[The S2k guideline: Indications for knee endoprosthesis : Evidence and consent-based indications for total knee arthroplasty]. / S2k-Leitlinie: Indikation Knieendoprothese : Evidenz- und konsensbasierte Indikationsstellung in der Knie-Endoprothetik (EKIT-Knie).

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

A global call to action to improve the care of people with fragility fractures.

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity. Initiated by the Fragility Fracture Network (FFN) at a "Presidents' Roundtable" during the 5th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay. There is an urgent need to improve: To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.

EULAR/EFORT recommendations for management of patients older than 50†years with a fragility fracture and prevention of subsequent fractures.

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

[Influence of registries on the quality of care]. / Einfluss von Registern auf die Versorgungsqualität.

Registries are a topic of lively debate amongst all stakeholders in healthcare, politics and economics. In general, registries are national or international (prospective) databases documenting the current state of diagnostic, therapeutic and long-term outcome variables of subjects with a distinct condition or health problem. The access to and handling of registry information is subject to strict legal, methodological and ethical principles and regulations before these data can be scientifically utilized and reentered into the routine daily practice. Because of the representativeness and reality of data, registries are widely regarded as the backbone of health systems and budgets.Currently there is only indirect evidence that registries influence outcomes and the quality of care. Recent statistical techniques may allow quasi-experimental modelling of observational information. In orthopedic and trauma surgery, current and upcoming registries should be wisely utilized to develop and evaluate innovations and to make informed decisions relevant to care.

A new responder criterion (relative effect per patient (REPP) > 0.2) externally validated in a large total hip replacement multicenter cohort (EUROHIP).

OBJECTIVE: To validate a new method to identify responders (relative effect per patient (REPP) >0.2) using the OMERACT-OARSI criteria as gold standard in a large multicentre sample. METHOD: The REPP ([score before - after treatment]/score before treatment) was calculated for 845 patients of a large multicenter European cohort study for THR. The patients with a REPP >0.2 were defined as responders. The responder rate was compared to the gold standard (OMERACT-OARSI criteria) using receiver operator characteristic (ROC) curve analysis for sensitivity, specificity and percentage of appropriately classified patients. RESULTS: With the criterion REPP>0.2 85.4% of the patients were classified as responders, applying the OARSI-OMERACT criteria 85.7%. The new method had 98.8% sensitivity, 94.2% specificity and 98.1% of the patients were correctly classified compared to the gold standard. CONCLUSION: The external validation showed a high sensitivity and also specificity of a new criterion to identify a responder compared to the gold standard method. It is simple and has no uncertainties due to a single classification criterion.

[Rehabilitation concepts and return to sport after interventions on the shoulder]. / Rehabilitative Konzepte und Rückkehr zum Sport nach Eingriffen an der Schulter.

BACKGROUND: Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport. OBJECTIVES: The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes. METHODS: A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration. RESULTS: This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion. CONCLUSION: Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

SCOPE: a scorecard for osteoporosis in Europe.

SUMMARY: The scorecard summarises key indicators of the burden of osteoporosis and its management in each of the member states of the European Union. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. INTRODUCTION: The scorecard for osteoporosis in Europe (SCOPE) is an independent project that seeks to raise awareness of osteoporosis care in Europe. The aim of this project was to develop a scorecard and background documents to draw attention to gaps and inequalities in the provision of primary and secondary prevention of fractures due to osteoporosis. METHODS: The SCOPE panel reviewed the information available on osteoporosis and the resulting fractures for each of the 27 countries of the European Union (EU27). The information researched covered four domains: background information (e.g. the burden of osteoporosis and fractures), policy framework, service provision and service uptake e.g. the proportion of men and women at high risk that do not receive treatment (the treatment gap). RESULTS: There was a marked difference in fracture risk among the EU27. Of concern was the marked heterogeneity in the policy framework, service provision and service uptake for osteoporotic fracture that bore little relation to the fracture burden. For example, despite the wide availability of treatments to prevent fractures, in the majority of the EU27, only a minority of patients at high risk receive treatment for osteoporosis even after their first fracture. The elements of each domain in each country were scored and coded using a traffic light system (red, orange, green) and used to synthesise a scorecard. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. CONCLUSIONS: The scorecard will enable healthcare professionals and policy makers to assess their country's general approach to the disease and provide indicators to inform future provision of healthcare.

Burden of postmenopausal osteoporosis in Germany: estimations from a disease model.

UNLABELLED: This article describes the adaptation of a model assessing the incidence of osteoporotic fractures and prevalence of postmenopausal osteoporosis (PMO) in Germany. PURPOSE: The purpose of this paper is to estimate the epidemiological burden of PMO in Germany from 2010 to 2020. METHODS: For each year of the study, the 'incident cohort' (women experiencing a first osteoporotic fracture) was identified and run through a Markov model using 1-year cycles until 2020. Health states were based on the number of fractures (1, 2 or ≥3) and deaths. Although the fracture site was not explicitly accounted for in the model structure, the site (hip, vertebral, non-hip non-vertebral) was tracked for each health state. Transition probabilities reflected the site-specific risk of death and of subsequent fractures. Model inputs included population size and life tables from 1970 to 2020, incidence of fracture and BMD by age in the general population (mean and standard deviation). RESULTS: In 2010, the number of osteoporotic fractures was estimated at 349,560 in women aged 50 years or more, including 80,177 hip and 48,550 vertebral fractures. By 2020, the population is expected to grow by 13.1 %. As a result, the number of fractures is predicted to increase by 15.2 %. The improvement in life expectancy is predicted to lead to a relatively smaller increase in the number of deaths attributable to fractures (+12.8 %), but also to an increase in the prevalence of women with multiple prior fractures (+25.5 %). CONCLUSION: The PMO disease model, first developed for Sweden, was adapted to Germany. Due to the ageing of the population, the number of osteoporotic fractures is expected to increase markedly by +15.2 % by 2020.

[Undergraduate education in orthopaedic and trauma surgery - a nationwide survey in Germany]. / Die studentische Lehre im gemeinsamen Fach Orthopädie-Unfallchirurgie - eine deutschlandweite Statuserhebung.

AIM: Musculoskeletal conditions consume enormous resources and costs, and their incidence is increasing worldwide. Therefore, an appropriate education of medical students about these conditions is required. This study examines the extent of medical education in orthopaedic and trauma surgery in Germany. MATERIAL AND METHODS: A questionnaire comprising 7 topics (curriculum design, lecture, practical training, e-learning, examination, evaluation, resources) with a total of 44 items was sent to all assistant lecturers in orthopaedic and trauma surgery at the 37 medical schools in Germany. RESULTS: The survey attained a return rate of 76 % for orthopaedic surgery and 81 % for trauma surgery, respectively. Medical training in musculoskeletal conditions represents with an average of 38.4 hours of lectures and further 55.9 hours of practical training less than 6 % of the entire undergraduate medical education. This study demonstrates a high inhomogeneity regarding the curriculum design when comparing the different German medical schools not only in total training time but also regarding its contents. E-learning as additional teaching method is only offered in 39 % of orthopaedic training and in 47 % of the trauma surgery training. Practical examinations like the OSCE are offered at 8 medical schools for orthopaedic training and 15 schools for trauma surgical training, respectively. CONCLUSION: Medical training in musculoskeletal conditions is very inhomogeneous and requires further improvement and standardisation regarding quantity and implementation.

[Methods of health economic evaluation for health services research]. / Methoden der gesundheitsökonomischen Evaluation in der Versorgungsforschung.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[Outcome assessment in geriatric trauma]. / Outcomes bei Alterstrauma.

The number of elderly and old patients with fractures is steadily increasing. Identification of relevant functional deficits and comorbidities is crucial for an efficient treatment strategy and outcome assessment in this patient group. For this reason the integration of a geriatric assessment in every orthopedic traumatology practice seems recommendable. Assessing the outcome of frequent fragility fractures (hip, radius) requires instruments oriented to the International Classification of Functioning, Disability and Health (ICF) which allow analysis of bodily function and structure as well as activity and participation. A combination of disease and body region-specific scores with generic scores seems to be reasonable. It can also be sensible to include instruments for health economic analyses.

[Using the international classification of functioning, disability and health (ICF) in trauma care]. / Anwendung der Internationalen Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) in der Traumatologie.

The International Classification of Functioning, Disability and Health (ICF) provides a comprehensive and structured treatment management and outcome evaluation in trauma care based on specific ICF core sets and the ICF-based Rehab-CYCLE. The Rehab-CYCLE allows the problem-based assessment of functioning in a multi-professional team under physician-guidance and the definition of long-term, intervention and cycle goals. Defined intervention goals are assigned to the appropriate intervention principles and techniques as well as the specific evaluation instruments. Together with the patient additional intervention goals are identified, intervention principals adapted and the further treatment setting planned based on a multi-professional outcome evaluation. The standardized documentation is reported multi-professionally on the ICF assessment sheet which reflects the patient perspective with all their problems and needs as well as the perspective of the treatment team.

[Introduction to the international classification of functioning, disability and health (ICF)]. / Einführung in die International Classification of Functioning, Disability and Health (ICF).

The WHO International Classification of Functioning, Disability and Health (ICF) allows a standardized description of functioning and disability based on individual and contextual factors. The ICF adopts a biopsychosocial model of disability and functioning and is complementary to the ICD-10 (International Classification of Diseases). For its implementation in clinical practice ICF-based instruments, such as the ICF core sets were developed in a standardized scientific process. These consist of the ICF categories which are most relevant for patients with specific diseases or in specific health care situations. In trauma care the ICF and ICF core sets can be applied in defined health problems and treatment situations for documentation of functioning, structured planning and implementation of interventions as well as outcome assessment.

EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee.

OBJECTIVES: The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of variation in diagnostic and therapeutic performance across disciplines, have found consensus in starting task forces aiming at achieving diagnostic and therapeutic uniformity, and have identified medical conditions with which representatives of both organisations will frequently be confronted in common clinical practice. The aim of the present work was to establish recommendations for the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee. METHODS: The EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations were followed. RESULTS: In all, 11 rheumatologists from 11 countries and 12 orthopaedic surgeons from 7 countries met twice under the leadership of 2 conveners, a clinical epidemiologist and a research fellow. After carefully defining the content and procedures of the task force, research questions were developed, a comprehensive literature search was performed and the results were presented to the entire committee. Subsequently, a set of 10 recommendations was formulated based on evidence from the literature if available, and after discussion and consensus building. CONCLUSIONS: This is the first combined interdisciplinary project of rheumatologists and orthopaedic surgeons, successfully aiming at achieving consensus in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

[Development of orthopedics over the next 20 years]. / Entwicklung der Orthopädie in den nächsten 20 Jahren.

The combination of orthopedic and traumatology surgery in one specialization allows the coexistence of specialized surgical subgroups. The long term morbidity forecast predicts an increased demand for orthopedic procedures for the next 20 years. The excellent training level must be maintained for the following generation of orthopedic and trauma surgeons. Besides the physicians, health care providers and hospitals as well as politics should help in mastering this difficult challenge. Orthopedic surgery and traumatology with a multitude of subspecialties remain an attractive specialty with a promising future.

[Sports and osteoarthrosis]. / Sport und Arthrose.

Many risk factors for developing osteoarthrosis exist. Osteoarthrosis is the most common cause of chronic disability in middle-aged and older people. On the one hand, physical exercise can lead to arthrosis; on the other hand, physical exercise is commonly used in preventing and treating it. Experimental and clinical studies have shown that increased high-impact running or competitive sports result in a higher risk for osteoarthrosis than moderate low-impact running. In particular, sudden-impact loading and twisting movements of the joints can result in premature osteoarthrosis. Also, sports with a high risk for injuries can lead to secondary osteoarthrosis. Preventive exercises to strengthen the skeletal muscles seem to have a pivotal role. There are different therapeutic approaches to osteoarthrosis, which will be more important in the future. Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity, or disability. Exercise should include local muscle strengthening and general aerobic fitness.

[Current application of osteoporosis guidelines--expert recommendations of the German Society of Orthopaedic Surgery and Traumatology]. / Umsetzung der Osteoporoseleitlinien in Orthopädie und Unfallchirurgie--Ergebnisse eines Expertenworkshops der DGOU.

AIM: As an increasing number of patients suffer from osteoporosis-related disorders worldwide, the medical as well as the socioeconomic impact of this problem is significant. Although evidence-based guidelines for diagnosis and treatment are available, their application in daily practice is insufficient. The aim of our initiative was to develop a strategy for supporting this transfer. METHODS: An expert group of the German Society of Orthopaedics and Traumatology (DGOU) has analysed the current scientific as well as health-care data bases regarding diagnosis and treatment of osteoporosis. Then a set of recommendations has been developed in order to improve this situation. RESULTS: The identified support strategy will focus on better identification of patients with osteoporosis and frailty, enhanced interdisciplinary approaches and increased activity to disseminate available guidelines. Additionally, more research activities are necessary in order to highlight the socioeconomic burden of the disease and to continuously improve surgical treatment strategies in the future. CONCLUSION: To ensure a successful application of the recommendations, continuous support of involved health professionals as well as political institutions, national health insurance systems, scientific societies and patient organisations is necessary.