Higher conversion rate to knee arthroplasty in female patients following medial open-wedge high tibial osteotomy.

PURPOSE: Most studies about medial open-wedge high tibial osteotomy (HTO) reported outcomes without focusing on gender differences. Therefore, the study compared the long-term survival rate and postoperative subjective knee function after HTO in female versus male patients with symptomatic medial compartment knee osteoarthritis. METHODS: The data of three cohorts with long-term outcomes were analysed (n = 245; 32% females; age: 49 ± 7 years; Kellgren Lawrence Grade I 6.1%, II 32.7%, III 42.4%; IV 18.8%). The minimum follow-up was at least 6 years or an earlier conversion to total knee arthroplasty (TKA). The gender-specific survival rate after HTO was calculated after 5 and 10 years and compared using Kaplan-Meier analysis and the logrank test. Baseline characteristics and subjective knee function (International Knee Documentation Committee [IKDC]/Lysholm) were analysed between both genders. RESULTS: Forty of 78 (51.3%) women and 41 of 167 men (24.5%) underwent TKA. HTO survival in females was significantly lower (p = 0.0010). The 5- and 10-year survival rates were 85.9% and 62.6% for females and 93.4% and 77.7% for males. In females and males, from preoperative to the last follow-up, the IKDC (43 ± 15 to 58 ± 17; 47 ± 14 to 67 ± 18) and the Lysholm (42 ± 18 to 72 ± 18; 55 ± 22 to 77 ± 23) improved significantly (all p < 0.0001). Females had significantly lower preoperative and postoperative IKDC (p = 0.0438; p = 0.0035) and Lysholm scores (p = 0.0002; p = 0.0323). But the absolute improvements of the IKDC and Lysholm were not significantly different between genders. CONCLUSIONS: Females had higher conversion rates to TKA and lower knee function at the last follow-up. However, preoperative knee function was lower in females and the absolute improvement following HTO was similar for both genders. In general, females benefit from HTO to treat medial knee arthritis, and TKA could be postponed for half of female patients for more than 10 years. However, surgeons must be aware of the described inferior outcomes in females for realistic patient expectation management. LEVEL OF EVIDENCE: Level II.

Work intensity and quality of life can be restored following double-level osteotomy in varus knee osteoarthritis.

PURPOSE: The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term. METHODS: Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: -11.0 ± 3.0° (-6.0 to -17.0), age: 49.1 ± 9.5 (31-65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5-43) months). RESULTS: The duration that the patients were unable to work was 12.2 ± 4.4 (6-20) weeks. The PCS improved from 32.1 ± 11.3 (14.5-53.3) preoperatively to 54.6 ± 8.5 (25.2-63.7) (p < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1-67.7) to 57.2 ± 3.1 (47.3-61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population (p < 0.001), whereas the preoperative MCS was similar between the two groups (n.s.). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0-5.0) to 4.0 (2.0-7.0) (p < 0.001). CONCLUSION: Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO. LEVEL OF EVIDENCE: Study type: therapeutic, IV.

Overweight patients benefit from high tibial osteotomy to the same extent as patients with normal weights but show inferior mid-term results.

PURPOSE: The purpose of this prospective study was to analyze the impact of obesity on the clinical and radiological outcomes 6 years after open-wedge high tibial osteotomy (HTO). METHODS: A total of 120 prospectively recorded patients with medial compartment osteoarthritis underwent open-wedge HTO between 2008 and 2011. The study cohort was frequently examined over a minimum of a 6-year follow-up. The cohort was divided into three groups according to body mass index (BMI): normal weight patients (BMI < 25 kg/m2), pre-obese patients (BMI 25-30 kg/m2) and obese patients (BMI > 30 kg/m2). Clinical and functional outcomes (Oxford Knee Score, Hospital for Special Surgery Score, Lequesne Score, Tegner Activity Scale), subjective health-related quality of life (SF-36), change in mechanical limb alignment (mTFA) as well as conversion to unicompartmental or total knee arthroplasty (TKA) were evaluated. To compare clinical scoring between the groups, univariate variance analysis was applied. Changes in outcome variables over time were analyzed with dependent t tests. RESULTS: From 120 patients, 85 were followed-up over a 6.7-year period on average (6-11.8 years) after HTO. The mean BMI was 28.6 ± 4.6 kg/m2. Each group showed a significant pre- to postoperative increase in all recorded scores (p < 0.05). In absolute terms, both mental and clinical scores of overweight patients did not reach the peak values of the normal weighted population during the period of observation. There was a conversion to TKA in 10.5% after an average of 50.1 ± 25.0 months following surgery. A total of five complications occurred without significant differences (BMI < 25: n = 1, BMI 25-30: n = 2, BMI > 30: n = 2; n.s.). There was a mean pre- to postoperative (six weeks after surgery) correction difference of 6.9° ± 3.2° (mTFA) with higher loss of correction over time in overweight patients. CONCLUSION: In terms of clinical outcome and health-related quality of life, overweight patients may receive a benefit from open-wedge HTO to the same extent as patients with normal weights and show similar complication rates. However, they have inferior preoperative clinical and functional results and mid-term results after open-wedge HTO compared to patients with normal weights. LEVEL OF EVIDENCE: Level III.

Increased tibial tubercle-trochlear groove and patellar height indicate a higher risk of recurrent patellar dislocation following medial reefing.

PURPOSE: Identifying anatomical risk factors on recurrent dislocation after medial reefing is important for deciding surgical treatment. The present study aimed to retrospectively analyze the preoperative magnetic resonance imaging (MRI)-based parameters of patients treated with medial reefing and whether these parameters lead to a higher risk of recurrent dislocation. METHODS: Fifty-five patients (18.6 ± 6.6 years) who underwent medial reefing after primary traumatic patellar dislocation (84% with medial patellofemoral ligament [MPFL] rupture) were included. Patients were followed up for at least 24 months postoperatively (3.8 ± 1.2 years) to assess the incidence of recurrent patellar dislocation. In patients without recurrent dislocation, the Kujala and subjective IKDC scores were assessed. Moreover, the tibial tubercle-trochlear groove (TT-TG), sulcus angle, patellar tilt, patellar shift, and lateral trochlea index (LTI) were measured. The patellar height was measured using the Caton-Dechamps (CDI), Blackburne-Peel (BPI), and Insall-Salvati index (ISI). The cohort was subclassified into two groups with and without recurrent dislocation. Differences between groups were analyzed with respect to the MRI parameters. RESULTS: Forty percent had a pathological sulcus angle of > 145°, 7.2% had an LTI of < 11°, 47.3% had a patellar tilt of > 20°, and 36.4% had a TT-TG of ≥ 16 mm. Increased patellar height was observed in 34.5, 65.5, and 34.5% of the patients as per CDI, BPI, and ISI, respectively. Nineteen (34.5%) patients suffered from recurrent dislocation. Compared with patients without recurrent dislocation, those with recurrent dislocation had a significantly lower LTI (p = 0.0467). All other parameters were not significantly different between the groups. Risk factor analysis showed higher odds ratios (OR > 2), although not statistically significant, for MPFL rupture (OR 2.05 [95% confidence interval 0.38-11.03], LTI (6.6 [0.6-68.1]), TT-TG (2.9 [0.9-9.2]), and patellar height according to ISI (2.3 [0.7-7.5]) and CDI (2.3 [0.7-7.5])). Patients without recurrent dislocation had a Kujala score of 93.7 ± 12.1 (42-100) points and an IKDC score of 90.6 ± 11.7 (55.2-100) points. CONCLUSION: Anatomical, MRI-based parameters should be considered before indicating medial reefing. A ruptured MPFL, an LTI < 11°, a TT-TG ≥ 16 mm, a patellar tilt > 20 mm, and an increased patellar height according to ISI and CDI were found to be associated, although not significantly, with a higher risk (OR > 2) of recurrent patellar dislocation after medial reefing. Thorough preoperative analysis is crucial to reduce the risk of recurrent dislocation in young patient cohorts. LEVEL OF EVIDENCE: Level IV.

Influence of axial limb rotation on radiographic lower limb alignment: a systematic review.

INTRODUCTION: The influence of limb malrotation on long-leg radiographs (LLR) is frequently discussed in literature. This systematic review aimed to describe the influence of limb rotation on alignment measurements alone and in combination with knee flexion, and determine its clinical impact. MATERIALS AND METHODS: A literature search was conducted in June 2021 using the databases MEDLINE, Cochrane, Web of Science (Clarivate Analytics), and Embase. The search term ((radiograph OR X-ray) AND (position OR rotation) AND limb alignment) was used. Database query, record screening, and study inclusion and exclusion were performed by two reviewers independently. Experimental studies (using either specimens or synthetic bones) or clinical studies (prospective or retrospective using radiographs of patients) analyzing the influence of limb rotation on anatomic and mechanical limb alignment measurements were included. Characteristics and results of the included studies were summarized, simplified, and grouped for comparison to answer the research question. Studies were compared descriptively, and no meta-analysis was performed. RESULTS: A total of 22 studies were included showing large heterogeneity, comprising studies with cadavers, patients, and synthetic bones. Most studies (7 out of 8) reported that external rotation (ER) causes less apparent valgus and leads to more varus and internal rotation (IR) causes more valgus and leads to less varus. However, there is no consensus on the extent of rotation influencing alignment measures. Studies reported about an average change of > 2° (n = 4) and < 2° (n = 4) hip-knee-ankle angle (HKA) between 15°IR and 15°ER. There is a consensus that the impact of rotation on mechanical alignment is higher if additional sagittal knee angulation, such as knee flexion, is present. All five studies analyzing the influence of rotation combined with knee flexion (5°-15°) showed an HKA change of > 2° between 15°IR and 15°ER. CONCLUSION: Malrotation is frequently present on LLR, possibly influencing the measured alignment especially in knees with extension deficit. Surgeons must consider this when measuring and treating deformities (high tibial osteotomy or total knee arthroplasties), and analyzing surgical outcomes. Especially in patients with osteoarthritis with knee extension deficits or postoperative swelling, the effect of malrotation is significantly greater.

Evaluation of the Constant score: which is the method to assess the objective strength?

BACKGROUND: The Constant score (CS) is one of the most frequently applied tools for the assessment of the shoulder joint. However, evaluation of strength is not standardized leading to potential bias when comparing different studies. METHODS: Seventy-six patients with fractures of the proximal humerus undergoing open reduction and internal fixation (ORIF) were assessed using standardized CS strength measurements at the deltoid muscle insertion and at the wrist in three different arm positions. Variation coefficients were evaluated for each patient and position. RESULTS: Forty women (57%) and 36 men (43%) were examined 96 months in mean after ORIF. We could state a maximum of 105.3 N difference if measurements were performed at the wrist or the insertion of the deltoid muscle in 90° forward flexion on the injured arm (167.9 ± 83.1 N; 62.6 ± 29.4 N). The lowest variation coefficient of the three performed measurements could be stated at the deltoid muscle insertion in a 90° abduction position in the scapula plane (6.94 ± 5.5). CONCLUSION: Following our study results, different positions of force measurement can change the total CS by a whole category (e.g. "very good" to "good"). We recommend performing the measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane. Otherwise, even in the non-injured, it is hard to reach a "normal" shoulder function, based on the CS. When using the CS as outcome parameter, authors must give detailed information about the force measuring and use an exact measuring device.

Periprosthetic tibial fractures in total knee arthroplasty - an outcome analysis of a challenging and underreported surgical issue.

BACKGROUND: Periprosthetic fractures after total knee arthroplasty (TKA) are an increasing problem and challenging to treat. The tibial side is commonly less affected than the femoral side wherefore few studies and case reports are available. The aim of this study was to analyze the outcome of periprosthetic tibial fractures and compare our data with current literature. METHODS: All periprosthetic tibial TKA fractures that were treated at our Level 1 Trauma Center between 2011 and 2015 were included and analyzed consecutively. The Felix classification was used to assess the fracture type and evaluation included the radiological and clinical outcome (Knee Society Score/KSS, Oxford Knee Score/OKS). RESULTS: From a total of 50 periprosthetic TKA fractures, 9 cases (7 female, 2 male; 2 cruciate retaining, 7 constrained TKAs) involving the tibial side were identified. The mean age in this group was 77 (65-85) years with a follow-up rate of 67% after a mean of 22 (0-36) months. The Felix classification showed type IB (n = 1), type IIB (n = 2), type IIIA (n = 4) and type IIIB (n = 2) and surgical intervention included ORIF (n = 6), revision arthroplasty (n = 1), arthrodesis (n = 1) and amputation (n = 1). The rate of adverse events and revision was 55.6% including impaired wound healing, infection and re-fracture respectively peri-implant fracture. Main revision surgery included soft tissue surgery, arthrodesis, amputation and re-osteosynthesis. The clinical outcome showed a mean OKS of 29 (19-39) points and a functional/knee KSS of 53 (40-70)/41 (17-72) points. Radiological analyses showed 4 cases of malalignment after reduction and plate fixation. CONCLUSIONS: Periprosthetic tibial fractures predominantly affect elderly patients with a reduced bone quality and reveal a high complication rate. Careful operative planning with individual solutions respecting the individual patient condition is crucial. If ORIF with a plate is considered, restoration of the correct alignment and careful soft tissue management including minimal invasive procedures seem important factors for the postoperative outcome.

Interview based malnutrition assessment can predict adverse events within 6 months after primary and revision arthroplasty - a prospective observational study of 351 patients.

BACKGROUND: Being at risk for malnutrition can be observed among hospitalized patients of all medical specialties. There are only few studies in arthroplasty dealing with defining and assessing malnutrition as such a potentially risk. This study aims to identify the risk for malnutrition following primary (pAP) and revision arthroplasty (rAP) (1) using non-invasive interview based assessment tools and to analyze effects on clinical outcome (2) and quality of life (3). METHODS: A consecutive series of hospitalized patients of a Department of Arthroplasty at a Level 1 Trauma Center in Western Europe was observed between June 2014 and June 2016. Patients were monitored for being at risk for malnutrition at hospital admission (T1) and 6 months post surgery (T2) by non-invasive interview based assessment tools (NRS 2002, SF-MNA, MNA). Adverse events, length of hospital stay and quality of life (HRQL, SF-36) were monitored. RESULTS: 351 (283 pAP/ 68 rAP) patients were included. At T1, 13.4% (47) / 23.9% (84) / 27.4% (96) and at T2 7.3% (18) / 17.1% (42) / 16.0% (39) of all patients were at risk for malnutrition regarding NRS/SF-MNA/MNA. Prevalence of malnutrition risk was higher in rAP (22.1-29.4%) compared to pAP (11.3-26.9%). Patients being at risk for malnutrition showed prolonged hospitalization (NRS 14.5 to 12.5, SF-MNA 13.7 to 12.4, MNA 13.9 to 12.3 days, p < 0.05), delayed mobilization (NRS 2.1 to 1.7, SF-MNA 1.8 to 1.7, MNA 1.9 to 1.7 days), lower values in HRQL and more adverse events. CONCLUSIONS: There is a moderate to high prevalence of risk for malnutrition in arthroplasty that can easily be assessed through interview based screening tools. Being at risk for malnutrition can reduce the clinical outcome following pAP and rAP. Patients with an impaired nutritional status show reduced values in physical and mental aspects of HRQL. Non-invasive interview-based nutritional assessment can predict adverse events in primary and revision total arthroplasty and can therefore help identifying patients at risk before surgery. TRIAL REGISTRATION: The study protocol was approved by the local ethics committee (193/2014BO2) and registered at the German Clinical Trials Register according to WHO standard ( DKRS00006192 ).

Health-related quality of life after open-wedge high tibial osteotomy.

PURPOSE: (1) To monitor longitudinal changes in health-related quality of life (HRQOL), pain, knee function, and return to work (RtW) following high tibial osteotomy (HTO) for medial compartment osteoarthritis (OA), and (2) to investigate the influences of psychopathological comorbidities on preoperative impairment and post-operative course. METHODS: Sixty-four patients were prospectively followed for 24 months after HTO to determine HRQOL, pain, functional outcome, and RtW. Psychopathological comorbidities (e.g. depression) were determined preoperatively. Patients with no psychological distress (ND) were compared to patients with psychological distress (PD) in order to investigate the influence of psychopathological comorbidities on outcome. RESULTS: There was a significant increase in HRQOL and decrease in pain from 6 month follow-up on. Functional outcomes increased significantly from 12 month follow-up on. In general, there was a steady state of outcomes from 6- to 12-month follow-up on. At final follow-up, 90 % returned to their previous occupation without limitations. Mental component summary (MCS) and functional outcome showed a positive correlation with RtW, while depression had a negative one. A significantly inferior outcome of group PD versus ND was observed at baseline and early follow-up. RtW was significantly prolonged in group PD (8.9 ± 7.6 vs. 3.9 ± 3 months; p < 0.001). At final follow-up, both groups presented with comparable outcomes. CONCLUSION: HTO for medial compartment OA significantly improves HRQOL, pain, and knee function. Time to RtW is high and critically depends on PD. Further, extend of preoperative impairments, an initially inferior course, and inferior MCS outcome was influenced by PD. However, otherwise no significant differences were observed between groups PD and ND at final follow-up. LEVEL OF EVIDENCE: Prospective case series, II.

Factors circulating in the blood of type 2 diabetes mellitus patients affect osteoblast maturation - description of a novel in vitro model.

Type 2 diabetes mellitus (T2DM) is one of the most frequent metabolic disorders in industrialized countries. Among other complications, T2DM patients have an increased fracture risk and delayed fracture healing. We have demonstrated that supraphysiological glucose and insulin levels inhibit primary human osteoblasts׳ maturation. We aimed at developing a more physiologically relevant in vitro model to analyze T2DM-mediated osteoblast changes. Therefore, SCP-1-immortalized pre-osteoblasts were differentiated with T2DM or control (non-obese and obese) sera. Between both control groups, no significant changes were observed. Proliferation was significantly increased (1.69-fold), while AP activity and matrix mineralization was significantly reduced in the T2DM group. Expression levels of osteogenic marker genes and transcription factors were altered, e.g. down-regulation of RUNX2 and SP-7 or up-regulation of STAT1, in the T2DM group. Active TGF-ß levels were significantly increased (1.46-fold) in T2DM patients׳ sera. SCP-1 cells treated with these sera showed significantly increased TGF-ß signaling (2.47-fold). Signaling inhibition effectively restored osteoblast maturation in the T2DM group. Summarizing our data, SCP-1 cells differentiated in the presence of T2DM patients׳ serum exhibit reduced osteoblast function. Thus, this model has a high physiological impact, as it can identify circulating factors in T2DM patients׳ blood that may affect bone function, e.g. TGF-ß.

Health-related quality of life and clinical outcomes following medial open wedge high tibial osteotomy: a prospective study.

BACKGROUND: Open wedge high tibial osteotomy (HTO) is an established method for the treatment of patients with varus malalignment and medial compartment osteoarthritis. In these patients, health-related quality of life (HRQL) can be improved by using this procedure. The purpose of the present study consisted in evaluating HRQL up to 18 months after HTO, comparing the results to values of the German normal population, and in analyzing the impact of preoperative HRQL on the postoperative clinical result. It was hypothesized that normal values in physical and mental health can be achieved within 18 months after operation. STUDY DESIGN: Prospective case series. LEVEL OF EVIDENCE: IV. METHODS: 120 patients were included in this prospective case series from 12/2008 to 12/2011. All patients underwent open wedge HTO without a bone graft using the TomoFix(TM) plate. HRQL was assessed by using the SF-36 questionnaire, preoperatively, as well as 6, 12, and 18 months postoperatively. Regular scoring, norm-based scaling, and the physical and mental component summary scores (PCS and MCS) were evaluated. Clinical outcome was assessed by using Lequesne, Lysholm, HSS and IKDC Score. RESULTS: HRQL could be described in 96 patients. The PCS of HRQL showed a statistically significant pre- to postoperative improvement (30.2 ± 13.4 to 45.9 ± 13.5 after 18 months). A reduced preoperative mental component summary score (MCS) resulted in lower values of each clinical score (p < 0.05) and in a prolonged duration of incapacity for work (MCS < 50:15.0 ± 12.8 weeks, vs. MCS ≥ 50: 9.1 ± 4.8 weeks, p < 0.05). MCS values improved from the pre- to postoperative measurements and comparable values to the normal population were reached already within 6 months after surgery (46.0 ± 14.9 pre-operatively and 48.5 ± 13.7 after 6 months), and after 18 months even a score of 49.5 ± 12.4 was achieved. CONCLUSION: Lower preoperative mental component score results in reduced postoperative clinical outcome and prolonged duration of incapacity for work after HTO. In contrast to PCS, MCS showed comparable values to the normal population within 6 months after HTO.

Postoperative management following osteotomies around the knee: a narrative review.

The present narrative review provides a summary of postoperative therapy modalities and their effectiveness following osteotomies around the knee. The topics that are discussed in the scientific discourse include support of cartilage cell regeneration, pain management, drainage insertion, tourniquet use, pharmacological and mechanical thromboembolism prophylaxis, weight-bearing protocols and bone consolidation. There is evidence for the use of pharmacological thromboembolism prophylaxis and weight-bearing protocols. A standardized postoperative treatment concept following osteotomies around the knee cannot be derived due to lack of evidence for the other topics in current literature.

Digital planning of high tibial osteotomy. Interrater reliability by using two different software.

PURPOSE: The purpose of the study was to determine the interrater reliability as well as the correlation of mediCAD(®) and PreOPlan(®) in deformity analysis and digital planning of osteotomies. METHODS: Digital radiographs were obtained from 81 patients planned to undergo an open wedge high tibial osteotomy. The JPEG files of the radiographs were imported to landmark-based software. Deformity analysis and planning of correction were performed by 1 experienced and 2 unexperienced observers. Osteotomy planning was aimed at correction to the predefined mechanical tibiofemoral angle of 3° valgus leg alignment. The interrater reliability of measurements was assessed using intraclass correlation coefficients (ICCs) and the confidence interval. RESULTS: The ICC of PreOPlan(®) was from 0.841 (mechanical lateral distal femur angle) to 0.993 (wedge-angle) and from 0.896 (joint line convergence angle) to 0.995 (mechanical tibiofemoral angle) of mediCAD(®). The ICC of height of wedge-base was 0.979 with PreOPlan(®) and 0.969 with mediCAD(®). Comparing PreOPlan(®) and mediCAD(®), the ICC of the height of wedge-base of the observers was 0.966, 0.956 and 0.969, respectively. CONCLUSIONS: The results show a high interrater reliability of digital planning software. Experience of the observer had no influence on results. Furthermore, a high interrater reliability and correlation of digital planning specific parameters was found. Surgeons need to master limb geometry measurements and osteotomy planning on digital radiographs as digital planning reports are used for intercolleagual correspondence, teaching purposes and as medicolegal documents. The digital planning software tested agrees with the actual demands and could be recommended for deformity analysis and planning of osteotomies. LEVEL OF EVIDENCE: Diagnostic studies, Level I.

[MRI case series shows the development of medial gonarthrosis after medial meniscus tear and partial medial meniscectomy]. / Fallbericht zur Entstehung einer medialen Gonarthrose nach Innenmeniskusläsion und erfolgter Teilresektion.

Meniscal injuries lead to changes in pressure distribution in the knee joint. The risk of developing gonarthrosis increases by the amount of resected meniscal tissue. Based on 4 MRI examinations conducted over an 8­year time period, the present case report shows the progress of cartilage degeneration after a traumatic medial meniscus lesion and subsequent partial meniscus resection in a 46-year-old male patient. Congenital or accident-independent risk factors, such as a varus limb deformity must be considered during a medical report.

Clinical Outcome of Carbon Fiber Reinforced Polyetheretherketone Plates in Patients with Proximal Humeral Fracture: One-Year Follow-Up.

BACKGROUND: Proximal humerus fractures are seen frequently, particularly in older patients. The development of new osteosynthesis materials is being driven by the high complication rates following surgical treatment of proximal humerus fractures. Plate osteosyntheses made of steel, titanium and, for several years now, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) are used most frequently. METHODS: A prospective, randomized study was conducted in order to evaluate whether there are differences in the functional postoperative outcome when comparing CFR-PEEK and titanium implants for surgical treatment of proximal humerus fractures. The primary outcome of shoulder functionality 1 year after surgery was measured with the DASH score, the Oxford Shoulder Score, and the Simple Shoulder Test. RESULTS: Bony consolidation of the respective fracture was confirmed in all the patients included in the study within the scope of postoperative follow-up care. No significant differences in the DASH score, Oxford Shoulder Score, or Simple Shoulder Test were observed 1 year post-operatively when comparing the implant materials CFR-PEEK and titanium. CONCLUSIONS: There are no differences in terms of the functional outcome between CFR-PEEK plates and titanium implants 1 year after surgery. Studies on the long-term outcomes using CFR-PEEK plates in osteoporotic bone should be the subject of further research.

Weight-bearing Restrictions after Distal Femur Fractures - Review of Current Literature. / Belastungsvorgaben nach distaler Femurfraktur - eine aktuelle Literaturübersicht.

The incidence of distal femur fractures increases in the geriatric patient. The primary treatment goal in these fractures is early mobilisation to prevent secondary injuries associated with immobility. In light of the increasing spectrum of therapeutic options for postoperative fracture treatment, including double plating, nail-plate combination and distal femur replacement as postoperative treatments, weight-bearing recommendations are becoming increasingly important. The aim of this study was thus to analyse the weight-bearing recommendations and associated therapy results within the literature of the past 9 years and compare the recommendations to our own approach.

Increased Age, Cardiovascular Comorbidities, COPD, and Diabetes mellitus Determine Excess Mortality in Trauma Patients with SSI or Chronic Wounds. / Erhöhtes Alter, kardiovaskuläre Nebenerkrankungen, COPD und Diabetes mellitus bedingen eine Übersterblichkeit in der septischen Unfallchirurgie.

BACKGROUND: The constant aging of the German population leads, among other things, to an increase in the average age of hospitalised patients. In association with the reduced physiological reserve and the endogenous defence mechanism, this results in an increased susceptibility to infections and complications. Compared with that in trauma patients, the age distribution in patients with surgical site infections (SSI) has been poorly studied. Studies on the impact of age, diverse underlying diseases and influence of alcohol and nicotine consumption on the mortality risk in patients with SSI are limited. METHODS: In 2014/15 (Exam 1), 345 patients with SSI were included in this study. The 3-year follow-up examination was performed in 2017/18 (Exam 2). The questionnaires (Exams 1 and 2) assessed demographic parameters, comorbidities, medication use, alcohol and nicotine consumption, and different risk factors related to morbidity. The mortality risk in patients with SSI was calculated as a function of various risk factors (age, comorbidities, medication intake, and noxious agents). Furthermore, the development of the patients' age in the trauma department, especially of those with SSI, were evaluated between 2010 and 2019. RESULTS: In 2014/15 (Exam 1), 345 patients were included in the study. Of these, 274 (79.4%) were contacted by telephone in 2017/18. Thirty-six (10.4%) declined to be questioned again. Twenty (8.4%) of the 238 remaining participants had already died, resulting in 218 patients (63.2%) re-participating. From 2010 (n = 492) to 2019 (n = 885), the number of patients with SSI increased by 79.9%, especially those aged < 65 years. After the age of 60 years, the mortality risk increased rapidly (60 years: 0.0377 vs 70 years: 0.1395); the mortality risk of a 60-year-old patient with SSI was equal to that of an 80-year-old in the general population. Nicotine (p = 0.93) and alcohol consumption (p = 0.344) had no significant effect on mortality, whereas history of cardiac disease (p = 0.01), chronic obstructive pulmonary disease (COPD) (p = 0.01), diabetes mellitus (p = 0.05) and peripheral artery disease (p = 0.01) were associated with a significant increase in the mortality risk. CONCLUSION: Age, pre-existing cardiac conditions, as well as COPD, diabetes mellitus and peripheral artery disease are associated with a significantly increased mortality risk in patients with SSI. Thus, an exponential increase in mortality risk was found between the ages of 50 and 60 years, with the mortality risk of a 60-year-old patient with SSI being equivalent to that of an 80-year-old in the general population.

The modified 5-item frailty index determines the length of hospital stay and accompanies with mortality rate in patients with bone and implant-associated infections after trauma and orthopedic surgery.

BACKGROUND: Bone and implant-associated infections are severe complications after trauma and orthopedic surgery. The modified 5-item frailty index (mFI-5) is an easily applicable score to predict adverse outcome after surgery. The current literature regarding mFI-5 is focused on a period of 30-days postoperative. PURPOSE: This study aims to assess the impact of frailty in orthopedic trauma patients with bone and implant-associated infections. mFI-5 was calculated from a database, which prospectively collects data about factors potentially correlated with peri- and postoperative complications since 2014. METHODS: In a level I trauma center a total of 345 patients with surgical site infections were enrolled in this study. Hereof, patients with fracture-related infections after osteosynthesis, periprosthetic joint infections of the hip and knee and post-operative osteomyelitis were included. Extensive medical baseline examination was performed in 2013/14, a three-year follow-up was organized as a telephone interview. The mFI-5 score was calculated based on the 5 factor-principle as established by Subramaniam. The nutritional status was assessed using the Nutritional Risk Screening (NRS-2002). RESULTS: 130 patients were included, whereof seven had died, resulting in 123 patients. A grouping of our patients was performed in mFI-5 = 0 (n = 46; 36,4%), mFI-5 = 1 (n = 41; 33,3%) or mFI-5 ≥ 2 (n = 36; 29,3%). Sex distribution showed 69,1% male and 30,9% female patients. Frailty did neither impact on the re-admission (p = 0,433) nor the reoperation (p = 0,327) rate in our cohort. The mortality risk nearly doubled (1,7 times) in frail patients, but did not reach significance. In hospital stay was prolonged due to frailty (12,1 ± 11,8; p = 0,004) compared to those with a mFI-5 = 0 (5,9 ± 5,1) or mFI-5 = 1 (6,9 ± 5,9). Frailty goes along with a risk of malnutrition and increases with age. CONCLUSION: The modified 5-item frailty index is not a suitable screening tool for predicting revision rate, re-admission rate, and mortality in our orthopedic trauma patient population with bone and implant-associated infections. Nevertheless, frailty is associated with an increased risk of malnutrition and increases with age.

Long-term Outcomes after Medial Open Wedge High Tibial Osteotomy - A Retrospective Study of 69 Patients.

High tibial osteotomy (HTO) is a widespread option to avoid or delay total knee arthroplasty (TKA). The present study aimed to assess the long-term survival rate and postoperative subjective knee function after isolated medial open wedge HTO in patients with symptomatic medial compartment knee osteoarthritis (OA) and varus malalignment.Sixty-nine patients (48.8 ± 6.7, 35-66 years; preoperative mechanical tibiofemoral angle [mTFA] -5.3 ± 3.4; -14.9-0.0° varus) treated with medial open wedge HTO using a TomoFix plate were included in this retrospective study, with a follow-up of at least 10 years (11.8 ± 1.0 years). The survival rate after HTO was calculated after 5 and 10 years. Subjective knee function was assessed using Hospital for Special Surgery (HSS), Oxford knee, Lequesne, and Lysholm scores.Thirty-three patients underwent conversion to TKA, on average, 7.0 ± 3.4 (1.3-13.7) years after HTO. Five- and ten-year survival rates were 84.1 and 60.9%, respectively. Patients without conversion to TKA showed a Lysholm score of 64.5 (35-92), Lequesne score of 7 (1-13), HSS score of 71 (56-86), and Oxford knee score of 38.5 (25-44) at the last follow-up (more than 10 years). Significantly higher scores were registered at the last follow-up compared to the preoperative state regarding the Lysholm score (preoperative: 43.5 [12-95]; follow-up: 64.5 [35-92]; p < 0.001). The HSS score (preoperative: 69.5 [43-93]; follow-up: 71 [56-86]; p = 0.6941) showed no statistically significant change during the 10-year follow-up period. The Lequesne score was significantly lower than the preoperative score (preoperative: 11.5 [0.5-22]; follow-up: 7 [1-13]; p < 0.001), indicating a lower handicap.The majority of patients with a valgus medial compartmental knee OA treated with HTO with fixation using the TomoFix plate can expect no conversion to TKA for more than 10 years. Furthermore, patients without conversion to TKA after 10 years still had a significantly higher subjective knee function than preoperatively. Further research is needed to identify risk factors for conversion to TKA. This helps to guide surgeons in selecting patients who will benefit most from HTO.

Fractures of the Humeral Ulnar Condyle in Children - a Rare but Complicated Injury. / Die Condylus-ulnaris-humeri-Fraktur des Kindes ­ eine seltene, aber komplikationsträchtige Verletzung.

BACKGROUND: Ulnar humeral condyle fractures are rare paediatric elbow fractures, classified as Salter-Harris IV paediatric elbow injuries. Due to constant radiological changes in the elbow with varying manifestation of ossification centres as well as late ossification of the trochlea, diagnosis of these injuries is challenging. To avoid long-term complications, the treating surgeon should be familiar with the rare injury picture, diagnostics and adequate therapeutic measures. MATERIAL AND METHODS: The present retrospective study includes data on all paediatric cases from 2002 to 2019 with primary or secondary treatment at a paediatric traumatology centre for ulnar condyle fracture with a minimum follow-up of 12 months. Range of motion, joint stability under valgus and varus stress as well as axial ratios of the injured and uninjured side were evaluated in a clinical follow-up examination. The Mayo Elbow Performance Score was used to objectify functional results. RESULTS: 20 children, average age 8.6 years (4 - 13) and average follow-up time 25 months, were included. Radiological evaluation based on Jakob and Fowles classification revealed a type I fracture in three cases, a type II fracture in one case and a type III fracture in 16 cases. Three cases were treated nonoperatively with an upper arm cast. 17 children were treated with open reduction and internal fixation. Diagnosis of three fractures was delayed. No postoperative complications such as infections, nerve damage or nonunions. 15 children showed free elbow function. Three children showed slightly restricted elbow extension by less than 10° and two by 10°-20°. All children showed free pro/supination. 18 children showed a physiological and bilaterally identical arm axis compared to the uninjured side. Two children showed a slightly increased cubitus valgus with a 5 - 10° difference between sides. Radiologically, two children with delayed fracture treatment showed partial necrosis of the trochlea. The Mayo Elbow Score showed good (2) to excellent results in all children (18). CONCLUSION: Very good clinical and functional results can be expected if the injury is diagnosed without delay followed by adequate therapy. Misdiagnosis of ulnar condyle fractures can be associated with the development of nonunions and functional restrictions as well as, after operative therapy, trochlear necrosis. Children up to the age of 6 in particular are at risk of misdiagnosis due to faulty assessment of the cartilaginous trochlea.