Comparison of needle and conventional arthroscopy for visualisation of predefined anatomical structures of the knee joint: a feasibility study in human cadavers and patients.

BACKGROUND: In terms of the optics used for Knee arthroscopy, a large number of different endoscopes are currently available. However, the use of the 30° optics in knee arthroscopy has been established as the standard procedure for many years. As early as the 1990s, needle arthroscopy was occasionally used as a diagnostic tool. In addition to the development of conventional optics technology in terms of camera and resolution, needle arthroscopes are now available with chip-on-tip image sensor technology. To date, no study has compared the performance of this kind of needle arthroscopy versus standard arthroscopy in the clinical setting in terms of the visibility of anatomical landmarks. In this monocentric prospective feasibility study, our aim was to evaluate predefined anatomical landmarks of the knee joint using needle arthroscopy (0° optics) and conventional knee arthroscopy (30° optics) and compare their performance during knee surgery. METHODS: Examinations were performed on eight cadavers and seven patients who required elective knee arthroscopy. Two surgeons independently performed the examinations on these 15 knee joints, so that we were able to compare a total of 30 examinations. The focus was on the anatomical landmarks that could be visualized during a conventional diagnostic knee arthroscopy procedure. The quality of visibility was evaluated using a questionnaire. RESULTS: In summary, the average visibility for all the anatomic landmarks was rated 4.98/ 5 for the arthroscopy using 30° optics. For needle arthroscopy, an average score of 4.89/ 5 was obtained. Comparatively, the needle arthroscope showed slightly limited visibility of the retropatellar gliding surface in eight (4.5/ 5 vs. 5/ 5), medial rim of the patella in four (4.85/ 5 vs. 5/ 5), and suprapatellar recess in four (4.83/ 5 vs. 5/ 5) cases. Needle arthroscopy was slightly better at visualizing the posterior horn of the medial meniscus in four knee joints (4.9/ 5 vs. 4.85/ 5). CONCLUSION: Needle arthroscopy is a promising technology with advantages in terms of minimally invasive access and good visibility of anatomical landmarks. However, it also highlights some limitations, particularly in cases with challenging anatomy or the need for a wide field of view.

Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study.

INTRODUCTION: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE: Level II.

Combined Humeral Head and Shaft Fractures: Outcome Following Intramedullary Nailing and Plating.

Background and Objectives: Combined fractures of the humeral head and shaft (FHS) are rare but frequently involve an intermuscular fracture as its characteristic pattern. The aim of this retrospective study was to investigate intramedullary nailed and plated FHS in terms of outcomes and complications. Materials and Methods: The present study included patients with FHS, treated via either intramedullary nailing or plating within a period of 10 years, with a minimum follow-up of 12 months. Functional outcome was assessed using the age- and sex-adapted Constant-Murley Score (CMS-K). Rates of complications and revision surgeries were registered. Results: Twenty-five patients (18 females, 7 males, age 60.1 ± 14.2 years, range 23-76 years) were included in the study. Nailing was performed in 16 patients (12 females, 4 males, age 62.6 ± 12.4 years), whereas plating was executed in nine patients (6 females, 3 males, age 55.8 ± 17.0 years). Follow-up among all patients was 45.1 ± 26.3 months (range 12-97 months). CMS-K was 70.3 ± 32.3 in the nailing group, with reoperation in four cases, and 76.0 ± 31.0 in the plating group, with one reoperation (p = 0.42). Patients with no metaphyseal fragment displacement (n = 19; CMS-K 76.7 ± 17.3) demonstrated significantly better functional outcomes versus those with secondary displacement of the metaphyseal fragments (n = 6; CMS-K 60.0 ± 17.1), p = 0.046. Conclusions: Comparable acceptable clinical outcome is obtained when comparing nailing with additional open cerclage or lag-screw fixation techniques versus plating with open reduction. However, a higher revision rate was observed after nailing. The correct metaphyseal fragment fixation seems to be crucial to avoid loss of reduction and hence the need for revision surgery, as well as a worse outcome.

Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: A randomised clinical trial.

OBJECTIVE: To compare the one-year postoperative outcomes of anti-gravity treadmill rehabilitation with those of standard rehabilitation in patients with ankle or tibial plateau fractures. DESIGN: An open-label prospective randomised study. SETTING: Three trauma centres. SUBJECTS: Patients were randomised into the intervention (anti-gravity treadmill) or control (standard protocol) rehabilitation group. MAIN MEASURES: The primary endpoint was changes in the Foot and Ankle Outcome Score for ankle fractures and Knee Injury and Osteoarthritis Outcome Score for tibial plateau fractures from baseline to 12 months after operation. Secondary endpoints were the subscores of these scores, muscle atrophy (leg circumference at 20 cm above and 10 cm below the knee joint) and the Dynamic Gait Index. RESULTS: Initially, 73 patients (37 vs 36) underwent randomisation. After 12 months, 29 patients in the intervention group and 24 patients in the control group could be analysed. No significant difference was noted in the Foot and Ankle Outcome Score (80.8 ± 18.4 and 78.4 ± 21.1) and Knee Injury and Osteoarthritis Outcome Score (84.8 ± 15.2 and 81.7 ± 17.0). The change in the Dynamic Gait Index from 12 weeks to 12 months differed significantly between the groups (P = 0.04). Patients with tibial plateau fractures had a 3 cm wider thigh circumference in the intervention group than those in the control group (95% confidence interval: -0.2 to 6.3 cm, P = 0.08). CONCLUSION: One year after surgery, patients who had undergone anti-gravity treadmill rehabilitation showed better gait than patients in the control group, and those with tibial plateau fractures had less muscle atrophy.

Online consultation in an orthopedic trauma surgery outpatient clinic: is there a learning curve?

BACKGROUND: In the context of the German contact restrictions due to the COVID-19 pandemic of March 2020, an online-based consultation system was established in our university orthopedic outpatient department to maintain patient care. As a basis for contact-minimizing communication, this was continued after the contact restrictions were lifted. The aim of this prospective pilot study was to assess the effectiveness, technical feasibility, and patient flow in this system under lockdown conditions and in the period afterwards. METHODS: The evaluation took place from the beginning of the first lockdown on March 13, 2020, until May 31, 2021. For each patient encounter, the quality of the sound and video connections was documented. The outcomes of the consultations were recorded. Four categories were distinguished: 1) no follow-up necessary, 2) follow-up via online consultation, 3) referral for surgical therapy, and 4) follow-up in the outpatient clinic for physical examination. A comparison was made between an early cohort right after implementation of the online consultation and and a late cohort after establishment of the consultation. RESULTS: There were 408 patient encounters via online consultation. A total of 360 (88%) consultations were uninterrupted. Initial presentations accounted for 124 (30%) consultations. In 75 (18%) patients, no further follow-up was necessary. Follow-up via online consultation was scheduled in 82 (20%) patients, direct referral for surgery was made in 86 (21%) patients, and a follow-up for physical examination was arranged in 165 (40%) patients. When comparing the early and late cohort, there was no difference in the duration of the conversation (p = 0.23). A significant difference was found in the type of further treatment. In the late cohort, conservative therapy was used more often (p < 0.01), resulting in a lower number of follow-up visits for clinical examination (p < 0.01). CONCLUSION: While a definite decision for further procedure was possible solely by online consultation in a large percentage of cases, 40% of patients still needed an additional in-person consultation for physical examination. A learning curve could be observed regarding the selection of patients suited for online consultation. Overall, online consultation is a useful measure to manage patient volume and to visibly support direct doctor-patient contact.

Germany has a high demand in meniscal allograft transplantation but is subject to health economic and legal challenges: a survey of the German Knee Society.

PURPOSE: To determine the current status and demand of meniscal allograft transplantation (MAT) in Germany among members of the German Knee Society (= Deutsche Kniegesellschaft; DKG). METHODS: An online survey was conducted between May 2021 and June 2021 and sent to all members of the DKG. The survey questionnaire consisted of 19 questions to determine the demand and technical aspects of MAT among the participants and to identify areas of improvement in MAT in Germany. RESULTS: Overall, 152 participants, 136 (89.5%) from Germany, 8 (5.3%) from Switzerland, 6 (4.0%) from Austria, and 2 (1.3%) from other countries completed the online survey, with the majority working in non-academic institutions. According to the regulations of the DKG, 87 (57.2%) participants were board certified as specialized knee surgeons and 97 (63.8%) worked primarily in the field of orthopedic sports medicine. MAT was considered clinically necessary in Germany by 139 (91.5%) participants. Patient age (83.6%), post-meniscectomy syndrome in isolated lateral (79.6%) and medial (71.7%) meniscus deficiency, and functional and athletic demands (43.4%) were the most important determinants to consider MAT in patients. Participants reported that reimbursement (82.9%), jurisdiction over the use of donor grafts (77.6%), and the availability of meniscal allografts (76.3%) are the main challenges in performing MAT in Germany. The most frequently used meniscal allograft types by 54 (35.5%) participants who had already performed MAT were fresh-frozen grafts (56.6%), peracetic acid-ethanol sterilized grafts (35.9%), and cryopreserved grafts (7.6%). Participants reported to perform suture-only fixation more often than bone block fixation for both medial (73.6% vs. 22.6%) and lateral (69.8% vs. 24.5%) MAT. CONCLUSION: More than 90% of the responding members of the DKG indicated that MAT is a clinically important and valuable procedure in Germany. Reimbursement, jurisdiction over the use of donor grafts, and the availability of meniscal allografts should be improved. This survey is intended to support future efforts to facilitate MAT in daily clinical practice in Germany. LEVEL OF EVIDENCE: Level V.

Simultaneous 18F-FDG-PET/MRI for the detection of periprosthetic joint infections after knee or hip arthroplasty: a prospective feasibility study.

PURPOSE: This study investigated the diagnostic value of simultaneous 18F-fluordeoxyglucose positron emission tomography/magnetic resonance imaging (PET/MRI) in suspected periprosthetic joint infection (PJI) of the hip and knee. METHODS: Sixteen prostheses from 13 patients with suspected PJI were prospectively examined using PET/MRI. Image datasets were evaluated in consensus by a radiologist and a nuclear physician for the overall diagnosis of 'PJI' (yes/no) and its anatomical involvement, such as the periprosthetic bone margin, bone marrow, and soft tissue. The imaging results were compared with the reference standard obtained from surgical or biopsy specimens and subjected to statistical analysis. RESULTS: Using the reference standard, ten out of the 13 prostheses (ten hips, threes knees) were diagnosed with PJI. Using PET/MRI, every patient with PJI was correctly diagnosed (sensitivity, 100%; specificity, 100%). Considering the anatomical regions, the sensitivity and specificity were 57% and 50% in the periprosthetic bone margin, 75% and 33% in the bone marrow, and 100% and 100% in the soft tissue. CONCLUSION: PET/MRI can be reliably used for the diagnosis of PJI. However, assessment of the periprosthetic bone remains difficult due to the presence of artefacts. Thus, currently, this modality is unlikely to be recommended in clinical practice.

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients.

INTRODUCTION: This study aimed to investigate the influence of epidemiologic parameters on complications that needed operative revision of operatively treated proximal humerus fractures. METHODS: We performed a retrospective single-center study in a level 1 trauma center. We included all patients with operatively treated proximal humerus fractures from January 1 2005 to December 31 2015. We characterized our cohort and subgroup using descriptive statistics. The primary outcome was postoperative complications. For this purpose, postoperative complications were defined in advance, an operative revision was necessary on a general rule. The secondary outcome was a model of the risk factors for complications created with multiple logistic regression. RESULTS: We included 1109 patients. The average age was 67.2 years (± 16.4), and 71.4% of the fractures occurred in women. A total of 644 patients (58.1%) had between one to three comorbidities, and 27.8% had four or more. The fracture morphology was as follows: 3 part 41.8%, 4 part 26.9%, 2 part 24.3%, and dislocation fracture 6.7%. Complications occurred in 150 patients (13.5%). The number of comorbidities [odds ratio (OR) 2.85, p < 0.01], body weight (OR 1.15, p = 0.02), and substance abuse (OR 1.82, p = 0.04) significantly correlated with the risk of complications. We achieved a sensitivity of 48% and a specificity of 74% for the variables body weight, substance abuse, age, and comorbidities CONCLUSION: The epidemiologic parameters, comorbidities, substance abuse, weight, and age are independent risk factors for complications. If these factors are present, one can predict a postoperative complication requiring surgical revision with low sensitivity and moderate specificity. Therefore, concerning the high number of multi-morbid patients with proximal humerus fractures, an increased postoperative complication rate can be expected. LEVEL OF EVIDENCE: Level of evidence IV.

Impact of anti-gravity treadmill rehabilitation therapy on the clinical outcomes after fixation of lower limb fractures: A randomized clinical trial.

OBJECTIVE: To compare the effects of anti-gravity treadmill rehabilitation with those of standard rehabilitation on surgically treated ankle and tibial plateau fractures. DESIGN: Open-label prospective randomized multicenter study. SETTING: Three level 1 trauma centers. SUBJECTS: Patients with tibial plateau or ankle fractures who underwent postoperative partial weight-bearing were randomized into the intervention (anti-gravity treadmill use) or control (standard rehabilitation protocol) groups. MAIN MEASURES: The primary endpoint was the change in the Foot and Ankle Outcome Score for ankle fractures and total Knee injury and Osteoarthritis Outcome Score for tibial plateau fractures (0-100 points) from baseline (T1) to six weeks after operation (T4) in both groups. Leg circumference of both legs was measured to assess thigh muscle atrophy in the operated leg. RESULTS: Thirty-seven patients constituted the intervention and 36 the control group, respectively; 14 patients dropped out during the follow-up period. Among the 59 remaining patients (mean age 42 [range, 19-65] years), no difference was noted in the Foot and Ankle Outcome Score (54.2 ± 16.1 vs. 56.0 ± 16.6) or Knee injury and Osteoarthritis Outcome Score (52.8 ± 18.3 vs 47.6 ± 17.7) between the intervention and control groups 6 weeks after operation. The change in the leg circumference from T1 to T4 was greater by 4.6 cm in the intervention group (95% confidence interval: 1.2-8.0, P = 0.005). No adverse event associated with anti-gravity treadmill rehabilitation was observed. CONCLUSION: No significant difference was noted in patient-reported outcomes between the two groups. Significant differences in muscular atrophy of the thigh were observed six weeks after operation.

Clinical suspicion of spondylodiscitis with equivocal MRI findings: does diffusion-weighted imaging prove helpful here?

BACKGROUND: Despite the high sensitivity of magnetic resonance imaging (MRI), early detection of spondylodiscitis (SpD) remains challenging due to its low specificity. PURPOSE: To assess the diagnostic value of diffusion-weighted imaging (DWI) in suspected cases of SpD with ambiguous early MRI findings in the differentiation of degenerative disorders (DD). MATERIAL AND METHODS: In this prospective study, 52 patients suspected of having SpD underwent a whole-spine 3-T MRI scan comprising sagittal DWI. Of 58 conspicuous, T2-weighted, signal increased discs, 39 were successfully evaluated using DWI. Apparent diffusion coefficient (ADC) values and ADC maps were blindly analyzed using the region of interest of the conspicuous disc and a normal adjacent reference disc. Intraindividual ratios (conspicuous disc: reference disc) were calculated. RESULTS: All conspicuous discs showed increased absolute ADC values, which did not differ significantly between SpD (n = 22) and DD (n = 17). However, ADC ratio was significantly higher in SpD vs. DD (P < 0.05). In receiver operating characteristic curve analysis, an ADC ratio threshold of 1.6 resulted in 45% sensitivity and 88% specificity (area under the curve = 0.69) for SpD diagnosis. CONCLUSION: The absolute ADC value does not provide a reliable diagnosis of SpD. Increased diffusivity can be an indication of infection but should always be discussed in the context of existing disc degeneration.

Clinical outcomes of arthroscopic and navigation-assisted two tunnel technique for coracoclavicular ligament augmentation of acute acromioclavicular joint dislocations.

BACKGROUND: The purpose of this study was to present a navigated image-free augmentation technique for the acromioclavicular joint (ACJ) and coracoclavicular (CC) ligaments and to report the clinical and radiological outcomes. METHODS: From 2013 to 2018, 35 eligible patients were treated with our navigated image-free ACJ- and CC-augmentation technique. The average follow-up was 3 years. Follow-up evaluations included the Constant-Murley Score, subjective shoulder value, Taft score, and the acromioclavicular joint instability (ACJI) score. The patients' quality of life was assessed using the EuroQol-5D (EQ-5D) questionnaire. In addition, in accordance with the instability criteria, radiographs were evaluated before surgery, after surgery, and during follow-up. RESULTS: Overall, 25 patients (71%) suffered an acute type V disruption, 5 (14%) had a type IV disruption, and 5 (14%) had an acute Rockwood type IIIb injury. The mean Constant-Murley Score was 90 (range: 56-100; p = 0.53) on the injured side, and the mean subjective shoulder value was 92% (range: 80-100%). The mean Taft and ACJI scores were 10 (range: 4-12) and 86 (range: 34-100), respectively and the mean EQ-5D was 86 (range: 2-100). The mean CC difference of the injured side was 4 mm (range: 1.9-9.1 mm) at follow-up, which was not significantly different than that of the healthy side (p = 0.06). No fractures in the area of the clavicle or the coracoid were reported. CONCLUSIONS: The arthroscopic- and navigation-assisted treatment of high-grade ACJ injuries in an anatomical double-tunnel configuration yields similar clinical and radiological outcomes as the conventional technique using an aiming device. Precise positioning of the navigation system prevents multiple drillings, which avoids fractures.

Impact of surgical site infection on patients' outcome after fixation of tibial plateau fractures: a retrospective multicenter study.

BACKGROUND: Surgical site infection (SSI) occurs in 3-10 % of patients with surgically treated tibial plateau fractures. This study aimed to evaluate the impact of SSI on patients' outcome after fixation of tibial plateau fractures. METHODS: We conducted a retrospective multicenter study in seven participating level I trauma centers between January 2005 and December 2014. All participating centers followed up with patients with SSI. In addition, three centers followed up with patients without SSI as a reference group. Descriptive data and follow-up data with patient-reported outcome scores (Knee Injury and Osteoarthritis Outcome Score [KOOS] and Lysholm knee scoring scale score) were evaluated. RESULTS: In summary, 287 patients (41 with SSI and 246 without SSI; average 50.7 years) with an average follow-up of 75.9 ± 35.9 months were included in this study. Patients with SSI had a significantly poorer overall KOOS (KOOS5) (48.7 ± 23.2 versus [vs.] 71.5 ± 23.5; p < 0.001) and Lysholm knee scoring scale score (51.4 ± 24.0 vs. 71.4 ± 23.5; p < 0.001) than patients without SSI. This significant difference was also evident in the KOOS subscores for pain, symptoms, activities of daily living (ADL), and quality of life (QoL). SSI remained an important factor in multivariable models after adjusting for potential confounders. Clinically relevant differences in the KOOS5 and KOOS subscores for symptoms, pain, and ADL were found between those with SSI and without SSI even after adjustment. Furthermore, the number of previous diseases, Arbeitsgemeinschaft für Osteosynthesefragen Foundation (AO) C fractures, and compartment syndrome were found to be additional factors related to poor outcome. CONCLUSIONS: Compared to previous studies, validated patient-reported outcome scores demonstrated that the impact of SSI in patients with surgically treated tibial plateau fractures is dramatic, in terms of not only pain and symptoms but also in ADL and QoL, compared to that in patients without SSI.

[Posterior meniscus root tears]. / Posteriore Wurzelverletzungen der Menisken.

Meniscus root tears are radial tears in the region of the posterior insertion zones. Medial root injuries usually occur in individuals > 50 years of age without adequate trauma and are associated with obesity and varus deformities. The root lesion leads to a loss of ring tension, which results in extrusion of the meniscus and a strong increase in joint pressure that is biomechanically equivalent to a complete meniscectomy. When indicating arthroscopic transosseous refixation of the medial root lesion, factors such as accompanying cartilage damage, osteoarthritis, obesity and varus deformity must be taken into account. Injuries to the root of the lateral meniscus are mostly observed in younger patients in combination with a rupture of the anterior cruciate ligament. Arthroscopic transosseous refixation in combination with cruciate ligament surgery is therefore also recommended for type I and type II lesions. In summary, both the medial and the lateral root lesions of the menisci are injuries with high biomechanical relevance.

Outcomes of tissue reconstruction in distal lower leg fractures: a retrospective cohort study.

BACKGROUND: Open and closed fractures can be associated with posttraumatic or postoperative soft tissue defects caused by initial trauma, operative procedures, or infections. This study evaluated the postoperative outcomes in patients with open or closed lower leg fractures, related soft tissue defects, and subsequent flap coverage. METHODS: We performed a retrospective single-center cohort study in a level 1 trauma center. We analyzed the patients treated from January 2012 through December 2017 and recorded demographics, treatment, and outcome data. The outcome data were measured via patient-reported Foot and Ankle Outcomes Scores (FAOS) and EQ-5D-5L scores. RESULTS: We included 22 patients with complicated fractures (11 open and 11 closed) and subsequent soft tissue defects and flap coverages. The mean follow-up time was 41.2 months. Twenty-one patients developed infections, and necrosis at the site of surgery manifested in all closed fractures. Therefore, all patients needed soft tissue reconstructions. Preoperatively, 16 patients underwent arterial examinations via angiography and six underwent ultrasound examinations of the venous system. Ten patients had complications involving the flaps due to ischemia and consequent necrosis. The mean EQ-5D index was 0.62 ± 0.27, and EQ-5D VAS score was 57.7 ± 20.2. The mean FAOS was 60.7 ± 22.2; in particular, quality of life was 32.3 ± 28.8. The rate of returning to work in our patient group was 37.5% after 1 year. CONCLUSIONS: Distal tibial fractures often require revisions and soft tissue reconstruction. The evaluated patient population had poor outcomes in terms of function, quality of life, and return to work. Furthermore, patients suffering from flap ischemia have worse outcomes than those without flap ischemia.

The single-suture technique for anterior cruciate ligament graft preparation provides similar stability as a three-suture technique: a biomechanical in vitro study in a porcine model.

PURPOSE: Numerous techniques have been described for the tibial-sided graft preparation in anterior cruciate ligament (ACL) reconstruction. The use of less suture material for graft preparation is thought to improve ingrowth and to reduce the risk for infection. At the same time, the suture construct should be strong enough to resist the surgeon's pull during tensioning of the transplant. METHODS: In total, 39 fresh-frozen procine deep flexor tendons were used and prepared as four-strand grafts. In the three-suture group (n = 19), graft preparation was performed using three tibial-sided sutures, with each tendon end sutured separately. In the one-suture group (n = 20), a modified graft preparation using only one tibial-sided suture was applied. Each sample underwent load-to-failure testing (Nmax) after cyclic pre-loading. To estimate intraoperative tension forces acting on the tibial-sided suture constructs, the maximal tension force of 26 volunteers on such a construct was measured using a load cell. RESULTS: The biomechanical testing of the two different suture constructs showed a significantly higher load-to-failure for the three-suture group (711 N ± 91 N) compared to the one-suture group (347 N ± 24 N) (p = 0.0001). In both groups, the mode of failure was a tear of the suture in all samples. A failure of the suture-tendon interface was not observed in any case. The median maximal tension force on the construct applied by the 26 volunteers was 134 N (range 73-182 N). CONCLUSION: The presented single-suture tendon graft preparation resisted to smaller failure loads than the conventional three-suture technique. However, no failures in the suture-tendon interface were seen and the failure loads observed were far beyond the tension forces that can be expected intraoperatively. Hence, the single-suture graft preparation technique may be a valuable alternative to the conventional technique.

Real-time intraoperative 3D image intensifier-based navigation in reversed shoulder arthroplasty- analyses of image quality.

BACKGROUND: Due to the high anatomical variability and limited visualization of the scapula, optimal screw placement for baseplate anchorage in reversed total shoulder arthroplasty (rTSA) is challenging. Image quality plays a key role regarding the decision of an appropriate implant position. However, these data a currently missing for rTSA and were investigated in the present study. Furthermore, the rate of required K-wire changes for the central peg as well as post-implantation inclination and version were assessed. METHODS: In ten consecutive patients (8 female, 86 years, range 74-94) with proximal humeral fracture and indication for rTSA, an intraoperative 3D-scan of the shoulder with a 3D image intensifier (Ziehm Vision FD Vario 3D© [Ziehm Imaging GmbH, Nürnberg, Germany]) was performed after resection of the humeral head. Using the Vectorvision© Software (Brainlab AG, Feldkirchen, Germany), the virtual anatomy was compared to the visible anatomical landmarks. After implantation of the baseplate, a 3D scan was performed. All 3D scans included multiplanar reconstruction (MPR) and the cinemode to examine screw and baseplate placement. The rate of required K-wire changes was assessed. The intraoperative 3D image quality (modified visual analogue scale [VAS] and point system) was assessed before and after implantation of the glenoid component. Inclination and version were determined in post-implantation scans. RESULTS: The virtually presented anatomical landmarks always correlated to the anatomical visible points indicating an good virtual accuracy. The central K-wire position was corrected in three cases due to a deviation from the face plane technique position. The VAS was higher for the pre-implantation MPR (6.7, range 5-8) compared to the post-implantation acquired MPR (5.1, range 4-6; p = 0.0002). The point system showed a reduced quality in all subcategories, especially regarding the grading of the articular surfaces. The preoperative (7.9, range 6-9) and post-implantation (7.9, range 6-9) cinemode displayed no significant differences (p = 0.6). CONCLUSION: The present study underlines the need for the improvement of 3D image intensifiers algorithms to reduce artifact associated impaired image quality to enhance the benefit of real-time intraoperative 3D scans and navigation.

Outcome of patients after lower limb fracture with partial weight bearing postoperatively treated with or without anti-gravity treadmill (alter G®) during six weeks of rehabilitation - a protocol of a prospective randomized trial.

BACKGROUND: Partial or complete immobilization leads to different adjustment processes like higher risk of muscle atrophy or a decrease of general performance. The present study is designed to prove efficacy of the anti-gravity treadmill (alter G®) compared to a standard rehabilitation protocol in patients with tibial plateau (group 1)or ankle fractures (group 2) with six weeks of partial weight bearing of 20 kg. METHODS AND DESIGN: This prospective randomized study will include a total of 60 patients for each group according to predefined inclusion and exclusion criteria. 1:1 randomization will be performed centrally via fax supported by the Clinical Trial Centre Leipzig (ZKS Leipzig). Patients in the treatment arm will be treated with an anti-gravity treadmill (alter G®) instead of physiotherapy. The protocol is designed parallel to standard physiotherapy with a frequency of two to three times of training with the treadmill per week with duration of 20 min for six weeks. DISCUSSION: Up to date no published randomized controlled trial with an anti-gravity treadmill is available. The findings of this study can help to modify rehabilitation of patients with partial weight bearing due to their injury or postoperative protocol. It will deliver interesting results if an anti-gravity treadmill is useful in rehabilitation in those patients. Further ongoing studies will identify different indications for an anti-gravity treadmill. Thus, in connection with those studies, a more valid statement regarding safety and efficacy is possible. TRIAL REGISTRATION: NCT02790229 registered on May 29, 2016.

Infection following fractures of the proximal tibia - a systematic review of incidence and outcome.

BACKGROUND: To systematically review all available studies of operatively treated proximal tibia fractures and to report the incidence of superficial or deep infection and subsequent outcomes. METHODS: A systematic review of the literature in Medline, Cochrane, Embase and GoogleScholar was conducted to identify studies with cohorts of patients with infection after surgical treatment of proximal tibia fractures. Studies were included according to predefined inclusion and exclusion criteria. The studies were analysed for methodological deficiencies and quality of outcome reporting based on the Level of Evidence (LOE) and Coleman Methodology Scoring (CMS.) RESULTS: In total 32 studies were included. There was heterogeneity between the studies, in terms of subject of the studies, outcome criteria, fracture type and classification, surgical techniques and length of follow-up. Therefore, no meta-analysis could be performed. The average CMS was 54.2 (range 36-75). The included studies were 25 case series (LOE IV), 6 were prospective cohort studies (LOE III) and one was a prospective randomized trial (LOE I). 203 (12.3%, range: 2.6-45.0%) infections occurred in the overall population (n = 2063). Those were divided into 129 deep infections and 74 superficial infections. Revision due to infection was reported in 29 studies, microbiological results in 6, respectively. 72 (55,8%) of 129 cases reporting outcome after deep infection had an unsatisfactory outcome with substantial limitations of the affected joint and leg. CONCLUSIONS: Postoperative infections are a challenge, sometimes requiring several revisions and often with a worse outcome. Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes.

In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up.

BACKGROUND: The incidence of pelvic ring fractures in the elderly significantly increased. Because of persistent pain and immobilization associated with this injury, surgical treatment is recommended. To minimise comorbidities and surgical risk, percutaneous techniques are becoming more relevant. In-screw cement augmentation of sacroiliac screw fixation is a promising procedure; however, clinical follow-up data remain scarce. This study investigated the safety and possible complications of the procedure along with a 1-year follow-up. METHODS: Thirty-four patients (treated with 43 screws) were prospectively included. Data on patients' age and sex, the mechanism of accident, fracture pattern, duration of hospital stay, surgery and adverse events were recorded. Data were obtained postoperatively on the reduction of pain and complications, such as infection, cement leakage and neurological deficits, and at 1-year follow-up on pain, quality of life according to the 12-Item Short Form Survey and mobility. Implant failure was defined as retraction or dislocation of screws and was also documented. RESULTS: Screw-related complications occurred with 2 of 43 screws. None of these complications were related to cement augmentation. In-hospital adverse events occurred in 6 of 34 patients. Postoperative pain, measured by the visual analogue scale, was significantly reduced from 6.7 ± 1.4 preoperatively to 2.7 ± 1.0 postoperatively (p < 0.001). Although patients complained of pain at the 1-year follow-up, they reported a significant decline compared with pain at admission (3.4 ± 2.3; p < 0.001). Results on the quality of life were comparable with those for the age- and gender matched German population. All patients were mobile, and no implant failure was detected. CONCLUSIONS: The results indicate that in-screw augmented sacroiliac screw fixation for fragility fractures of the pelvis is a safe technique. Pain was significantly reduced immediately after surgery compared to the preoperative state. Furthermore, significant pain reduction after one year compared to the preoperative state and quality of life was comparable to the age- and gender- matched German population. Thus, we recommend in-screw augmentation for screw fixation for sacral fragility fractures of the pelvis following failed conservative treatment.

Synovial cytokine expression in ankle osteoarthritis depends on age and stage.

PURPOSE: Aim of the study was the analysis of cytokine expression in ankle osteoarthritis (OA) hypothesizing age-dependent regulation patterns. METHODS: Forty-nine patients undergoing an arthroscopy of the ankle with different stages of chronic OA were prospectively included in a clinical trial comparing the group <18 years (n = 9, Ø15.1 ± 2.0 years) with the older patients (≥18 years, n = 40, Ø36.5 ± 11.9). Lavage fluids were analysed by ELISA for levels of aggrecan, BMP-2/7, IGF-1/R, bFGF, CD105, MMP-13, and IL-1ß. Additionally, clinical parameters and scores (FFI, CFSS, AOFAS) were evaluated and supplemented by radiographic scores [Kellgren-Lawrence Score (KLS) for conventional X-rays, Ankle Osteoarthritis Scoring System (AOSS) for MRI]. RESULTS: In contrast to distribution of gender and BMI (p < 0.005), parameters characterizing the cartilage defect as ICRS grading, size, and duration of symptoms were not dependent on age. The incidence of osteochondritis dissecans (OCD) was higher in the group <18 years (p < 0.006), but the average degree of OCD grading was not different. KLS and AOSS were significantly higher in the group ≥18 years (p < 0.02). Correlating with the higher degree of OA in the elderly, clinical function measured by FFI and AOFAS was statistically significantly worse (p < 0.05). Intra-articular concentrations of aggrecan (3.1-fold), bFGF (8.7-fold), BMP-7 (2.7-fold), and CD105 (1.5-fold) were statistically significantly higher in the group ≥18 years (p < 0.03). CONCLUSIONS: Confirming the hypothesis, increased synovial levels of aggrecan, bFGF, BMP-7, and CD105 were found in patients over 18 years. This correlated with a higher stage of OA determined by radiographic changes or deteriorated function and may offer starting points for new diagnostics and interventional strategies. LEVEL OF EVIDENCE: II.