Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury.

BACKGROUND: This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury. METHODS: The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed. RESULTS: On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs. CONCLUSIONS: After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review.

INTRODUCTION: From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems. MATERIALS AND METHODS: A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account. RESULTS: Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily. CONCLUSION: SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.

Medial augmentation plating of aseptic distal femoral nonunions.

BACKGROUND: Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants. METHODS: We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D). RESULTS: Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection. CONCLUSIONS: According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Complication rates following stand-alone lateral interbody fusion: a single institution series after 10 years of experience.

PURPOSE: This retrospective single institution study's goal was to analyze and report the complications from stand-alone lateral lumbar interbody fusions (LLIF). METHODS: This research was approved by the institutional review board (STUDY2021000113). We retrospectively reviewed the database of patients with adult degenerative spine deformity treated via LLIF at our institution between January 2016 and December 2020. RESULTS: Stand-alone LLIF was performed in 158 patients (145 XLIF, 13 OLIF; mean age 65 y.; 88 f., 70 m.). Mean surgical time was 85 min (± 24 min). Mean follow-up was 14 months (± 5 m). Surgical blood loss averaged 120 mL (± 187 mL) and the mean number of fused levels was 1.2 (± 0.4 levels). Overall complication rate was 19.6% (31 total; 23 approach-related, 8 secondary complications). CONCLUSION: Lateral interbody fusion appears to be a safe surgical intervention with relatively low complication- and revision rates.

Introduction of a modified Degan classification to specify treatment algorithms in fractures of the anterior process of the calcaneus.

BACKGROUND: Fractures of the anterior process of the calcaneus are often missed, and their treatments and results receive little attention in the current literature. The aim of this study was to specify treatment algorithms through a modification of the Degan classification. METHODS: Between 2009 and 2019, patients with APC fractures were retrospectively analyzed. The Degan classification was used and modified. Type III fractures were further divided into subgroups A (not displaced) and B (displaced). The type of treatment and complications were recorded. Return to work and posttraumatic osteoarthritis were determined as primary and secondary outcome parameters, respectively. RESULTS: Forty-one patients with 43 fractures were included. Follow-up averaged 35,5 months (range 1,5-152 months). Fractures were eight type I, six type II, 15 type IIIA and 14 type IIIB. The fracture was initially recognized in 29 (70,7%) patients, and missed in 12 (29,3%) patients, respectively. Overall, the delayed diagnosed fractures had a significantly higher complication rate (p < 0,000) than the initially diagnosed fractures and received surgical treatment significantly (p < 0,009) more often. After surgical treatment of 13 type IIIB, one nonunion occurred. Six missed type IIIA fractures were treated surgically after delayed diagnosis because of persistent symptoms. Two type I fractures required arthrodesis of the Chopart joint. Four patients did not return to work during the follow-up (3 missed type IIIA fractures, 1 type II fracture). CONCLUSION: Missed APC type IIIA fractures are at risk to develop complications, which is why computed tomography diagnostics should be performed if there is any clinical suspicion.

Rehabilitation during early postoperative period following total knee arthroplasty using single-joint hybrid assistive limb as new therapy device: a randomized, controlled clinical pilot study.

INTRODUCTION: The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients' range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ. MATERIALS AND METHODS: Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded. RESULTS: OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ. CONCLUSIONS: In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.

Simultaneous septic arthrodesis of the tibiotalar and subtalar joints with the Ilizarov external fixator-an analysis of 13 patients.

PURPOSE: Treatment of joint destruction of the tibiotalar and subtalar joints caused by acute or chronic infections in compromised hosts is a challenging problem. In these cases, simultaneous septic arthrodesis with the use of the Ilizarov external fixator represents a possible alternative to amputation. This case series presents the results and complications of patients with acute or chronic infection of the tibiotalar and subtalar joints. METHODS: Between 2005 and 2015, 13 patients with acute or chronic infections were treated by simultaneous single-stage debridement/arthrodesis of the tibiotalar and subtalar joints. In seven patients, there was a florid infection with fistula formation and soft tissue defects, and in six patients, there was chronic osteomyelitis with closed soft tissue. In addition to the demographic data, the time spent in the fixator, the major and minor complications and the endpoint of consolidation were reviewed. RESULTS: The mean time spent in the fixator was 18 (min 15, max 26) weeks. The mean follow-up time for nine patients was 100 (min 3, max 341) weeks. Complete osseous consolidation of both the tibiotalar and subtalar joints was achieved in 10 patients (77%). In three (23%) patients, there was complete consolidation of one of the joints and partial consolidation of the other joint. CONCLUSION: The Ilizarov external fixator allows for simultaneous arthrodesis of the tibiotalar and subtalar joints in septic joint destruction. However, the healing rates are below the rates reported in the literature for isolated tibiotalar or tibiocalcaneal arthrodesis in comparable clinical situations.

The Impact of the SARS-COVID-19 Lockdowns on the Subjectively Perceived Performance Level of Amateur Athletes after Returning to the Gyms.

Since December 2019, few issues have garnered as much global attention as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-19). The imposed lockdowns in 2020/21, which led to the closure of all gyms, barred people from participating in their favourite sports activities. This study explores athletes' self-evaluations of their performance levels upon return to training facilities post-reopening. Data were collected in May 2021, after the end of the second lockdown, using a national online questionnaire. The study recorded 20 demographic and training-specific parameters to discern the factors influencing self-perceived performance upon resuming gym activities after the 2020/2021 lockdown. A total of 1378 respondents participated in the study. Of the total number of participants, 27.5% (365) reported regaining 100% of their original performance level after reopening their studios, a proportion that comprised 212 males, 150 females, and 3 individuals of unspecified gender. Additionally, 35.7% (474) estimated their performance level to be up to 75%, followed by 30% (398) recording their performance level at 50%, and a minority of 6.8% (90) determining their performance level to be up to 25%. Exercise intensity prior to lockdown, training experience, sex, and concurrent practice of another sport significantly influenced the athletes' self-assessment of their current fitness levels (p > 0.001, p > 0.001, p > 0.001, and 0.006, respectively). We need to understand the factors that shape self-perception, especially in case of another lockdown, in order to provide preventive assistance concerning mental and physical well-being. Positive influences on self-perception include prior athletic experience, intensive training before the lockdown, and continued participation in sports throughout the lockdown. Younger age is also favourable, but this may not necessarily reflect the benefits of youth; rather, it could indicate the current lack of accessible online sports activities for older individuals. Women, however, might have a less favourable perception of their own athletic performance.

A salvage procedure: Radial head excision in children and adolescents-short-to-midterm outcomes and overview of the literature.

Purpose: Purpose of the study was to report the outcomes after radial head excision in children and adolescents in addition with a review of the current literature. Methods: We report a series of five children and adolescents, who had undergone a post-traumatic radial head excision. Clinical outcomes were evaluated in terms of elbow/wrist range of motion, stability, deformity and discomforts or restrictions at two follow-up points. Radiographic changes were evaluated. Results: Patient's age at time of the radial head excision averaged 14.6 (13-16) years. Mean time from the injury to the radial head excision was 3.6 (0-9) years. Follow-up I averaged 4.4 (1-8) years and follow-up II 8.5 (7-10) years. At follow-up I, patients showed an average elbow range of motion of 0-10-120° Ext/Flex and 90-0-80° Pro/Sup. Two patients reported discomfort or pain at the elbow. Four (80%) patients had a symptomatic wrist with pain or crepitation at the distal radio ulnar joint. In three (60%) of them, an ulna plus at the wrist was present. Two patients required ulna shortening and autograft stabilization of the interosseous membrane. At final follow-up, all patients reported full functioning with daily activities. Restrictions were present with sport activities. Conclusion: Functional results at the elbow joint might be improved and pain syndromes lessen due to the radial head excision. Problems at the wrist are likely secondary to the procedure. A critical analysis of other options should be performed ahead of the procedure and a careless application should be avoided by all means. Level of evidence: IV.

Rate of progressive healing with a carbon-fiber orthosis in cases of partial union and nonunion after ankle arthrodesis using the Ilizarov external fixator.

BACKGROUND: The Ilizarov fixator is a popular device for treating arthrodesis of the ankle joint in complex situations. However, the therapy can fail, with nonunion or partial union that might not be load stable. There is the possibility of follow-up surgery or extended wearing of the fixator. Full weight bearing with a carbon orthosis remains another treatment option, which has not yet been investigated.The aim of the study was to determine the rate of progress that can be obtained with a carbon orthosis in cases of partial union or nonunion after fixator removal. METHODS: In this retrospective observational study thirty-three patients received a carbon orthosis after fixator removal due to nonunion or partial union. All patients were allowed to walk with the orthosis under full load. The consolidation rate was determined radiologically and compared with the imaging data obtained during the last follow-up. In addition to demographic data, the Foot and Ankle Ability Measure and pain using a numeric rating scale were determined. Nine patients had to be excluded due to insufficient follow-up, and finally n = 24 patients were included in the study. RESULTS: The average duration of fixator use was 21 weeks (range 15-40 weeks), and the total average follow-up after removal of the fixator was 16 months (range 4- 56). For 14 (58.33%) patients, there was a further increase in consolidation with the orthosis after the fixator was removed. CONCLUSION: The results show that if there is only partial union or nonunion, further consolidations can be achieved after the application of a carbon orthosis. In a difficult patient population, using an orthosis should therefore be attempted to avoid unnecessary revision operations.

Cage subsidence-A multifactorial matter!

STUDY DESIGN: Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates. METHODS: This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, t­scores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch. RESULTS: Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (p = 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (p = 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal t­scores (p = 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (p = 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (p < 0.01). CONCLUSION: Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low t­scores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.

The impact of knee arthrodesis on gait kinematics, muscle activity and patient-reported outcome.

BACKGROUND: The aim of this retrospective study was to analyze gait kinematicsandoutcome parameters after knee arthrodesis. METHODS: Fifteenpatients with a mean follow-up of 5.9 (range0.8-36) years after unilateral knee arthrodesis were included. A 3D gait analysis was performed and compared to a healthy control group of14patients. Comparative electromyography was performed bilaterally at the rectus femoris, vastuslateralis/medialisand tibialis anterior muscles. The assessment further included standardized outcome scores- Lower Extremity Functional Scale (LEFS) andShort Form Health Survey (SF-36). RESULTS: The 3D analysis showed a significantly shortened stance phase (p = 0.000), an extended swing phase (p = 0.000), and an increased time per step (p = 0.009) for the operated side compared with thenonoperatedside. There were statistically significant differences in the extent of movement of the hips, knees and ankles among the operated andnonoperatedsides and the control group. For the mean EMG measurement, no significant difference was found between the healthy control group and the patients with arthrodesis.The average LEFSscorewas 27.5 ± 10.6out of a maximum of 80 points,and the mean physical total scale and mean emotional total scale scores for the SF-36 were 27.9 ± 8.5and 52.9 ± 9.9, respectively. CONCLUSIONS: Arthrodesis of the knee joint causes significant kinematic changes in gait pattern,and patients achieve poor results in subjective and functional outcomes(SF- 36, LEFS).Arthrodesis ensures that the extremities are preserved and can enable walking, but it must be viewed as a severe handicap for the patient.

Femoral Neck Osteotomy: A Salvage Procedure for Unstable and Locked Acetabulum Fractures in Selected Frail Patients.

Introduction: Purpose of the study is to present and discuss the femoral neck osteotomy as a salvage procedure for unstable, locked geriatric acetabular fractures in selected frail patients. When disadvantages and possible risks of other treatments exceed the benefits, this method may relieve pain and allow for early wheelchair mobilization in frail patients with limited mobility. Materials and Methods: We report nine patients from 2008 to 2020, which were treated with an osteotomy of the femoral neck for an unstable acetabular fracture. Indications, ASA-Score, Frailty Index, operative procedure, length of hospital stay, complications and outcomes will be discussed. Results: Patient's age averaged 86 years (range 81-92). Acetabular fractures were classified as six both column fractures, two anterior column posterior hemitransversal fractures and one destruction of the acetabulum by multiple metastases. Fracture dislocation with medialization plus locking of the femoral head and a superomedial dome impaction were present in all patients. All patients were classified as ASA III/ IV and the average value on the CSHA Frailty index was 7 (range 6-7). The operation time averaged 52 min (range 34-62). Immediate wheelchair mobilization in seven out of nine patients was started postoperatively. Conclusion: The osteotomy of the femoral neck may be discussed as a salvage procedure in low functional demanding, multimorbid, frail geriatric patients with unstable acetabular fractures and impairment of mobilisation due to a locked femoral head. The procedure has the advantages of a short operation time and immediate mobilization of the patients. However, this procedure only applies as a salvage solution in selected individual cases.

Locking the Taylor Spatial Frame - The effect of three additional longitudinal rods on osteotomy site movements.

BACKGROUND: In clinical practice, even when the fixator is locked, a noticeable laxity of the construct can be observed. This study was designed to measure the stiffness of the fixator and to analyze the movements of the osteotomy site. Furthermore, the effect of three additional longitudinal rods on the locking of the construct was analyzed. METHODS: Five synthetic tibia/fixator models (Model A) were tested under rotational torque (40 Nm) and axial compression (700 N). Three additional rigid rods were subsequently mounted, and the tests were repeated (Model B). The movements of the fixator as well as the osteotomy site were registered by a digital optical measurement system. Load- deformation curves, and so stiffness of the models, were calculated and compared. FINDINGS: Under rotational and axial loadings, Model A was found to be less rigid than Model B (p = 0.034; p = 0.194). Notably, Model A showed a region of laxity around neutral rotational (ΔF = 5 Nm) and axial (ΔF = 16.64 N) loading before a linear deformation trend was measured. Concomitantly, greater osteotomy site movement was measured for Model A than for Model B under full loading (p = 0.05) and within the region of increased laxity (p = 0.042). INTERPRETATION: The fixator showed an element of laxity around neutral axial and rotational loading, which transferred to the bone and led to a notable amount of osteotomy gap movement. Mounting three additional rods increased the stiffness of the construct and therefore reduced the movement of the osteotomy site.

The Use of the Ilizarov Fixator for the Treatment of Open and Closed Tibial Shaft and Distal Tibial Fractures in Patients with Complex Cases.

INTRODUCTION: Open and closed fractures of the tibial shaft or distal tibia can be challenging for surgeons to treat if the fractures are accompanied by aggravating conditions, such as various accompanying diseases, pronounced soft tissue injuries, osteomyelitis, and/or noncompliance. The aim of this retrospective study was to present our approach and results with the Ilizarov fixator as a treatment option for such individually complex cases. MATERIALS AND METHODS: Between 2005 and 2018, 20 patients were treated with the Ilizarov fixator for fractures of the tibial shaft/distal tibia. The indication for this was a 2nd- to 3rd-degree open fracture in 10 patients, a 1st-degree open fracture in one patient, and closed fractures in 9 patients. Aggravating conditions included soft tissue injuries, osteomyelitis, leg deformities, multiple traumas, smoking, alcohol/drug abuse, and obesity (BMI > 60). In addition to demographic data, the time of fixator treatment, complications, and the endpoint of consolidation were evaluated retrospectively. RESULTS: The mean time of fixator treatment was 29 (range 15-65) weeks. Complete fracture consolidation was achieved in 13 patients (65%) with the Ilizarov fixator. The mean follow-up period after fixator removal was 36 (range 2-186) months in 14 patients. Five patients with complete consolidation were lost to further follow-up. One patient was amputated. In six patients without union, internal osteosynthesis was carried out. CONCLUSION: The use of the Ilizarov fixator is a treatment option for individual high-risk patients with complicating courses but should be seen as a salvage procedure due to the high complication rate and long treatment process.

Qualitative Evaluation of Educational Content on Lateral Spine Surgery YouTube™ Demonstrations.

OBJECTIVE:  This study assessed the quality of educational content for lateral spine fusion procedures on YouTube™. METHODS:  YouTube™ was searched using the following keywords and phrases: "Lateral lumbar interbody fusion," "lateral lumbar spine surgery," "Oblique lateral interbody fusion (OLIF)," "Extreme lateral interbody fusion (XLIF)," and "Lateral lumbar interbody fusion (LLIF)." An expert panel of three senior-level spine surgeons [rater one to three (R1-R3)] rated videos on 13 qualitative evaluation parameters via a modified Delphi approach. RESULTS:  Thirty-eight videos were included for evaluation. Interrater reliability analysis indicated a moderate agreement between R1 and R2 (κ=0.50; standard error, SE = 0.05), R1 and R3 (κ = 0.60, SE = 0.04), and a substantial agreement between R2 and R3 (κ = 0.65, SE = 0.04). Unanimously positive assessments of the quality of the intraoperative presentation varied between 42% and 63% of the rated videos. However, perioperative quality features were unanimously rated positively less than 21% of the videos. CONCLUSION:  With regard to the surgical approach and execution of lateral lumbar fusions, YouTube™ videos can be seen as a valuable addition to academic education. The main problem, however, is the lack of control mechanisms that check the quality of the content offered before it is consumed by patients, students, and doctors in training.

Analysis of bone transport for ankle arthrodesis as a limb salvage procedure for the treatment of septic pilon fracture nonunion.

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients' medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12-63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29-86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture.