[Surgery during the SARS-CoV-2 pandemic : Recommendations on operative procedures]. / Chirurgie in der SARS-CoV-2-Pandemie : Empfehlungen zum operativen Vorgehen.

BACKGROUND: In February 2020 Germany was also hit by the SARS-CoV­2 pandemic. Even patients infected by SARS-CoV­2 or COVID-19 may need operative procedures. Currently, no uniform recommendations exist on precautions to be taken when operating on these patients. Furthermore, they may differ from one hospital to another. METHODS: The task force COVID-19 of the emergency, intensive and severely injured section of the German Trauma Society (DGU e. V.) has developed consensus-based recommendations on surgical treatment of patients with SARS-CoV­2 infections. Great importance is placed on the implementation in hospitals at all levels of care. RESULTS: The indications for surgical interventions in patients with COVID-19 infections require an extremely critical evaluation. When indicated these surgical intervention should ideally be performed in a separate operating theater. All personnel involved should wear personal protective equipment with FFP2 masks, face shields and double gloves. The emergency team in the resuscitation bay should generally wear the same personal protective equipment. Special training is mandatory and the exposure of team members should be minimized. CONCLUSION: The recommendations are principally used for all kinds of surgery and comply with the currently available knowledge. Nevertheless, all recommendations represent a compromise between maximum safety of all medical staff and practicability in the routine hospital workflow.

Current management of open fractures: results from an online survey.

BACKGROUND: Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment. METHODS: Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing. RESULTS: Of 653 respondents, 364 (65 %) completed the first part and 314 (48 %) completed the second part of the online survey. 55 % answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25 % leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40 % make this decision depending on information provided by pre-hospitalisation emergency personnel. 84 % participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61 % of respondents. In Gustilo type II (74 %) and type III fractures (93 %), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22 % responding surgeons in Gustilo type I fractures, 53 % for type II fractures and 67 % for type III fractures. CONCLUSIONS: Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.

Retrospektive Analyse von56 Weichteildefekten nach einzeitiger Rekonstruktion unter Verwendung von Dermisersatzpräparaten.

HINTERGRUND: Der Verschluss von Wunden mit ausgeprägtem Weichteilschaden stellt eine chirurgische Herausforderung dar und erfordert häufig umfangreiche plastische Operationen sowie freie Lappenplastiken. Die Kombination von Dermisersatzpräparaten und Spalthauttransplantationen ist eine innovative Methode die zur Versorgung von komplexen Verletzungen der Extremitäten angewandt werden kann. Wir haben diese Technik in das Standard-Handwerkszeug bei komplexen Verletzungen der Extremitäten aufgenommen. Die klinischen Ergebnisse von 56 behandelten Patienten werden vorgestellt. PATIENTEN UND METHODEN: In 44 Fällen (78,6 %) wurde die beschriebene Methode an Defekten der unteren Extremitäten verwendet, einschließlich sieben Personen (12,5 %), die sich einer Stumpfdeckung nach Amputation unterzogen. Zwölf Defekte (21,4 %) befanden sich an den oberen Extremitäten. In zwei Fällen (3,6 %) wurde die Matriderm(®) -Matrix verwendet, um Nerven von unmittelbar angrenzenden chirurgischen Implantaten zu schützen. ERGEBNISSE: Bei 41 Patienten (73,2 %) kam es zur Einheilung des Transplantats ohne Komplikationen. Fünfzehn Patienten (26,8 %) zeigten eine gestörte Wundheilung nach Defektverschluss, die unter konservativer Therapie zur Ausheilung gebracht werden konnte. Ein Patient (1,8 %) zeigte ein Transplantatversagen, was eine Revisionsoperation erforderlich machte. Umfangreiche plastische Rekonstruktionen mussten bei keinem Patienten angewandt werden. SCHLUSSFOLGERUNGEN: Bei Fällen, in denen ausgedehnte plastische Operationen nicht möglich oder nicht erwünscht sind, ist die Verwendung von Dermisersatzpräparaten in Kombination mit Spalthauttransplantationen eine vielversprechende Alternative zum Wundverschluss bei ausgedehnten Weichteilschäden.

Retrospective analysis of 56 soft tissue defects treated with one-stage reconstruction using dermal skin substitutes.

BACKGROUND: The closure of wounds associated with soft tissue defects is surgically challenging, frequently requiring extensive plastic surgery and free flaps. The combination of dermal skin substitutes and split-thickness skin grafting is an innovative method used to cover such wounds. We incorporated this technique into the standard therapeutic armamentarium for complex injuries to the extremities. Clinical results of 56 patients thus treated are presented. PATIENTS AND METHODS: In 44 (78.6 %) cases, the method described was used for defects on the lower extremities, including seven (12.5 %) individuals undergoing amputation stump coverage. Twelve (21.4 %) defects were located on the upper extremities. In two (3.6 %) cases, Matriderm(®) matrix was used to protect nerves from adjacent surgical implants. RESULTS: In 41 (73.2 %) patients, the graft healed without any complication. Fifteen (26.8 %) patients displayed impaired wound healing following defect closure and were subsequently managed conservatively. One patient (1.8 %) showed graft failure, leading to revision surgery. None of the patients required extensive plastic surgery. CONCLUSIONS: In cases where plastic surgery is unavailable or undesirable, the use of dermal skin substitutes in combination with split-thickness skin grafting represents a promising alternative for covering wounds associated with soft tissue defects.

Influencing factors for delayed diagnosed injuries in multiple trauma patients - introducing the 'Risk for Delayed Diagnoses Score' (RIDD-Score).

PURPOSE: Delayed diagnosed injuries (DDI) in severely injured patients are an essential problem faced by emergency staff. Aim of the current study was to analyse incidence and type of DDI in a large trauma cohort. Furthermore, factors predicting DDI were investigated to create a score to identify patients at risk for DDI. METHODS: Multiply injured patients admitted between 2011 and 2020 and documented in the TraumaRegister DGU® were analysed. Primary admitted patients with severe injuries and/or intensive care who survived at least 24 h were included. The prevalence, type and severity of DDI were described. Through multivariate logistic regression analysis, risk factors for DDI were identified. Results were used to create a 'Risk for Delayed Diagnoses' (RIDD) score. RESULTS: Of 99,754 multiply injured patients, 9,175 (9.2%) had 13,226 injuries first diagnosed on ICU. Most common DDI were head injuries (35.8%), extremity injuries (33.3%) and thoracic injuries (19.7%). Patients with DDI had a higher ISS, were more frequently unconscious, in shock, required more blood transfusions, and stayed longer on ICU and in hospital. Multivariate analysis identified seven factors indicating a higher risk for DDI (OR from 1.2 to 1.9). The sum of these factors gives the RIDD score, which expresses the individual risk for a DDI ranging from 3.6% (0 points) to 24.8% (6 + points). CONCLUSION: DDI are present in a sounding number of trauma patients. The reported results highlight the importance of a highly suspicious and thorough physical examination in the trauma room. The introduced RIDD score might help to identify patients at high risk for DDI. A tertiary survey should be implemented to minimise delayed diagnosed or even missed injuries.

[Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18 months ]. / Versorgung von Kriegsverletzten aus der Ukraine in den Traumanetzwerken der DGU ­ Anspruch, Wirklichkeit und Motivation im Verlauf von 18 Monaten .

BACKGROUND: The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented a challenge for more than 15 months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a 2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. MATERIAL AND METHODS: An online survey of senior physicians of the trauma network hospitals was carried out with a semistructured written questionnaire in December 2022 and a follow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. RESULTS: Of the questionnaires 113 could be evaluated in December 2022 and 70 completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7 patients were treated in all participating hospitals up to December and up to September no more than 5 in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. CONCLUSION: The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in a long course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

[Plastering-A technique fallen into obscurity]. / Gipsen ­ eine in Vergessenheit geratene Technik.

Immobilization of fractures and dislocations is a basic technique in orthopedic trauma surgery care. The orthopedic surgeon should be familiar with the various materials, techniques and possible complications. Despite other techniques, the classical white plaster cast remains an integral part of orthopedic trauma surgery care. The application of such a cast must be learned as failure to observe the basic principles can result in harm to the patient. In many hospitals, the application of a plaster cast is delegated to the nursing staff according to the physician's instructions. As a result, many young medical colleagues lack the knowledge of how to apply a plaster cast. In addition to the treatment of fractures, immobilization after dislocation, inflammation and ligamentous injuries are some of the areas of application. In this article the application of a plaster cast is described based on a case study, from the indications to the execution and possible complications.

Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison.

Background: Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR). Methods: The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015-2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis. Results: Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well. Conclusion: Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma.

BACKGROUND: Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. METHODS: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. RESULTS: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%). INTERPRETATION: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®.

PURPOSE: In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay. METHODS: Data from the TraumaRegister DGU® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability. RESULTS: In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h. CONCLUSIONS: In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

Proper estimation of blood loss on scene of trauma: tool or tale?

BACKGROUND: Visually estimated amount of blood loss may influence decision making in the prehospital setting. The purpose of this study was to determine the ability and accuracy of paramedics and emergency physicians to visually estimate a volume of external blood loss and the influence of different vital signs. METHODS: In a prospective, blinded, observational design, participants were asked to visually estimate the amount of blood in six simulated trauma scenarios. Casualties were provided with a simulated injury, and a certain amount of artificial blood that was poured on the casualties' clothing and on the floor. In addition, vital signs (i.e., blood pressure and heart rate) were given. Each two moulage patients were provided with the same injury pattern and the same simulated blood loss. Although one patient seemed to be normovolemic, the other seemed to be hypovolemeic by the given vital signs. RESULTS: With regard to all given amounts of blood loss, providing vital parameters suggesting instability (i.e., low blood pressure, high heart rate) led to a higher estimation of the lost blood volume in both paramedics and emergency physicians. However, estimations were influenced impressively by the given parameters. For both stable and unstable patients, small actual volumes were overestimated, whereas higher volumes tended to be underestimated. Neither occupational status (emergency physician or paramedic) nor gender or level of experience influenced accuracy of estimated blood loss significantly.

Factors that influence the complications and outcomes of femoral neck fractures treated by cannulated screw fixation.

To investigate the influence of various factors on the two outcome parameters "procedure - specific complication" (femoral head necrosis, infection, nonunion, femoral neck shortening, screw loosening, implant penetration) and "functional outcome" in patients with displaced and undisplaced femoral neck fracture treated by cannulated screw fixation. All cases of a femoral neck fracture, operated by cannulated screw fixation, in the period from December 2014 to December 2017 were included. The observation period of the included patients was 12 months. Information on their outcome was collected after evaluation of current x-ray images and on request from the responsible further treatment physician. Continuous data were presented as mean value ± standard deviation, categorical data as absolute and relative frequency. The effect of potential factors on endpoints was estimated with a multivariable logistic regression analysis and 95% confidence intervals calculated. The null hypothesis Odds Ratio = 1 was checked by the Wald test. The likelihood ratio test was used to test for deviation from linearity. The mean age of the 56 included patients was 72 years (36 min, 96 max), 44.5% (n = 25) were male and 55.5% (n = 25) female. The femoral neck fractures were classified as follows: Garden I: 73%, Garden II: 16%, Garden III: 11%, Pauwels I: 73%, Pauwels II: 21%, Pauwels III: 5%, 31-B1: 73%, 31-B2: 27%, 31-B3: 0%. The factor patient age showed a statistically significant influence on the outcome parameter procedure-specific complication. None of the remaining factors examined showed a statistically significant influence on both outcome parameters procedure-specific complication and functional outcome. 69% of the patients from age 80 onwards suffered a procedure-specific complication. A rate of 41% procedure-specific complications as an outcome parameter in trauma surgery shows a necessity for improvement. The increasing risk of procedure-specific complications for patients with a femoral neck fracture treated by cannulated screw fixation is associated with rising patient age. A more stable head-perserving operative method or an endoprosthetic procedure should be considered in high-risk patients (≥80 y.o.).

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®.

AIM OF THE STUDY: Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated. METHODS: All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded. RESULTS: 99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries. CONCLUSION: Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

Humane killers, human injury: functional outcome of vole captive bolt injuries.

BACKGROUND: High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients. METHODS: We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed. RESULTS: The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks. CONCLUSION: Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury.

[Lethal intoxication while driving a car]. / Letale Intoxikation im fahrenden PKW.

This report concerns a passenger car crash, which at first looked like a case of multiple trauma resulting in the death of the pinned-in driver. Conspicuous was a cuff that had been applied to the left forearm. No significant injuries could be determined during the autopsy of the corpse. The forensic toxicology results showed lethal toxic concentrations of the painkiller pethidine, which suggests that the driver had applied a lethal dose of the medication immediately before the collision as part of a complex suicide.

Analysis of pressure distribution below the metatarsals with different insoles in combat boots of the German Army for prevention of march fractures.

AIM: The aim of the present study was the assessment of metatarsal head loading in combat boots of the German armed forces. With respect to the prevention of metatarsal stress fractures, we evaluated how cushioning insoles (made of EVA foam or neoprene) achieved a load reduction in comparison with conventional insoles. MATERIAL AND METHODS: Local pressure, force and impulse values were determined with the pedar-m expert in-shoe pressure measurement system applied in 26 volunteers during walking with four different insoles made of synthetic mesh, EVA foam and neoprene. Data analysis was performed with SAS and tested for statistical differences with non-parametric tests (with p<0.05 as a significance level). RESULTS: For the peak pressures under the metatarsal heads (MT) the following order was found: MT-II>MT-III>MT-I>MT-IV>MT-V. A comparison of the insoles indicated that the neoprene insole resulted in the lowest peak pressures with significant load reductions under MT-III to MT-V (p<0.00001). Furthermore, the impulse values under MT-II to MT-V were significantly lower with neoprene insoles (p<0.0002). However, the subjects rated the conventional insoles as more comfortable and better fitting than the newly developed insoles. DISCUSSION/CONCLUSION: The cushioning insoles were superior to the conventional insoles with respect to the plantar pressure distribution. With respect to the load reduction we can conclude that the modified insoles might be able to reduce the incidence of march fractures. The biomechanical advantage does not appear to be related to personal preferences.

Navigated total knee replacement. A meta-analysis.

BACKGROUND: Proponents of navigated knee arthroplasty stress its potential to increase the precision of component placement. We conducted a systematic review and meta-analysis to substantiate the validity and relevance of this contention. METHODS: We searched major medical and publishers' databases for randomized trials and any other studies comparing navigated with conventional knee arthroplasty. Major periodicals were searched manually. We made no restrictions for types of studies or language. Methodological features were rated independently by two reviewers. After testing for publication bias and heterogeneity was done, the data were aggregated by random-effects modeling. We estimated the weighted mean differences of mechanical limb axes and functional scales and the risk ratios of deviations from the straight axis with 95% confidence intervals. RESULTS: We included thirty-three studies (eleven randomized trials) of varying methodological quality involving 3423 patients with a mean age (and standard deviation) of 67.3 +/- 4.1 years (62.6% were women, and 83.7% had primary osteoarthritis). The mean preoperative deviation from the mechanical axis was 2.3 degrees +/- 5.1 degrees. There was no evidence of publication bias, but there was strong statistical heterogeneity. The alignment of the mechanical axes did not differ between the navigated and conventional surgery group (weighted mean difference, 0.2 degrees; 95% confidence interval, -0.2 degrees to 0.5 degrees). Patients managed with navigated surgery had a lower risk of malalignment at critical thresholds of >3 degrees (risk ratio, 0.79; 95% confidence interval, 0.71 to 0.87) and >2 degrees (risk ratio, 0.76; 95% confidence interval, 0.71 to 0.82). No conclusive inferences could be drawn on functional outcomes or complication rates. Navigation lengthened the mean duration of surgery by 23%. CONCLUSIONS: Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. Its clinical benefits are unclear and remain to be defined on a larger scale.

Resorbable screws versus pins for optimal transplant fixation (SPOT) in anterior cruciate ligament replacement with autologous hamstring grafts: rationale and design of a randomized, controlled, patient and investigator blinded trial [ISRCTN17384369].

BACKGROUND: Ruptures of the anterior cruciate ligament (ACL) are common injuries to the knee joint. Arthroscopic ACL replacement by autologous tendon grafts has established itself as a standard of care. Data from both experimental and observational studies suggest that surgical reconstruction does not fully restore knee stability. Persisting anterior laxity may lead to recurrent episodes of giving-way and cartilage damage. This might at least in part depend on the method of graft fixation in the bony tunnels. Whereas resorbable screws are easy to handle, pins may better preserve graft tension. The objective of this study is to determine whether pinning of ACL grafts reduces residual anterior laxity six months after surgery as compared to screw fixation. DESIGN/METHODS: SPOT is a randomised, controlled, patient and investigator blinded trial conducted at a single academic institution. Eligible patients are scheduled to arthroscopic ACL repair with triple-stranded hamstring grafts, conducted by a single, experienced surgeon. Intraoperatively, subjects willing to engage in this study will be randomised to transplant tethering with either resorbable screws or resorbable pins. No other changes apply to locally established treatment protocols. Patients and clinical investigators will remain blinded to the assigned fixation method until the six-month follow-up examination. The primary outcome is the side-to-side (repaired to healthy knee) difference in anterior translation as measured by the KT-1000 arthrometer at a defined load (89 N) six months after surgery. A sample size of 54 patients will yield a power of 80% to detect a difference of 1.0 mm +/- standard deviation 1.2 mm at a two-sided alpha of 5% with a t-test for independent samples. Secondary outcomes (generic and disease-specific measures of quality of life, magnetic resonance imaging morphology of transplants and devices) will be handled in an exploratory fashion. CONCLUSION: SPOT aims at showing a reduction in anterior knee laxity after fixing ACL grafts by pins compared to screws.