%). CONCLUSIONS: A preference for surgical treatment of proximal humeral fractures was found, with stabilization predominantly being attempted by the use of angle-stable implants. The 2 most common complications were "nonanatomic reduction of fractures" and the more specific problem of "implant perforation" when fixed-angle implants were used for treatment.

Biomechanical analysis of a new expandable vertebral body replacement combined with a new polyaxial antero-lateral plate and/or pedicle screws and rods.

PURPOSE: Restoration of the anterior spinal profile and regular load-bearing is the main goal treating anterior spinal defects in case of fracture. Over the past years, development and clinical usage of cages for vertebral body replacement have increased rapidly. For an enhanced stabilization of rotationally unstable fractures, additional antero-lateral implants are common. The purpose of this study was the evaluation of the biomechanical behaviour of a recently modified, in situ distractible vertebral body replacement (VBR) combined with a newly developed antero-lateral polyaxial plate and/or pedicle screws and rods using a full corpectomy model as fracture simulation. METHODS: Twelve human spinal specimens (Th12-L4) were tested in a six-degree-of-freedom spine tester applying pure moments of 7.5 Nm to evaluate the stiffness of three different test instrumentations using a total corpectomy L2 model: (1) VBR+antero-lateral plate; (2) VBR, antero-lateral plate+pedicle screws and rods and (3) VBR+pedicle screws and rods. RESULTS: In the presented total corpectomy defect model, only the combined antero-posterior instrumentation (VBR, antero-lateral plate+pedicle screws and rods) could achieve higher stiffness in all three-movement planes than the intact specimen. In axial rotation, neither isolated anterior instrumentation (VBR+antero-lateral plate) nor isolated posterior instrumentation (VBR+pedicle screws and rods) could stabilize the total corpectomy compared to the intact state. CONCLUSIONS: For rotationally unstable vertebral body fractures, only combined antero-posterior instrumentation could significantly decrease the range of motion (ROM) in all motion planes compared to the intact state.

Septic arthritis of the knee: presentation of a novel irrigation-suction system tested in a cadaver study.

BACKGROUND: The established treatment for bacterial arthritis of the knee joint is arthroscopic surgery with irrigation and debridement. The aim of this article is to summarize the relevant data in treating bacterial arthritis of the knee joint, and based on these findings to present a novel irrigation suction system, tested in a cadaver study, as an additional tool in the postoperative treatment phase of arthroscopic surgery for knee joint infections. METHOD: The novel automated irrigation-suction system presented here was compared to conventional continuous suction irrigation in a total of six knee joints. All knee joints were filled with 80 ml methylene blue stain and rinsed by two different methods. Fluid specimens were taken after ten and twenty minutes to be compared by photometric extinction measurement at a wave length of 500 nm. RESULTS: After ten minutes, the average extinction was e(1C) = 0.8 for the continuous suction irrigation and e(1N) = 0.4 for the novel irrigation-suction system. After twenty minutes, we recorded an average extinction of e(2C) = 0.3 for continuous suction irrigation and e(2N) = 0.001 for the novel irrigation-suction system. The students t-test revealed superior results after ten and twenty minutes of washing out the knee joints with a p < 0.001 for the novel irrigation-suction system. CONCLUSION: A novel irrigation-suction system may be an effective tool for postoperative knee joint irrigation in arthroscopic therapy for bacterial arthritis of the knee. Further animal studies are needed to verify the effects in vivo.

Onset of preclinical osteoarthritis: the angular spatial organization permits early diagnosis.

OBJECTIVE: Superficial articular chondrocytes display distinct spatial remodeling processes in response to the onset of distant osteoarthritis (OA). Such processes may be used to diagnose early events before manifest OA results in tissue destruction and clinical symptoms. Using a novel method of spatial quantification by calculating the angles between a chondrocyte and its surrounding neighbors, we compared maturational and degenerative changes of the cellular organizations in rat and human cartilage specimens. METHODS: The nuclei of superficial chondrocytes obtained from intact rat cartilage and from human knee cartilage, as well as from cartilage with focal and severe OA, were digitally recorded in top-down views. Their Cartesian coordinates were used to determine the nearest neighbor for each chondrocyte and the angle between these 2 cells and a reference. These angles, cellularity, nearest neighbor distances, and aggregation were analyzed as a function of location and OA severity. RESULTS: Neighboring rat chondrocytes exhibited intricate angular patterns with 4 dominant angles that were maintained during maturation and during the onset and progression of OA. Within intact cartilage, human chondrocytes demonstrated 1 dominant angle and, thus, a significantly different angular organization. With early OA onset, human chondrocytes that were located within intact cartilage displayed an increased occurrence of 4 angles; the resulting angular patterns were indistinguishable from those observed in rats. The angular remodeling was associated with location- and OA severity-dependent changes in cellularity and aggregation. CONCLUSION: This study is the first to identify the presence of angular characteristics of spatial chondrocyte organization and species-specific remodeling processes correlating with OA onset. The appearance of distinct angular and spatial patterns between neighboring chondrocytes can identify the onset of distant OA prior to microscopically visible tissue damage and possibly before clinical onset. With further development, this novel concept may become suitable for the diagnosis and followup of patients susceptible to OA.

Current concepts review: septic arthritis of the knee pathophysiology, diagnostics, and therapy.

Treatments for bacterial arthritis of the knee joint are arthroscopic irrigation and debridement with systemic antibiotic medication. This article summarizes the relevant data of pathophysiology, stage of infection, symptoms, and diagnostics as well as stage-dependent treatment of bacterial arthritis of the knee joint. The major treatment principles are joint decompression, elimination of the causative organisms by intensive irrigation of the joint with elimination of proteolytic and lysosomal enzymes. Debridement of necrotic soft tissues with the aim of preserving the synovial membrane as an immune-competent structure, and a natural barrier, is recommended. Good results in treating knee infections have been achieved with arthroscopic joint revision and stage-dependent surgical therapy. The infection staging I-IV suggested by Gächter was used most commonly, which mainly reflects the pathophysiologic infection stages. For stages I-III, arthroscopic joint decompression with joint irrigation and debridement is effective and can be repeated in cases of persisting infection. The incidence of repeated arthroscopic joint irrigation depends on the initial stage of the infection and varies between 0 and 41% of the cases. For stage IV infections, the open revision is needed or in seldom cases of therapy failure under initial or repeated arthroscopic joint revision. The success rate of healing infections by arthroscopic irrigation was high with 90-100%.

Remodeling of articular cartilage and subchondral bone after bone grafting and matrix-associated autologous chondrocyte implantation for osteochondritis dissecans of the knee.

BACKGROUND: Osteochondritis dissecans (OCD) of the knee is a challenging problem. Previously, the authors implemented a novel 1-step surgical procedure for OCD treatment consisting of matrix-associated autologous chondrocyte implantation (ACI) and simultaneous bone reconstruction including the subchondral lamina. PURPOSE: This study presents the 2-to 5-year results after this technique, assessing correlations of clinical function and cartilage and bone remodeling processes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-six patients with symptomatic condylar knee OCD (International Cartilage Repair Society OCD III/IV) were treated with matrix-associated ACI and monocortical cancellous cylinders for defect filling and subchondral bone plate reconstruction using cortical graft layers as novel subchondral lamina. Evaluations were performed with clinical rating scales and 1.5-T magnetic resonance imaging using the magnetic resonance observation of cartilage repair tissue (MOCART) score and a newly implemented subchondral lamina remodeling grade. RESULTS: The defect size was 5.3 ± 2.3 cm(2). The defect depth was 8.7 ± 2.4 mm. After a follow-up of 39.8 ± 12.0 months, all scores improved significantly. Nineteen patients (73%) reached good/excellent results in the Lysholm-Gillquist score (preoperatively: 53.2 ± 18.0 points; latest follow-up: 88.5 ± 9.5 points) and the Cincinnati knee rating score (preoperatively: 51.7 ± 13.0 points; latest follow-up: 84.6 ± 11.7 points) and significant improvements in the subjective International Knee Documentation Committee (IKDC) score by 27.9% (preoperatively: 50.5% ± 16.1%; latest follow-up: 78.4% ± 13.4%). The MOCART score reached 62.4 ± 18.9 points. The clinical improvement and tissue remodeling occurred simultaneously and timed; thus, the cartilage defect filling and the lamina remodeling grades correlated significantly with each other, the follow-up time, and almost all clinical scores. CONCLUSION: The simultaneous reconstruction of deep osteochondral defects of the knee OCD with monocortical cancellous cylinders and matrix-associated ACI is a biological, 1-step alternative to osteochondral cylinder transfer or conventional ACI that leads to good clinical and magnetic resonance imaging results after an intermediate follow-up period. The present study demonstrated simultaneous remodeling processes of articular cartilage repair tissue and subchondral lamina; this synchronization is not yet understood and deserves further investigation.

Computer-assisted periacetabular screw placement: Comparison of different fluoroscopy-based navigation procedures with conventional technique.

The current gold standard for operatively treated acetabular fractures is open reduction and internal fixation. Fractures with minimal displacement may be stabilised by minimally invasive methods such as percutaneous periacetabular screws. However, their placement is a demanding procedure due to the complex pelvic anatomy. The aim of this study was to evaluate the accuracy of periacetabular screw placement assessing pre-defined placement corridors and comparing different fluoroscopy-based navigation procedures and the conventional technique. For each screw an individual periacetabular placement corridor was preoperatively planned using the planning software iPlan CMF(©) 3.0 (BrainLAB). 210 screws (retrograde anterior column screws, retrograde posterior column screws, supraacetabular ilium screws) were placed in an artificial Synbone pelvis model (30 hemipelves) and in human cadaver specimen (30 hemipelves). 2D- and 3D-fluoroscopy-based navigation procedures were compared to the conventional technique. Insertion time and radiation exposure to specimen were also recorded. The achieved screw position was postoperatively assessed by an Iso-C(3D) scan. Perforations of bony cortices or articular surfaces were analysed and the screw deviation severity (difference of the operatively achieved screw position and the preoperatively planned screw position in reference to the pre-defined corridors) was determined using image fusion. Using 3D-fluoroscopy-based navigation, the screw perforation rate (7%) was significantly lower compared to 2D-fluoroscopy-based navigation (20%). For all screws, the deviation severity was significantly lower using a 3D- compared to a 2D-fluoroscopy-based navigation and the conventional technique. Analysing the posterior column screws, the screw deviation severity was significantly lower using 3D- compared to 2D-fluoroscopy-based navigation. However, for the anterior column screw, the screw deviation severity was similar regardless of the imaging method. Despite the advantages of the 3D-fluoroscopy-based navigation, this method led to significantly longer total procedure and fluoroscopic times, and the applied radiation dose was significantly higher. Percutaneous periacetabular screw placement is demanding. Especially for posterior column screws, due to a lower perforation rate and a higher accuracy in periacetabular screw placement, 3D-fluoroscopy-based navigation procedure appears to be the method of choice for image guidance in acetabular surgery.

Bilateral posterior sternoclavicular dislocation.

Posterior sternoclavicular dislocations are a rare injury, representing <5% of all sternoclavicular dislocations and 1 in 1600 shoulder girdle injuries. Proper imaging with computed tomography and prompt diagnosis are essential steps in preventing potentially lethal complications observed in approximately 3% of all posterior sternoclavicular dislocations. Surgical treatment is necessary if closed reduction fails. With the medial clavicular epiphysis being the last to close (between ages 22 and 25), children and adolescents typically present with epiphyseal fractures rather than joint dislocations. If closed reduction fails, open reduction and internal fixation (ORIF) should be considered in fractures, whereas complex reconstructions with tendon graft procedures have been recommended for joint dislocations. This article presents a case of a traumatic bilateral posterior sternoclavicular dislocation due to an epiphyseal fracture in a 15-year-old boy. To our knowledge, this is the first reported case of a bilateral posterior sternoclavicular dislocation. Attempted closed reduction failed with redislocation after 2 days. The patient subsequently required ORIF. This article describes our technique with anterior retraction of the medial clavicle, closure of the posterior periosteum, and ORIF using nonabsorbable sutures. Postoperative shoulder mobilization was started on day 1. At final follow-up, the patient was completely asymptomatic.

Effect of proximal humeral fractures on the age-specific prevalence of rotator cuff tears.

BACKGROUND: This study examined the effect of proximal humeral fractures on the age- and shoulder-specific prevalence of rotator cuff tears (RCTs) as well as the association with fracture severity, patient age, and clinical outcome. METHODS: Sixty-three fractures were treated conservatively; in 114 cases, minimally invasive osteosynthesis, and in 125 cases, open reduction and plate fixation were performed without rotator cuff reconstruction. After 4.4 years, all 302 patients were clinically and sonographically examined. RESULTS: We examined 139 two-part, 95 three-part, and 68 four-part fractures according to Neer and 134 A, 86 B, and 82 C fractures according to the AO classification. There were 52 patients (17%) with a complete rotator tear (RCT) only at the injured shoulder and 11 patients (4%) with a complete RCT only at the contralateral shoulder (p < 0.0001). Independent of the patient's age at follow-up, the prevalence of an RCT in the fractured shoulder was 13% higher than the prevalence in the opposite shoulder. Four-part fractures showed a significant association with a complete RCT (p = 0.047).Of 74 patients with a satisfactory or poor Constant Score, 33 (44.6%) had RCTs. In the remaining 228 patients with a good to excellent result, only 26 (11.4%) had RCTs. We showed that 66% of the RCTs observed at the fractured shoulder were caused by trauma. There was no association between treatment modality and a complete RCT. CONCLUSION: RCTs may need special attention in initial diagnostics, management, and follow-up especially in severe proximal humeral fractures.

Inter- and intra-observer reliability of the Cobb angle in the measurement of vertebral, local and segmental kyphosis of traumatic lumbar spine fractures in the lateral X-ray.

INTRODUCTION: Measurement of the vertebral, local and segmental kyphosis according to Cobb is a standard procedure in the assessment of traumatic, idiopathic and degenerative spinal deformities. The purpose of this study was to evaluate the inter- and intra-observer reliability of these three radiological angles on the basis of lateral X-rays in lumbar spine fractures with spinal kyphosis. PATIENTS AND METHODS: A consecutive series of 88 patients with traumatic lumbar spine fractures with kyphotic deformities were included in the study. All patients were younger that 50 years of age and had an adequate trauma leading to the fracture. Three independent observers with different levels of clinical training measured the vertebral, segmental and local kyphosis of these patients on the basis of lateral X-rays. The readings were repeated 4 weeks later to assess intra-observer reliability. RESULTS: The most common injury mechanism was a fall from a height of more than 3 m. The first lumbar vertebra was the most commonly affected. Mean inter- and intra-observer reliabilities were good for the vertebral (mean ICC: 0.6607; mean ICC: 0.6979) and local (mean ICC: 0.7778; mean ICC: 0.7642) kyphosis and excellent (mean ICC: 0.8129; mean ICC: 0.8103) for the segmental kyphosis. CONCLUSION: In this study, the segmental-, vertebral-, and local kyphosis angle according to Cobb showed sufficient inter- and intra-observer reliability for the use in daily practice and scientific studies.

Inter- and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fractures: evaluation in lateral X-rays and sagittal computed tomographies.

Evaluation of the kyphosis angle in thoracic and lumbar burst fractures is often used to indicate surgical procedures. The kyphosis angle could be measured as vertebral, segmental and local kyphosis according to the method of Cobb. The vertebral, segmental and local kyphosis according to the method of Cobb were measured at 120 lateral X-rays and sagittal computed tomographies of 60 thoracic and 60 lumbar burst fractures by 3 independent observers on 2 separate occasions. Osteoporotic fractures were excluded. The intra- and interobserver reliability of these angles in X-ray and computed tomogram, using the intra class correlation coefficient (ICC) were evaluated. Highest reproducibility showed the segmental kyphosis followed by the vertebral kyphosis. For thoracic fractures segmental kyphosis shows in X-ray "excellent" inter- and intraobserver reliabilities (ICC 0.826, 0.802) and for lumbar fractures "good" to "excellent" inter- and intraobserver reliabilities (ICC = 0.790, 0.803). In computed tomography, the segmental kyphosis showed "excellent" inter- and intraobserver reliabilities (ICC = 0.824, 0.801) for thoracic and "excellent" inter- and intraobserver reliabilities (ICC = 0.874, 0.835) for the lumbar fractures. Regarding both diagnostic work ups (X-ray and computed tomography), significant differences were evaluated in interobserver reliabilities for vertebral kyphosis measured in lumbar fracture X-rays (p = 0.035) and interobserver reliabilities for local kyphosis, measured in thoracic fracture X-rays (p = 0.010). Regarding both fracture localizations (thoracic and lumbar fractures), significant differences could only be evaluated in interobserver reliabilities for the local kyphosis measured in computed tomographies (p = 0.045) and in intraobserver reliabilities for the vertebral kyphosis measured in X-rays (p = 0.024). "Good" to "excellent" inter- and intraobserver reliabilities for vertebral, segmental and local kyphosis in X-ray make these angles to a helpful tool, indicating surgical procedures. For the practical use in lateral X-ray, we emphasize the determination of the segmental kyphosis, because of the highest reproducibility of this angle. "Good" to "excellent" inter- and intraobserver reliabilities for these three angles could also be evaluated in computed tomographies. Therefore, also in computed tomography, the use of these three angles seems to be generally possible. For a direct correlation of the results in lateral X-ray and in computed tomography, further studies should be needed.

Long-term results after non-plate head-preserving fixation of proximal humeral fractures.

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70-75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.

Histologic analysis of ruptured quadriceps tendons.

Quadriceps tendon ruptures are uncommon injuries. Degenerative changes in the tendon are felt to be an important precondition for rupture. We retrospectively reviewed 45 quadriceps tendon ruptures in 42 patients. Quadriceps tendon ruptures occurred most often in the sixth and seventh decade of life. Men were affected six times as often as women. A tissue sample from the rupture-zone was obtained in 22 cases and histologic analysis was performed. Degenerative changes were present in only 14 (64%) of the 22 samples. We observed an increasing ratio of degenerative to nondegenerative tendons with increasing patient age. Our data suggests that quadriceps tendon rupture, especially in younger patients, can occur in the absence of pathologic tendon degeneration.

Clinical and radiological evaluation of minimally displaced proximal humeral fractures.

INTRODUCTION: The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization. METHOD: Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score. PATIENTS: There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points. RESULTS: All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15 degrees angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement. CONCLUSION: Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.