Clinical and radiological outcome of acute quadriceps tendon repair at 2 - year follow-up.

PURPOSE: Though previous studies on surgical quadriceps tendon repair reported good to satisfactory results its impact on knee extensor strength and patellofemoral joint is unknown. The purpose of the study was to assess the clinical and functional outcome by quantifying subjective knee related outcome, isokinetic extensor strength complemented by magnetic resonance imaging (MRI). METHODS: For this retrospective clinical trial twenty-one patients with a mean age of 59.1 (±14.9) years were carried out for follow-up evaluation. For clinical outcome numeric rating scale for pain (NRS), Kujala anterior knee pain score, Knee osteoarthritis outcome score (KOOS) with its subscores, Tegener Activity Score (TAS), Isokinetic extensor strength testing (ISO) and the Limb symmetry index (LSI) were utilized. Muscle volume (Vmqf), atrophy and cartilage status were assessed on MRI. Tendon integrity and implant loosening were evaluated. Statistical analysis was carried out using Student´s t-test, Pearson and Spearman correlation coefficient. RESULTS: Mean follow-up was 56.2 (± 17.5) months. Clinical outcomes in mean were as follows: NRS 1.7 (±2.0), Kujala score 75.8 (± 15.8) points; KOOS 62.9 (±30.6) % (Subscores: (KOOSPain 84 (± 18.3)%, KOOSSymptoms 63.4 (± 15.3) %, KOOSADL 79.8% (± 19.4)%, KOOSSports&Rec 61.5 (± 28.8))%, TAS 3.7 (± 1.2). Mean ISO difference was 3.7 (±32.3) %). 41.2% of patients had an LSI < 90% and showed non-significantly (p > 0.05) better outcomes in NRS, Kujala score and KOOS than patients with LSI < 90%. ISO correlated with better subjective outcome (r > 0.5) but not with MRI findings. Vmqf asymmetry > 10% was seen in 41,2% of patients. Degenerative muscle and cartilage changes were few and low grade. One tendon showed partial retear. Patients showed no signs of implant loosening. CONCLUSION: Distal quadriceps tendon repair leads to satisfactory subjective outcome in patients with low to moderate activity levels. Tendon integrity was reliably restored. However, extensor strength deficits remain in more than 40% of patients. Atrophy signs of advanced fatty infiltration were recorded in 15% and patellofemoral cartilage defects in 20% of all patients, indicating that previous assessment tools do not display functional outcome adequately.

Percutaneous elevation of radial head fractures without fixation - a promising technique.

The aim of the study is to describe the surgical technique and to report the outcomes of triceps reflecting anconeus pedicle (TRAP) approach for intercondylar fractures of the humerus. Twenty two patients with intercondylar fractures of the humerus were operated on by open reduction via the TRAP approach and internal fixation with dual precontoured locking plates. Data were collected on union time, postoperative complications, range of motion (ROM), triceps power, and objective clinical measurement. All fractures were united with a mean union time of 16.5 weeks (range 12-22). All patients had good-to-excellent Mayo Elbow Performance (MEP) score results with a mean ROM of 118.2 degrees (range 90-135). Triceps power was grade 5 in 16 patients and grade 4 in 6. There were 3 transient ulnar nerve palsy and 1 heterotopic ossification. TRAP approach is safe and effective in terms of utility for articular reduction, restoration of elbow motion, and triceps function for intercondylar fractures of the humerus.

Therapeutic anticoagulation complications in the elderly: a case report.

BACKGROUND: The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed. CASE PRESENTATION: We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient's renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home. DISCUSSION AND CONCLUSIONS: Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications.

Rotation osteotomy of the distal femur influences coronal femoral alignment and the ischiofemoral space.

INTRODUCTION: Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the remaining planes and adjacent joints are still to be defined. It was, therefore, the aim of this study to determine the influence of a distal femoral rotation osteotomy on the coronal limb alignment and on the ischiofemoral space of the hip joint. MATERIALS AND METHODS: Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar rotational osteotomies of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip-knee-ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), and the ischiofemoral space were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test. RESULTS: Twenty-seven patients underwent isolated supracondylar external rotation osteotomy to reduce the overall antetorsion of the femur. The osteotomy resulted in a 2.4° ± 1.4° mean increase in HKA and 2.4 mm ± 1.7 mm increase in the ischiofemoral space (p < 0.001). CONCLUSION: Supracondylar external rotation osteotomy of the femur leads to valgisation of the coronal limb alignment and increases the ischiofemoral space. This is resultant to the reorientation of the femoral antecurvature and the femoral neck. When planning a rotational osteotomy of the lower limb, this should be appreciated and may also aid in the decision regarding osteotomy site.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System.

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Osteotomies around the knee lead to corresponding frontal realignment of the ankle.

INTRODUCTION: Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation. MATERIALS AND METHODS: Long-leg standing radiographs of 154 consecutive patients undergoing valgisation or varisation osteotomy around the knee in 2017 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip knee ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), the mechanical medial proximal tibia angle (mMPTA) and five angles around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test. RESULTS: One hundred fifty-four patients (96 males, 58 females) underwent osteotomies around the knee for coronal realignment. The mean age was 51 ± 11 years. Correction osteotomies consisted of 73 HTO, 54 DFOs, and 27 double level osteotomies. Of all osteotomies, 118 were for valgisation and 36 for varisation. For valgisation osteotomies, the mean HKA changed from 5.8° ± 2.9° preoperatively to - 0.9° ± 2.5° postoperatively, whereas the mMPTA changed from 85.9° ± 2.7° to 90.7° ± 3.1° and the malleolar-horizontal-orientation-angle (MHA) changed from 16.4° ± 4.2° to 10.9° ± 4.2°. For varisation osteotomies, the mean HKA changed from - 4.3° ± 3.7° to 1.1° ± 2.2° postoperatively, whereas the mLDFA changed from 85.7° ± 2.2° to 89.3° ± 2.3° and the MHA changed from 8.8° ± 5.1° to 11.2° ± 3.2°. CONCLUSION: Osteotomies around the knee for correction of coronal limb alignment not only lead to lateralization or medialization of the weight-bearing line at the knee but also lead to a coronal reorientation of the ankle. This can be measured at the ankle using the MHA. When planning an osteotomy around the knee for correction of genu varum or valgum, the ankle should also be appreciated-especially in patients with preexisting deformities, ligament instabilities, or joint degeneration around the ankle.

The ischiofemoral space of the hip is influenced by the frontal knee alignment.

PURPOSE: The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD. METHODS: A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD. RESULTS: Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (ß-0.4, confidence-interval - 0.5 to - 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment. CONCLUSION: These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints. LEVEL OF EVIDENCE: IV.

Influence of reduction accuracy in lateral tibial plateau fractures on intra-articular friction - a biomechanical study.

BACKGROUND: Lateral tibial split fractures (LTSF) usually require surgical therapy with screw or plate osteosynthesis. Excellent anatomical reduction of the fracture is thereby essential to avoid post-traumatic osteoarthritis. In clinical practice, a gap and step of 2 mm have been propagated as maximum tolerable limit. To date, biomechanical studies regarding tibial fractures have been limited to pressure measurement, but the relationship between dissipated energy (DE) as a friction parameter and reduction accuracy in LTSF has not been investigated. In past experiments, we developed a new method to measure DE in ovine knee joints. To determine weather non-anatomical fracture reduction with lateral gap or vertical step condition leads to relevant changes in DE in the human knee joint, we tested the applicability of the new method on human LTSFs and investigated whether the current limit of 2 mm gap and step is durable from a biomechanical point of view. METHODS: Seven right human, native knee joint specimens were cyclically moved under 400 N axial load using a robotic system. During the cyclic motion, the flexion angle and the respective torque were recorded and the DE was calculated. First, DE was measured after an anterolateral approach had been performed (condition "native"). Then a LTSF was set with a chisel, reduced anatomically, fixed with two set screws and DE was measured ("even"). DE of further reductions was then measured with gaps of 1 mm and 2 mm, and a 2 mm step down or a 2 mm step up was measured. RESULTS: We successfully established a measurement protocol for DE in human knee joints with LTSF. While gaps led to small though statistically significant increase (1 mm gap:ΔDE compared with native = 0.030 J/cycle, (+ 21%), p = 0.02; 2 mm gap:ΔDE = 0.032 J/cycle, (+ 22%), p = 0.009), this increase almost doubled when reducing in a step-down condition (ΔDE = 0.058 J/cycle, (+ 56%), p = 0.042) and even tripled in the step-up condition (ΔDE = 0.097 J/cycle, (+ 94%), p = 0.004). CONCLUSIONS: Based on our biomechanical findings, we suggest avoiding step conditions in the daily work in the operating theatre. Gap conditions can be handled a bit more generously.

Total hip arthroplasty following acetabular fracture: a clinical and radiographic outcome analysis of 67 patients.

BACKGROUND: Total hip arthroplasty (THA) is a challenging option for the treatment of posttraumatic arthritis due to acetabular fractures. METHODS: The study aimed to determine the short- and mid-term clinical and radiographic results of THA following acetabular fracture. The fracture pattern, the extent of injury and the initial fracture treatment were considered to evaluate the influence of these factors on the clinical-radiographic outcome. RESULTS: 67 patients who received THA for the treatment of posttraumatic osteoarthritis after acetabular fracture between January 2007 and December 2012 were analyzed consecutively. The group consisted of 13 female (19%) and 54 male (81%) patients with a mean age of 59 (25-87) years at the time of THA. The time between acetabular injury and arthroplasty was 107 (1-504) months on average. The all-cause 8-year survival rate was 0.87% (0.76-0.93) and there were 8 revisions, half of them were due to aseptic loosening of the cup. The Harris Hip Score achieved was 75.7 ± 21.3 (26.9-100) points. Prior to THA, heterotopic ossifications were detected in 28% and after THA implantation in 42%. CONCLUSION: The decrease of the interval between injury and arthroplasty was associated with increasing patient age (p = 0.001) and surgical treatment of the acetabular fracture (p = 0.04). Complex fracture patterns were accompanied by acetabular bone defects more often than simple patterns (p = 0.03). Overall, arthroplasty due to posttraumatic osteoarthritis after acetabular fracture resulted in decreased overall survival rates and poorer clinical outcome as compared to primary arthroplasty.

[Custom-made glenoid component via 3D print : A rescue prosthetic option for patients with massive glenoid destruction and simultaneous cuff-arthropathy]. / Custom-made-Glenoidkomponente via 3D-Print : Spezielle Prothesenversorgung als finale Behandlungsoption bei massivem Glenoidaufbrauch und gleichzeitiger Rotatorenmanschetten-Defektarthropathie.

The combination of glenoid destruction with cuff arthropathy remains a challenge. A 75-year old woman presented with a post-traumatic loss of the glenoid and concomitant cuff arthropathy. Using CT-data a custom-made glenoid component was created by 3D printing. 6 months after reverse shoulder arthroplasty, the patient was free of pain with acceptable ROM. An individual glenoid component created by 3D printing is a feasible therapeutic option in patients with loss of the glenoid and concomitant cuff arthropathy.

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.

Dynamic intraligamentary stabilization for ACL repair: a systematic review.

PURPOSE: It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports. METHODS: Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed. RESULTS: Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and  patient age have been found to influence the risk of failure. CONCLUSION: There is sufficient evidence to support that DIS repair may be an effective modality for the treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors. LEVEL OF EVIDENCE: IV.

The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping.

PURPOSE: Most biomechanical investigations of tendon repairs were based on output measures from hydraulic loading machines, therefore, accounting for construct failure rather than true gapping within the rupture zone. It was hypothesized that the elastic capacity of a tendon-repair construct influences the force necessary to induce gapping. METHODS: A tendon-repair model was created in 48 porcine lower hind limbs, which were allocated to three fixation techniques: (1) Krackow, (2) transosseous and (3) anchor fixation. Loading was performed based on a standardized phased load-to-failure protocol using a servohydraulic mechanical testing system MTS (Zwick Roell, Ulm, Germany). Rupture-zone dehiscence was measured with an external motion capture device. Factors influencing dehiscence formation was determined using a linear regression model and adjustment performed as necessary. A 3-mm gap was considered clinically relevant. Analysis of variance (ANOVA) was used for comparison between groups. RESULTS: The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping of 3 mm (F3mm) [ß = 0.6, confidence interval (CI) 0.4-1.0, p < 0.001]. Furthermore, the three methods of fixation did not differ significantly in terms of maximum force to failure (n.s) or F3mm (n.s). CONCLUSION: The main finding of this study demonstrated that the higher the elastic capacity of a tendon-repair construct, the higher the force necessary to induce clinically relevant gapping. LEVEL OF EVIDENCE: Controlled biomechanical study.

Improved results of ACL primary repair in one-part tears with intact synovial coverage.

PURPOSE: It was the aim to assess the influence of synovial sheath disruption on early failure of primary anterior cruciate ligament (ACL) repair. It was hypothesized that more-part ACL tears with disruption of the synovial sheath are associated with a higher risk of failure after primary ACL repair. METHODS: A cohort study was conducted comprising patients with primal ACL tears undergoing primary ACL repair and dynamic intraligamentary stabilization (DIS). The patients were stratified into three groups: A-one-part rupture with intact synovial membrane (n = 50), B-two-part ruptures resultant to separation of the ACL into two main bundles with synovial membrane tearing (n = 52) and C-more parts involving multilacerated ruptures with membrane disruption (n = 22). Failure was defined as a retear or residual laxity (anterior posterior translation > 5 mm compared to healthy knee). Adjustment for potential risk factors was performed using a multivariate logistic-regression model. RESULTS: The overall failure rate was 17.7% throughout the mean follow-up period of 2.3 ± 0.8 years. The failure rate in patients with one-part ACL tears with an intact synovial membrane was 4% (n = 2) (Group A), which was significantly lower than the failure rates in groups B and C, 26.9% (n = 14) (p = 0.001) and 27.3% (n = 6) (p = 0.003), respectively. Disruption of the synovial sheath in two- or more-part tears was identified as an independent factor influencing treatment failure in primary ACL repair (OR 8.9; 95% CI 2.0-40.0). CONCLUSION: The integrity of the ACL bundles and synovial sheath is a factor that influences the success of ACL repair. This needs to be considered intra-operatively when deciding about repair. LEVEL OF EVIDENCE: IV.

[Black knee-ochronotic alterations in alkaptonuria]. / Das schwarze Knie ­ ochronotische Veränderungen im Rahmen einer Alkaptonurie.

This article presents the case of a 53-year-old male patient born in Sri Lanka, who presented to the outpatient unit with the suspicion of empyema of the knee joint. Within the framework of knee arthroscopy, the diagnosis of ochronosis was made and later confirmed by histopathological biopsy. The alkaptonuria is caused by a homogentisate 1,2-dioxygenase deficiency and leads to an accumulation of homogentisic acid, a degradation product of tyrosine. This leads to the characteristic appearance of ochronosis with bluish-black deposits in the tissue (e.g. in connective tissue, sclera and ear cartilage) and a black coloration of the urine.

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 ).

Duration of incapacity of work after tibial plateau fracture is affected by work intensity.

BACKGROUND: Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Tibial plateau fractures have an impact not only on physically demanding jobs but notably on general professional life too. The aim of this study was to assess how the professional activity of patients will be affected after a tibial plateau fracture. METHODS: 39 consecutive patients (ages 20-61 years) were retrospectively included in the study and were clinically examined at a minimum of 14 month postoperatively. Inclusion criteria were surgical treatment of tibial plateau fractures between November 2009 and December 2012. The clinical evaluation included the Lysholm score and the Oxford Knee Score. Fractures were classified and analyzed using the AO classification. Intensity of work was classified as established by the REFA Association. The patients themselves provided postoperative duration of the incapacity of work and subjective ratings. RESULTS: 17 (43.6%) women and 22 (56.4%) men were examined with a mean follow-up of 29.7 ± 10.4 months (range 14-47). According to the AO classification there were 20 (51.3%) B-type-fractures and 19 (48.7%) C-type-fractures. The median incapacity of work was 120 days (range 10-700 days) with no significant differences between B- and C-type-fractures. Four (10.3%) patients reduced their working hours by 10.5 h per week on average. Patients with low workload (REFA 0-1, median incapacity of work 90 days, range 10-390 days) had a significant shorter incapacity of work than patients with heavy workload (REFA 2-4, median incapacity of work 180 days, range 90-700 days) (p < 0.05). The median Lysholm score decreased significantly from 100 points (range 69-100) before the injury to 73 points (range 23-100) at the time of the follow-up. All patients received postoperative physiotherapy (median 25 appointments, range 6-330), with a significant higher number of appointments for C-type-fractures than for B-type-fractures (p = 0.004). CONCLUSION: A relationship was found between workload and the duration of incapacity of work after tibial plateau fractures. The post-injury shift to less demanding jobs and the reduction of working hours highlight the impact of a tibial plateau fracture on a patient's subsequent physical ability to work.

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.

Recovery of ACL function after dynamic intraligamentary stabilization is resultant to restoration of ACL integrity and scar tissue formation.

PURPOSE: Dynamic intraligamentary stabilization (DIS) is recognized as a ligament preserving technique for the treatment of acute anterior cruciate ligament (ACL) injuries. The aim of this study was to assess the integrity and morphology of the recovered ACL after DIS repair. METHODS: The cohort comprised 47 patients with an acute proximal ACL rupture undergoing DIS repair. All patients underwent diagnostic arthroscopy after a minimum postoperative interval of 6 months for semi-quantitative evaluation of ACL integrity, function and scar tissue formation. Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores as well as objective anteroposterior (ap) translation were assessed at 6 weeks, 3-, 6-  and 12 months postoperatively. RESULTS: Full restoration of the ACL volume was affirmed in 30 (63.8%) patients and two-third restoration in 13 (27.7%). Hypertrophic scar formation was observed in 23 (48.9%) patients. Forty-four patients (93.6%) demonstrated sufficient ACL tensioning intraoperatively upon anterior stress. At final follow-up, the median Tegner activity level was 5.5 (3-10), Lysholm and IKDC scores were 100 (64-100) and 94 (55-100) points, respectively. The mean ap-translation differed from the normal knee by 2.1 ± 2.2 mm. Deficient ACL recovery was noted in four patients (8.5%), none of which required secondary reconstructive surgery. CONCLUSION: The results demonstrate that clinical recovery of ACL function after DIS repair is resultant to both restoration of ACL volume and scar tissue formation. Factors influencing the degree of scar tissue formation need further investigation to enable future attempts of guiding a balanced biological healing response. LEVEL OF EVIDENCE: IV.

A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test.

PURPOSE: (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS: An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS: Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION: The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE: III.