The effect of different alignment strategies on trochlear orientation after total knee arthroplasty.

PURPOSE: When planning and delivering total knee arthroplasty (TKA), there are multiple coronal alignment strategies such as functional alignment (FA), kinematic alignment (KA), mechanical and adjusted mechanical alignment (MA, aMA). Recent three-dimensional and robotic-assisted surgery (RAS) studies have demonstrated that KA potentially better restores the trochlear anatomy than MA. The purpose of this study was to compare the restoration of the native trochlear orientation in patients undergoing RAS TKA using four different alignment strategies. It was hypothesised that FA would result in the lowest number of outliers. METHODS: This is a prospective study of 200 patients undergoing RAS-TKA with a single implant. All patients were analysed for MA and KA prebalancing, and 157 patients received aMA and 43 patients FA with intraoperative balancing. Preoperative transverse computed tomography scans were used to determine the posterior condylar axis (PCA), lateral trochlear inclination (LTI) angle, sulcus angle (SA) and anterior trochlear line (ATL) angle. Implant measurements were obtained using a photographic analysis. Intraoperative software data combined with implant data and preoperative measurements were used to calculate the differences. Outliers were defined as ≥3° of alteration. Trochlea dysplasia was defined as LTI < 12°. RESULTS: Native transepicondylar PCA had a median of 2°, LTI 18°, SA 137°, ATL 4°. LTI outliers were observed in 47%-60% of cases, with KA < FA < aMA < MA. For ATL, the range of outliers was 40.5%-85%, KA < FA < aMA < MA. SA produced 81% of outliers. Of all median angle values, only LTI when using KA was not significantly altered compared to the native knee. CONCLUSION: There is a significant alteration of trochlear orientation after TKA, regardless of the alignment strategy used. KA produced the lowest, but a substantial, number of outliers. The uniform design of implants causes the surgeon to compromise on balance in flexion versus trochlear position. The clinical relevance of this compromise requires further clinical investigations. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Jumper's fracture of the sacrum: a novel and reproducible way for successful reduction and fixation.

PURPOSE: Surgical treatment of jumper's fractures is a highly demanding situation for the surgeon due to its rareness and frequent association with severe concomitant injuries. There is no current consensus regarding a standard treatment approach, thus reducing quality of care. Our objectives were to describe, apply and assess a novel surgical technic. METHODS: The presented research is an observational retrospective study of patients who underwent the described novel surgical intervention in a level 1 trauma center. We conducted analyses of the patient cohort using patient-related outcome measures at least 1 year after surgery, as well as investigating pain, quality of life and the clinical effectiveness of the procedure. RESULTS: A total of 24 patients (17 male and 7 female) with an average age 47 ± 16.3 years were included. ISS scores ranged from 9 to 66 with a mean ISS of 40 ± 15. Clinical scores exist of 15 out of 24 patients (62.5%). The mean VAS score was 53.7 ± 12.9. The mean EQ-5D index was 0.68 ± 0.22. Significant negative correlation existed between the ISS value and the EQ-5D index (r = - 0.704; p < 0.005) and EQ-5D VAS (r = - 0.809; p < 0.001). Anatomical reduction was achieved in all patients (n = 24). Radiological follow-up was performed in 58%. CONCLUSION: We present one of the largest studies with operatively treated jumper's fractures of the sacrum. The technique is capable of reproducibly restoring the physiological anatomy of the patient and allows pain-adapted mobilization.

Identification of hip fracture patients at risk for postoperative mobilisation complications via handgrip strength assessment.

INTRODUCTION: Treatment of older adult hip fracture patients can be challenging and requires early postoperative mobilisation to prevent complications. Simple clinical tools to predict mobilisation/weight-bearing difficulties after hip fracture surgery are scarcely available and analysis of handgrip strength could be a feasible approach. In the present study, we hypothesised that patients with reduced handgrip strength show incapability to follow postoperative weight-bearing instructions. MATERIALS AND METHODS: Eighty-four patients aged ≥ 65 years with a proximal femur fracture (trochanteric, n = 45 or femoral neck, n = 39), who were admitted to a certified orthogeriatric center, were consecutively enrolled in a prospective study design. Five days after surgery (intramedullary nailing or arthroplasty), a standardised assessment of handgrip strength and a gait analysis (via insole forcesensors) was performed. RESULTS: Handgrip strength showed positive correlation with average peak force during gait on the affected limb (0.259), postoperative Parker Mobility Score (0.287) and Barthel Index (0.306). Only slight positive correlation was observed with gait speed (0.157). These results were congruent with multivariate regression analysis. CONCLUSION: Assessment of handgrip strength is a simple and reliable tool for early prediction of postoperative mobilisation complications like the inability to follow weight-bearing instructions in older hip fracture patients. Follow-up studies should evaluate if these findings also match with other fracture types and result in personalised adjustment of current aftercare patterns. In addition, efforts should be made to combine objectively collected data as handgrip strength or gait speed in a prediction model for long-term outcome of orthogeriatric patients.

Implementation of an integrated care programme to avoid fragility fractures of the hip in older adults in 18 Bavarian hospitals - study protocol for the cluster-randomised controlled fracture liaison service FLS-CARE.

BACKGROUND: The economic and public health burden of fragility fractures of the hip in Germany is high. The likelihood of requiring long-term care and the risk of suffering from a secondary fracture increases substantially after sustaining an initial fracture. Neither appropriate confirmatory diagnostics of the suspected underlying osteoporosis nor therapy, which are well-recognised approaches to reduce the burden of fragility fractures, are routinely initiated in the German healthcare system. Therefore, the aim of the study FLS-CARE is to evaluate whether a coordinated care programme can close the prevention gap for patients suffering from a fragility hip fracture through the implementation of systematic diagnostics, a falls prevention programme and guideline-adherent interventions based on the Fracture Liaison Services model. METHODS: The study is set up as a non-blinded, cluster-randomised, controlled trial with unequal cluster sizes. Allocation to intervention group (FLS-CARE) and control group (usual care) follows an allocation ratio of 1:1 using trauma centres as the unit of allocation. Sample size calculations resulted in a total of 1216 patients (608 patients per group distributed over 9 clusters) needed for the analysis. After informed consent, all participants are assessed directly at discharge, after 3 months, 12 months and 24 months. The primary outcome measure of the study is the secondary fracture rate 24 months after initial hip fracture. Secondary outcomes include differences in the number of falls, mortality, quality-adjusted life years, activities of daily living and mobility. DISCUSSION: This study is the first to assess the effectiveness and cost-effectiveness/utility of FLS implementation in Germany. Findings of the process evaluation will also shed light on potential barriers to the implementation of FLS in the context of the German healthcare system. Challenges for the study include the successful integration of the outpatient sector as well as the future course of the coronavirus pandemic in 2020 and its influence on the intervention. TRIAL REGISTRATION: German Clinical Trial Register (DRKS) 00022237 , prospectively registered 2020-07-09.

Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study.

AIM: The treatment of tibial fractures with an intramedullary nail is an established procedure. However, torsional control remains challenging using intraoperatively diagnostic tools. Radiographic tools such as the Cortical Step Sign (CSS) and the Diameter Difference Sign (DDS) may serve as tools for diagnosing a relevant malrotation. The aim of this study was to investigate the effect of torsional malalignment on CSS and DDS parameters and to construct a prognostic model to detect malalignment. METHODS: A proximal tibial shaft fracture was set in human tibiae. Torsion was set stepwise from 0° to 30° in external and internal torsion. Images were obtained with a C-arm and transferred to a PC for measuring the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD) in AP and the anterior cortical thickness (ACT) as well as the posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and the distal main fragment. RESULTS: There were significant differences between the various degrees of torsion for each of the absolute values of the examined variables. The parameters with the highest correlation were TD, LCT and ACT. A model combining ACT, LCT, PCT and TD lateral was most suitable model in identifying torsional malalignment. The best prediction of clinically relevant torsional malalignment, namely 15°, was obtained with the TD and the ACT. CONCLUSION: This study shows that the CSS and DDS are useful tools for the intraoperative detection of torsional malalignment in proximal tibial shaft fractures and should be used to prevent maltorsion.

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design.

BACKGROUND: Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF's. METHODS: This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. DISCUSSION: Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03598530 .

Self-Assessment of Mobility of People over 65 Years of Age.

BACKGROUND AND OBJECTIVES: Nowadays, various clinical scoring systems are used in the medical care of the elderly to assess the quality of mobility. However, people often tend to under- or overestimate themselves in many aspects. Since this can have serious consequences in their treatment and care, the aim of this study was to identify differences in the self and external assessment of mobility of persons over 65 years of age. MATERIALS AND METHODS: 222 participants over 65 years of age and one external, closely-related relative or professional caregiver were interviewed by a unique study assistant using a standardized questionnaire. Participants were divided into people living in nursing homes and independent people living at home, where either the caregivers or the relatives provided the external assessment of mobility, respectively. The questionnaire included demographics, cognitive abilities (Mini Mental Status Test); fall risk (Hendrich 2 Fall Risk Model); as well as the Parker Mobility Score, Barthel Index, and EQ-5D-5L to measure mobility, activities of daily life and quality of life. In each case, the participant and the external person were asked for their assessment to the participants' mobility situation. Statistical significance of the difference between self and external assessment was calculated with a Wilcoxon rank-sum test and assumed with a p-value of ≤ 0.05. RESULTS: Self-assessment indicated a significantly higher value, when compared to an external assessment for the Parker Mobility Score for females in nursing homes (p ≤ 0.01), as well as for the Barthel Index for females (p ≤ 0.01) and males (p ≤ 0.01) in nursing homes. The EQ-5D-5L received a significantly higher self-assessment value for females (p ≤ 0.01) and males (p ≤ 0.01) living at home and females (p ≤ 0.01) and males (p ≤ 0.05) in nursing homes. CONCLUSIONS: Persons over 65 years of age tend to overestimate their level of mobility, quality of life and activities of daily life. Especially for people living in nursing homes, these scoring systems should be treated with caution due to the differences between the verbal statements. It is important to properly assess the mobility situation of elderly patients to ensure correct medical treatment and prevention of falls.

Tenogenic Contribution to Skeletal Muscle Regeneration: The Secretome of Scleraxis Overexpressing Mesenchymal Stem Cells Enhances Myogenic Differentiation In Vitro.

Integrity of the musculoskeletal system is essential for the transfer of muscular contraction force to the associated bones. Tendons and skeletal muscles intertwine, but on a cellular level, the myotendinous junctions (MTJs) display a sharp transition zone with a highly specific molecular adaption. The function of MTJs could go beyond a mere structural role and might include homeostasis of this musculoskeletal tissue compound, thus also being involved in skeletal muscle regeneration. Repair processes recapitulate several developmental mechanisms, and as myotendinous interaction does occur already during development, MTJs could likewise contribute to muscle regeneration. Recent studies identified tendon-related, scleraxis-expressing cells that reside in close proximity to the MTJs and the muscle belly. As the muscle-specific function of these scleraxis positive cells is unknown, we compared the influence of two immortalized mesenchymal stem cell (MSC) lines-differing only by the overexpression of scleraxis-on myoblasts morphology, metabolism, migration, fusion, and alignment. Our results revealed a significant increase in myoblast fusion and metabolic activity when exposed to the secretome derived from scleraxis-overexpressing MSCs. However, we found no significant changes in myoblast migration and myofiber alignment. Further analysis of differentially expressed genes between native MSCs and scleraxis-overexpressing MSCs by RNA sequencing unraveled potential candidate genes, i.e., extracellular matrix (ECM) proteins, transmembrane receptors, or proteases that might enhance myoblast fusion. Our results suggest that musculotendinous interaction is essential for the development and healing of skeletal muscles.

[All internal segmental transport in tibial bone defects: first experiences with the PRECICE bone transport system]. / "All-internal"-Segmenttransport bei Knochendefekt an der Tibia: erste Erfahrungen mit dem PRECICE Bone Transport System.

Bone loss of the distal tibia represents a major challenge for the treating surgeons and the reconstruction technique. This is particularly true for septic bone loss. Several techniques are available, ranging from callus distraction of Ilizarov frames and monorail techniques as well as transport with plates and nails; however, implants for internal segmental transport for bone defects have so far not been available. This case report describes worldwide the first reconstruction of a distal tibial defect by reconstruction of the major arterial flow path with flap coverage and all inside segmental transport using a motorized segmental transport nail without additional osteosynthesis or add-on module.

Modified less invasive anterior subcutaneous fixator for unstable Tile-C-pelvic ring fractures: a biomechanical study.

BACKGROUND: Operative procedures for unstable pelvic ring fractures remain controversially discussed. Minimally invasive treatment options for pelvic ring fractures have several benefits for the patient. But they can also provide disadvantages. Anterior subcutaneous pelvic fixation (INFIX) has shown promising biomechanical results in pelvic ring fractures, but there is a high complication rate of nerve injuries. An additional screw to the INFIX seems to be more stable. The aim of this study is to compare biomechanical stability of a new modified unilateral INFIX fixing the unilateral injured pelvic ring with the standard INFIX. METHODS: 24 composite synthetic full pelvises were used in this study. 4 groups each with a number of six pelvic specimens were randomly assigned. A C1.3-type pelvic fracture was made with an osteotomy of the sacrum and an osteotomy of the anterior pelvic ring. Fracture fixation was performed within the four groups: (1) unilateral INFIX, (2) "extended" unilateral INFIX + additional pubic ramus pedicle screw, (3) bilateral INFIX, (4) "extended" bilateral INFIX + additional pubic ramus pedicle screw. All specimens were cyclic loaded with 200 N until maximum of 300 N. Distance/dislocation of the fracture fragments were detected with 3D-ultrasound measuring system. Stiffness was calculated. RESULTS: Extended unilateral INFIX showed the lowest mean dislocation. Lowest rotational stability was displayed by the standard bilateral INFIX. A significant difference (P = 0.04) was shown between the extended unilateral INFIX and the "standard" bilateral INFIX in terms of rotational stability. Extended unilateral INFIX showed significantly improved stability of anterior fracture dislocation (P = 0.01) and unilateral INFIX showed the highest rotational stiffness. Anterior fixation stiffness of the unilateral INFIX was significantly improved using an additional symphysis/pubic ramus screw (P = 0.002). CONCLUSION: Extended unilateral INFIX (+ additional pubic ramus pedicle screw) is a feasible minimally invasive treatment for anterior pelvic ring fractures. Higher stability and lower probability of bilateral nerve damage is provided by the extended unilateral INFIX compared to the standard bilateral INFIX.

Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study.

BACKGROUND: Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). METHODS: We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). RESULTS: A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. CONCLUSIONS: Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards. TRIAL REGISTRATION: The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.

Training with biofeedback devices improves clinical outcome compared to usual care in patients with unilateral TKA: a systematic review.

PURPOSE: Biofeedback following total knee arthroplasty (TKA) seems to be a feasible approach to improve rehabilitation, outcomes, mobility and reduce pain. This systematic review gives the practicing orthopedic surgeon a summary of what is available and how biofeedback affects clinical outcomes. METHODS: We reviewed the current literature regarding methods, devices and effects of biofeedback in patients who underwent total knee arthroplasty. Embase, Pubmed, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to May 2018 for the following keywords: Biofeedback OR Feedback AND Total Knee Arthroplasty OR TKA. Data were extracted according to a predefined setting (see Protocol for systematic review on PROSPEO). Devices used for biofeedback were recorded. Demographics, training methods and effects were also collected. RESULTS: The search resulted in 380 potentially eligible studies from which 11 met all inclusion criteria including 7 randomized controlled trials (RCTs), 3 cohort studies, and 1 cross-sectional study. A total of 416 patients with unilateral TKA were included, with an average of 37.8 patients per study. In patients with TKA, significant improvements in activity scores or pain were reported by 9 of 11 studies. Only two of the studies reported no significant influence of the feedback on the chosen outcome parameters. Devices for biofeedback varied between studies and included the use of a goniometer, force plate, balance board, treadmill, and/or electromyography (EMG). The most common type of feedback was visual followed by audio, with one study mentioning that the audio mode was preferred by the patients as it was easier to handle. Overall, 5 out of 6 different methods demonstrated a potential value for improving mobility and decreasing pain. CONCLUSIONS: This review suggests that biofeedback in early postoperative rehabilitation after TKA is effective in improving gait symmetry, reducing pain and increasing activity level. It should be noted that the great variety of devices used for feedback limits comparisons between studies. LEVEL OF EVIDENCE: IIa.

Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients.

BACKGROUND AND PURPOSE: Reduced mobility is a severe threat to the clinical outcomes and survival of elderly hip fracture patients. These patients generally struggle to comply with partial weight bearing, yet postoperative weight-bearing restrictions are still recommended by nearly 25% of surgeons. Therefore, we hypothesized that weight-bearing restrictions in elderly hip fracture patients merely leads to reduced mobility, while transposing full weight to the fractured extremity remains unaffected disregarding the prescribed aftercare. PATIENTS AND METHODS: 41 equally treated patients with pertrochanteric fractures were enrolled consecutively in a maximum care hospital in a pre-post study design (level of evidence 2). A study group of 19 patients was instructed to maintain partial weight bearing (PWB), whereas the control group of 22 patients was instructed to mobilize at full weight bearing (FWB). All patients were asked to participate in a gait analysis using an insole force sensor (loadsol®, Novel, Munich, Germany) on the fifth postoperative day. RESULTS: The postoperative Parker Mobility Score in the PWB group compared to the FWB group was significantly reduced (3.21 vs. 4.73, p < 0.001). Accordingly, a significantly lower gait speed in the PWB group of 0.16 m/s vs. 0.28 m/s was seen (p = 0.003). No difference in weight bearing was observed in between the groups (average peak force 350.25 N vs. 353.08 N, p = 0.918), nor any differences in the demographic characteristics, ASA Score, Barthel Index or EQ5D. INTERPRETATION: Weight-bearing restrictions in elderly hip fracture patients contributed to a loss of mobility, while no significant differences in loading of the affected extremity were observed. Therefore, postoperative weight-bearing restrictions in elderly hip fracture patients should be avoided, to achieve early mobilization at full weight bearing.

[Establishment of fracture liaison services in Germany]. / Etablierung von Frakturnetzwerken in Deutschland.

BACKGROUND: Osteoporosis results in fragility fractures that are associated with a high morbidity and mortality as well as an increased risk for subsequent fragility fractures. Thus, the first fragility fracture should be the last. To achieve this goal patients need treatment of osteoporosis according to the prevailing clinical guidelines. OBJECTIVE: This article presents the current clinical care situation of patients with a manifest osteoporosis in Germany and the accompanying risks. As a possible solution the concept of a fracture liaison service (FLS) as a new intersectoral care concept is presented and options for the establishment of FLS in Germany are provided. MATERIAL AND METHODS: A literature search (PubMed) was conducted using key terms. The practical experiences of the authors in the context of establishing an FLS were also considered. RESULTS: Compared to other countries, in Germany only a minority of patients receive treatment for osteoporosis after fragility fractures. To improve the care situation an intersectoral FLS provides a coordinated referral of patients with fragility fractures from inpatient care in hospitals to specialists in private practice. This enables the strict identification and treatment of high-risk patients according to the prevailing clinical guidelines. In Germany, different options exist to structure an FLS under consideration of the local circumstances. CONCLUSION: In Germany, FLS should be established nationwide and according to uniform standards. This would significantly improve the quality of clinical care of patients with manifest osteoporosis.

[Influence of specific osteoporosis drugs on fracture healing]. / Einfluss spezifischer Osteoporosemedikamente auf die Frakturheilung.

BACKGROUND: For the treatment of disturbed fracture healing, drugs could be given in addition to surgical procedures. Specific osteoporosis drugs affect the bone metabolism and are used to treat osteoporosis, particularly after a fragility fracture has occurred. Therefore, their use would be conceivable to improve a disturbed fracture healing. OBJECTIVE: This article presents the available and upcoming specific osteoporosis drugs and investigates whether these substances affect fracture healing in the context of osteoporosis. Furthermore, it is discussed whether disturbed fracture healing can be improved by the use of these substances. MATERIAL AND METHODS: A literature search (PubMed) was conducted using key terms. Preclinical studies, clinical studies, reviews and meta-analyses were considered in order to present the current knowledge in a clinically relevant context. RESULTS: Preclinical and clinical studies show that specific osteoporosis drugs have no relevant negative impact on the healing of fragility fractures. A tendency to improve a disturbed fracture healing was attributed to bone anabolic substances; however, studies are inconsistent and there is no approval for this application. CONCLUSION: Following a fragility fracture, osteoporosis should be diagnosed according to the guidelines and, if necessary, treated with specific osteoporosis drugs, since in principle they do not impair fracture healing but significantly reduce the risk of subsequent fractures. Approval to improve fracture healing requires further investigations.

[Is it sensible to use fix and flap also in old age?] / Ist "fix and flap" auch im hohen Alter sinnvoll anwendbar?

In older patients the optimal treatment strategy of complex bone and soft tissue injuries represents a new challenge. Currently, two treatment approaches are in competition. Whereas the amputation of the limb represents a rapid solution including short postoperative hospitalization, limb preservation in cases of open fractures is frequently associated with prolonged hospitalization and sometimes unsatisfactory functional outcomes. Therefore, especially in old patients the advantages and disadvantages should be weighed up. A possible alternative to the currently frequently used multistep procedure for limb preservation with continuous negative pressure treatment is the fix and flap or emergency free flap approach. Based on the case of a convulsion trauma in an 85-year-old patient, this case report describes a treatment approach for Gustilo-Anderson type IIIc fractures using a fix and flap procedure for limb preservation.

Influence of age and level of activity on the applicability of a walker orthosis - a prospective study in different cohorts of healthy volunteers.

BACKGROUND: Walker orthosis are frequently prescribed as they are removable to allow wound control, body care and physiotherapy and are adaptable to the soft tissue conditions. The prerequisite for successful treatment with any walker orthosis is a correct use by the patient. Therefore, the aim of this study was to investigate patients' handling of a commonly used walker. METHODS: Prospective observational study analyzing the applicability of a walker orthosis in different cohorts with varying age and level of activity. Volunteers were recruited from a mountain-biking-team (Sport), a cardiovascular-health-sports-group (Cardio) and a retirement home (Senior). The correct application was assessed following initial training (t0) and one week later (t1). Outcome parameters were an Application Score, strap tightness, vertical heel lift-off and subjective judgement of correct application. RESULTS: Thirty-three volunteers, 11 Sports group (31 ± 7a), 12 Cardio group (59 ± 11a), 10 Senior group, (82 ± 5a) were enrolled. No differences for any parameter could be observed between t0 and t1. Age showed a moderate correlation for all outcome parameters and the cohort influenced all variables. The Senior group presented significant inferior results to the Sport- and Cardio group for the Application Score (p = 0.002-p < 0.001) and strap tightness (p < 0.001). Heel lift-off was significantly inferior in the Cardio- and Senior- compared to the Sport group (p = 0.003-p < 0.001). 14% in the Sport-, 4% in the Cardio- and 83% in the Senior group achieved less than 9 points in the Application Score - which was considered insufficient. However, out of these 90% believed the application to be correct. CONCLUSIONS: The elderly cohort living in a retirement home demonstrated an impaired handling of the walker orthosis. Further, participants were incapable to self-assess the correct handling. These aspects should be respected when initiating treatment with a walker orthosis. TRIAL REGISTRATION: Retrospectively registered on the 16th of February 2018: # DRKS00013728 on DRKS.

Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures.

INTRODUCTION: In combined posterior-anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique. METHODS: Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2) treated by combined posterior-anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24-154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF. RESULTS: Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of - 15.6 ± 7.7° and - 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084). CONCLUSIONS: This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.

Fracture reduction by postoperative mobilisation for the treatment of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders.

INTRODUCTION: The aim of this study was to evaluate results of surgical stabilisation of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders using two different treatment strategies: the conventional open rigid posterior instrumentation and percutaneous less rigid posterior instrumentation. Surgical and non-surgical complications, the postoperative radiological course, and clinical outcome at final follow-up were comparatively assessed. Moreover, we sought to discuss important biomechanical and surgical aspects specific to posterior instrumentation of the ankylosed thoracolumbar spine as well as to elaborate on the advantages and limitations of the proposed new treatment strategy involving percutaneous less rigid stabilisation and fracture reduction by postoperative mobilisation. MATERIALS AND METHODS: Between January 2006 and June 2012, a consecutive series of 20 patients were included in the study. Posterior instrumentation was performed either using an open approach with rigid 6.0 mm bars (open rigid (OR) group) or via a percutaneous approach using softer 5.5 mm bars (percutaneous less rigid (PLR) group). Complications as well as the radiological course were retrospectively assessed, and patient outcome was evaluated at final follow-up using validated outcome scores (VAS Spine Score, ODI, RMDQ, Parker Mobility Score, Barthel Score and WHOQOL-BREF). RESULTS: Surgical complications occurred more frequently in the OR group requiring revision surgery in two patients, while there was no revision surgery in the PLR group. The rate of postoperative complications was lower in the PLR group as well (0.7 vs. 1.3 complications per patient, respectively). Fracture reduction and restoration of pre-injury sagittal alignment by postoperative mobilisation occurred within the first 3 weeks in the PLR group, and within 6 months in the OR group. The clinical outcome at final follow-up was very good in both groups with no relevant loss in VAS Spine Score (pain and function), Parker Mobility Score (mobility), and Barthel Index (social independency) compared to pre-operative values. CONCLUSIONS: This study indicates that the proposed treatment concept involving percutaneous less rigid posterior instrumentation and fracture reduction by postoperative mobilisation is feasible, seems to facilitate adequate reduction and restoration of pre-injury sagittal alignment, and might have the potential to reduce the rate of complications in the management of hyperextension injuries of the ankylosed thoracolumbar spine.