Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles.

BACKGROUND: In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time. PATIENTS AND MATERIALS: A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed. RESULTS: A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008. CONCLUSION: Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

Use of Pre- and Intensified Postprocedural Physiotherapy in Patients with Symptomatic Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement Study (the 4P-TAVR Study).

BACKGROUND: Physiotherapy prior to open-heart surgery lowers the rate of pneumonia and length of the hospital stay. Pneumonia is a major contributor to short-term mortality following transcatheter aortic valve replacement (TAVR). Hence, we hypothesized that pre- and intensified postprocedural physiotherapy in patients undergoing TAVR might impact the net functional and clinical outcome. METHODS AND RESULTS: The 4P-TAVR study was a prospective, monocentric, randomized trial. The study was designed to compare the efficacy and safety of intensified periprocedural physiotherapy including inspiratory muscle training versus standard postprocedural physiotherapy. Patients were randomized in a 1 : 1 fashion. 108 patients were included and followed up for 90 days after TAVR. While patients in group A (control group: 50 patients, age: 81.7 ± 5.0 years, 52% male) did not receive physiotherapy prior to TAVR, group B (intervention group: 58 patients, age: 82.2 ± 5.82 years, 47% male) participated in intensive physiotherapy. Compared to the control group, patients in the interventional group showed a lower incidence of postinterventional pneumonia (10 [20.0%] vs. 3 [5.1%], p=0.016) and had a 3-day shorter mean hospital stay (13.5 ± 6.1 days vs. 10.1 ± 4.7 days, p=0.02). The primary composite endpoint of mortality and rehospitalization was not different between the groups. CONCLUSION: Intensified physiotherapy is safe and has positive effects on clinical outcomes up to 90 days after TAVR but has no impact on the primary combined endpoint of mortality and rehospitalization. Longer follow-up, a multicenter design, and a higher number of subjects are needed to confirm these preliminary results. This trial is registered with DRKS00017239.

A survey on surgeon practice shows lack of consensus on the management of primary shoulder stiffness.

Shoulder stiffness is a condition of painful restriction in active and passive glenohumeral range of motion, which can arise spontaneously or as consequence of a known cause. Numerous therapeutic approaches are available; however, no consensus has been reached on the best algorithm for successful treatment. The aim of this study was to investigate local practice patterns regarding management of primary shoulder stiffness. Randomized controlled trials reporting results of shoulder stiffness treatment were collected and analyzed prior to study begin. Controversial elements in the treatment of primary shoulder stiffness were identified and a survey was created and administrated to clinicians participating at an annual national congress dedicated to shoulder pathologies and their treatment. 55 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 58% and injections of corticosteroids by 60%. Injective therapy with local anaesthetics was considered by 56% of the clinicians and acupuncture by 36%. 38% of the interviewed did never treat shoulder stiffness surgically. Various strategies to manage shoulder stiffness have been proposed and high-level evidence has been published. Numerous controversial points and a substantial lack of consensus emerged both from literature reviews and from this survey. The treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology, aiming primarily at identifying risk factors for recurrence, reducing pain, restoring range of motion and function and shortening the duration of symptoms.

[Challenges of discharge management in geriatric traumatology : Example of an integrated orthogeriatric service]. / Herausforderungen des Entlassmanagements in der Alterstraumatologie : Beispiel einer integrierten traumatologisch-geriatrischen Komplexbehandlung.

BACKGROUND: Geriatric patients are currently responsible for almost one third of all emergency hospital admissions. An increase of 50% is expected in the next decade. This age redistribution poses new challenges for inpatient care and discharge management. The requirements of an orthopedic trauma surgery clinic in the care of this patient group can be clarified with the help of this first collaboratively created geriatric orthopedic trauma surgery complex treatment unit of a university hospital. OBJECTIVE: What influence do age and delirium have on discharge management, length of inpatient stay and discharge destination in a geriatric cohort? MATERIAL AND METHODS: All patients who received inpatient treatment as part of the orthopedic trauma surgery geriatric complex treatment (GKB) between May 2017 and December 2019 were evaluated. An analysis of the demographics, length of inpatient stay, discharge destinations and evaluation of the Barthel index collected on admission and discharge, the mini-mental state examination (MMSE) and the geriatric depression scale (GDS) were carried out. RESULTS: Out of 312 patients, 110 men and 193 women with a median age of 81 years, 77 patients (24.6%) showed delirium when enrolled in the GKB and 39 (12.5%) dementia. Older patients presented more often with delirium than younger people (p = 0.013), especially those aged 70-79 years (p = 0.037). Dementia patients suffered more frequently from postoperative delirium (p < 0.01). The mean hospital stay was 17.79 days (±4.6 days). The GKB was regularly completed in 60.7% of all cases and 39.3% patients dropped out early. Patients with delirium were discharged significantly less often into their own home but into short-term care or nursing homes (p = 0.038). A general correlation between delirium development and the discharge destination was noticeable (p = 0.004). CONCLUSION: Patients with dementia are more likely to develop delirium postoperatively, which leads to an increase in the length of inpatient stay, an increase in treatment costs and more work for the discharge management team. In addition, the discharge to the patients' home is impaired by delirium, which means that the growing need for places in short-term care and nursing homes also creates socioeconomic burdens.

[Preoperative, neuropathic component in patients with back pain]. / Präoperative, neuropathische Komponente bei Rückenschmerzen.

BACKGROUND: The objectification of pain is essential for evaluation, treatment plan and follow-up; therefore, it is necessary to find reliable clinical parameters. OBJECTIVE: The goal of the study was the preoperative screening of a neuropathic component in patients with vertebral compression fracture (WKF), herniated disc (NPP) or spinal cord compression (SKS). MATERIAL AND METHODS: Depending on the preoperative condition on admittance, patients were classified into three groups: group 1 WKF, group 2 NPP and group 3 SKS. To characterize the pain we used the painDETECT questionnaire, the Oswestry questionnaire and further questionnaires. All patients were surgically treated according to the diagnosis, e.g. radiofrequency kyphoplasty, nucleotomy or spondylodesis. RESULTS: We evaluated the data from 139 patients (45% WKF, 34% NPP and 21% SKS). There were no differences in preoperative pain intensity (median ordinal scale 0-10) with a mean preoperative score of 7 for all groups. The total score of the painDETECT questionnaire showed significantly higher results in group 2 (median 18) and in group 3 (median 14) than in group 1 (median 9). There was even a significant difference between groups 2 and 3 (p = 0.03). The highest pain intensity was detected in group 1 with a median visual analog scale (VAS) of 71 mm. The total scores in the painDETECT questionnaire and the scores in the Oswestry questionnaire correlated in groups 2 and 3. CONCLUSION: The painDETECT questionnaire was shown to be a very suitable instrument for evaluating the neuropathic pain component in patients with dorsalgia. This could be very useful in planning further therapy.

Lower limb reconstruction in tumor patients using modular silver-coated megaprostheses with regard to perimegaprosthetic joint infection: a case series, including 100 patients and review of the literature.

PURPOSE AND OBJECTIVE: Bone resection regarding adequate surgical margins is the treatment of choice for malignant bone tumors. In the case of metastasis-related complications, so-called skeletal-related events, it is highly important to achieve pain relief and a stable joint situation to re-mobilize the patients immediately following surgery. To bridge the often large osseous defect zones after tumor resection, both cemented and uncemented modular endoprosthetic systems are widely used. Patients undergoing tumor-related endoprosthetic orthopedic surgery are facing high risk for developing a periprosthetic joint infection (PJI). The immunocompromised condition due to anti-neoplastic treatment and long operation time with large exposure of tissue contributes to a high risk of infection. METHODS: The authors present a case series of 100 patients (31% primary bone tumor and 69% metastasis-related surgery) undergoing tumor-related lower limb salvage surgery with special regard to periprosthetic joint infection and the management of this "difficult to treat" situation. Furthermore, a review of the current literature regarding infection following bone tumor resection and endoprosthetic reconstruction is performed and discussed. RESULTS: The median follow-up was 24 months (range 12-108 months). Ten patients (10%) suffered from a periprosthetic joint infection. We recorded six acute infections (type I) <4 weeks after surgery, one infection >4 weeks after surgery (type II), and three late infections (type III). According to the definition of Laffer et al., three of our patients (30%) are probably free of infection, one patient died of PJI-associated sepsis, and five patients were free of infection, but without restoration of the affected joint. CONCLUSION: In conclusion, our own results show that perimegaprosthetic joint infection among silver-coated implants, in patients undergoing tumor-related surgery of the lower limb, is lower compared to non-silver-coated implants. Due to heterogeneity of patients and potential treatment options, the treatment regime should be tailored for the patients' individual situation.

[Biological downsizing : Acetabular defect reconstruction in revision total hip arthroplasty]. / Biologisches Downsizing : Azetabuläre Knochendefekte in der Hüftrevisionsendoprothetik.

BACKGROUND: Periacetabular bony defects remain a great challenge in revision total hip arthroplasty. After assessment and classification of the defect and selection of a suitable implant the primary stable fixation and sufficient biological reconstitution of a sustainable bone stock are essential for long term success in acetabular revision surgery. Biological defect reconstruction aims for the down-sizing of periacetabular defects for later revision surgeries. TECHNIQUE: In the field of biological augmentation several methods are currently available. Autologous transplants feature a profound osseointegrative capacity. However, limitations such as volume restrictions and secondary complications at the donor site have to be considered. Structural allografts show little weight bearing potential in the long term and high failure rates. In clinical practice, the usage of spongious chips implanted via impaction bone grafting technique in combination with antiprotrusio cages for the management of contained defects have shown promising long time results. Nevertheless, when dealing with craniolateral acetabular and dorsal column defects, the additional implantation of macroporous metal implants or augments should be considered since biological augmentation has shown little clinical success in these particular cases. PROSPECT: This article provides an overview of the current clinically available biological augmentation methods of peri-acetabular defects. Due to the limitations of autologous and allogeneic bone transplants in terms of size and availability, the emerging field of innovative implantable tissue engineering constructs gains interest and will also be discussed in this article.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures.

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD.

[Antimicrobial prosthesis coatings]. / Antimikrobielle Prothesenbeschichtungen.

BACKGROUND: Antimicrobial coatings have a great potential in the treatment and prevention of periprosthetic joint infection. OBJECTIVE: To present established and novel concepts of antimicrobial coatings. METHODS: A literature review and discussion of published concepts in basic research, pre-clinical animal studies, and clinical practice were carried out. RESULTS: To date there has been a wide range of technical solutions (anti-adhesive surfaces, bioactive surfaces with antimicrobial effects, surfaces releasing antimicrobial substances, nanostructures, bioactive surfaces affecting biofilm development) demonstrating a high potential in pre-clinical studies. Only a few with the bactericidal activity of silver ions have been prepared for the market. Conclusive results with regard to biocompatibility and toxicity are lacking. DISCUSSION: Despite the great potential of antimicrobial coatings, no conclusive decisions can be made because of the limited data and the lack of evidence of their clinical efficacy on the basis of prospective controlled clinical studies. In addition to their unlimited biocompatibility, innovative concepts have to be feasible in everyday clinical routine.

[Total ankle replacement in patients with bleeding disorders]. / Endoprothetischer Ersatz des oberen Sprunggelenks bei Patienten mit Gerinnungsstörungen.

BACKGROUND: Total ankle replacement (TAR) is a well-accepted treatment option in patients with end-stage ankle osteoarthritis. However, published literature on patients with bleeding disorders treated with TAR is limited. Therefore, we carried out this prospective study to analyze mid-term postoperative results in patients with bleeding disorders treated by TAR. METHODS: A total of 34 patients with end-stage ankle osteoarthritis--14 patients with hemophilia type A and 20 patients with von Willebrand disease (VWD)--treated by TAR were included in this prospective study. The mean age of patients was 46.0 ± 9.0 years. Intraoperative and postoperative complications were recorded. The postoperative pain relief and functional results including range of motion (ROM) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were assessed after a mean follow-up of 6.3 ± 3.4 years. Additionally, the quality of life was analyzed using the SF-36 questionnaire. The alignment of prosthesis components was assessed using weight-bearing conventional radiographs. The results were compared with those obtained in the control group, including 72 and 33 patients with post-traumatic and rheumatoid ankle osteoarthritis respectively. RESULTS: One patient sustained an intraoperative medial malleolar fracture. In total, three revision surgeries were necessary in our patient cohort. There was significant pain relief from 8.2 ± 0.8 to 0.9 ± 1.0, as assessed using a visual analog scale. All categories of the SF-36 score showed significant improvement. The average ROM increased from 20.1° ± 6.9° to 27.5° ± 7.4°. The AOFAS hindfoot score increased from 34.5 ± 10.0 to 82.4 ± 10.2 of a maximum of 100 points. Radiographic assessment showed the neutral alignment of prosthesis components in all patients. The postoperative clinical and radiographic outcomes were comparable in both patients with hemophilia and those with VWD. Patients with bleeding disorders had significantly higher pain relief and significantly lower ROM than the patients in the control group with ankle osteoarthritis of post-traumatic or rheumatoid etiology. CONCLUSION: Our prospective study revealed encouraging mid-term outcomes after TAR in patients with bleeding disorders. However, this surgery should be limited to highly experienced foot and ankle surgeons. Furthermore, this patient cohort requires a multidisciplinary approach to ensure a good outcome.

Total ankle replacement in patients with haemophilia and virus infections--a safe alternative to ankle arthrodesis?

Despite reliable results of ankle fusion for advanced haemophilic arthropathy, total ankle replacement (TAR) may be functionally advantageous. There is only very limited literature data available on TAR in patients with haemophilia. The objective of this study is to evaluate the short- and mid-term results after TAR in patients with end-stage haemophilic ankle arthropathy and concomitant virus infections. In a retrospective study, results after eleven TAR in 10 patients with severe (n = 8) and moderate (n = 2) haemophilia (mean age: 49 ± 7 years, range, 37-59) were evaluated at a mean follow-up of 3.0 years (range, 1.2-5.4). Nine patients were positive for hepatitis C, five were HIV-positive. Range of motion (ROM), AOFAS-hindfoot-score, pain status (visual analogue scale, VAS) as well as patient satisfaction were evaluated. In two cases deep prosthesis infection occurred leading to the removal of the implant. In the remaining eight patients the mean AOFAS score improved significantly from 21.5 to 68.0 points (P < 0.0005), the VAS score decreased significantly from 7.6 to 1.9 points (P < 0.0005). ROM increased from 23.2 to 25.0 degrees (P = 0.51). At final follow-up all patients without any complications were satisfied with the postoperative results. Radiographic examination did not reveal any signs of prosthetic loosening. TAR is a viable surgical treatment option in patients with end-stage ankle osteoarthritis due to haemophilia. It provides significant pain relieve and high patient satisfaction. However, due to the increased risk of infection and lack of long-term results, TAR particularly in patients with severe haemophilia and virus infections should be indicated carefully.

[Rare complication after endoscopic discectomy]. / Seltene Komplikation der endoskopischen Nukleotomie.

Surgical treatment of the lumbar spine is a standard procedure in orthopedic and neurosurgery. After endoscopic discectomy an otherwise healthy patient developed massive dyspnea in combination with severe abdominal pain. Sonography revealed a large volume of free fluid in the abdominal cavity which proved to be surgical irrigation solution after computed tomography (CT) guided puncture. After insertion of a drainage channel fluid could be removed and the patient was transferred to a peripheral ward after a 24 h monitoring period. This review reports on the complications and anesthetic characteristics of percutaneous spinal interventions and presents differential diagnoses of postoperative dyspnea.

[Treatment of isolated fractures of the olecranon: percutaneous double-screw fixation versus conventional tension band wiring]. / Behandlung von isolierten Olekranonfrakturen: Perkutane Doppelschraubenosteosynthese vs. konventionelle Zuggurtung.

BACKGROUND: Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages. PATIENTS AND METHODS: A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring. RESULTS: No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motion was significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001). CONCLUSIONS: The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.

[Acetabular metastatic defect reconstruction using the modular revision support cup MRS-C]. / Rekonstruktion von metastasenbedingten Defekten des Azetabulums mittels der MRS-C-Abstützschale.

OBJECTIVE: Stabilization of metastatic acetabular defects with a bone cement-augmented revision support cup for remobilization of oncological patients in advanced cancer stages. INDICATIONS: Metastatic acetabular defects (Metastatic Acetabular Classification, MAC 2-4) in patients with a prognostic medium or long-term survival. CONTRAINDICATIONS: Highly limited survival due to metastatic disease (< 6 weeks). Local bone or soft tissue infection. Primary bone tumor with curative treatment option. Advanced pelvic discontinuity. Recent wound compromising systemic therapy. SURGICAL TECHNIQUE: Standard hip approach. Curettage of the metastatic defect and careful reaming of the acetabulum before insertion of the cup. Predrilling of the dome und flange screws before application of the bone cement through the center hole of the implant and filling of the acetabular defect. Complete insertion of the screws for compound osteosynthesis. Implant of a modular inlay or dual mobility system. POSTOPERATIVE MANAGEMENT: Full weight bearing or mobilization with two crutches according to the level of pain. Adjuvant local radiation therapy after wound consolidation. Continuation of systemic therapy according to tumor board decision. RESULTS: Between 2012 and 2019, we treated 14 patients with metastatic acetabular defects using the modular revision support cup "MRS-TITAN® Comfort", MRS-C, Peter Brehm GmbH, Weisendorf, Germany) at our institution. Mean Harris Hip Score improvement was 23.2 with a mean patient's survival of 9.7 months due to the reduced cancer-related prognosis; 13 of the 14 implants endured the patient's prognosis. One implant had to be removed due soft tissue defect-related periprosthetic joint infection.

[Orthopedic and trauma surgery in the German DRG system. Recent developments]. / Orthopädie und Unfallchirurgie im deutschen DRG-System. Aktuelle Entwicklungen.

BACKGROUND: Orthopedics and trauma surgery are subject to continuous medical advancement. The correct and performance-based case allocation by German diagnosis-related groups (G-DRG) is a major challenge. This article analyzes and assesses current developments in orthopedics and trauma surgery in the areas of coding of diagnoses and medical procedures and the development of the 2012 G-DRG system. METHODS: The relevant diagnoses, medical procedures and G-DRGs in the versions 2011 and 2012 were analyzed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Changes were made for the International Classification of Diseases (ICD) coding of complex cases with medical complications, the procedure coding for spinal surgery and for hand and foot surgery. The G-DRG structures were modified for endoprosthetic surgery on ankle, shoulder and elbow joints. The definition of modular structured endoprostheses was clarified. CONCLUSION: The G-DRG system for orthopedic and trauma surgery appears to be largely consolidated. The current phase of the evolution of the G-DRG system is primarily aimed at developing most exact descriptions and definitions of the content and mutual delimitation of operation and procedures coding (OPS). This is an essential prerequisite for a correct and performance-based case allocation in the G-DRG system.

[Evaluation of a 2D fluoroscopy-based navigation system for insertion of femoral neck screws. An experimental study]. / Evaluation eines 2-D-fluoroskopiebasierten Navigationssystems zur Implantation von Schenkelhalsschrauben. Eine experimentelle Studie.

INTRODUCTION: The aim of this study was the evaluation of a new computer-assisted planning and navigation system based on 2D-fluoroscopy for guidewire insertion in order to perform cannulated screw placement into the femoral neck. The image acquisition process was supported by a radiation-saving procedure called Zero-dose C-arm navigation. MATERIAL AND METHODS: In the context of a sawbone study, we performed insertion of 3 cannulated screws positioned under navigation control as well as using the conventional technique in 12 sawbones. Both procedures were performed using open and closed techniques. RESULTS: The computer-assisted technique significantly reduced the amount of intraoperative fluoroscopic images (open technique: -14±3 images, closed technique: -29.4±6 images). Drilling attempts were reduced in the computer-assisted groups (open technique: -1.2±1 attempts, closed technique: -1.7±1.5 attempts) and the femoral neck area covered by the screws was greater in the navigation-assisted groups (open technique: +32.1±16.3 mm(2), closed technique: +32.6±14.9 mm(2)), There was no difference concerning parallelism of the screws or perforation of femoral neck or head. The operation time was significantly longer in the navigation-assisted groups (open technique: +24.2±2.1 min, closed technique: +22.8±5.8 min). CONCLUSION: The addition of computer-assisted planning and surgical guidance supported by Zero-dose C-arm navigation can be useful for the fixation of medial femoral neck fractures with cannulated screws. Further studies with the goal of reducing the operation time are indispensable before integrating this navigation system into the clinical workflow.

Explant analysis and implant registries are both needed to further improve patient safety.

In the early days of total joint replacement, implant fracture, material problems and wear presented major problems for the long-term success of the operation. Today, failures directly related to the implant comprise only 2-3% of the reasons for revision surgeries, which is a result of the material and design improvements in combination with the standardization of pre-clinical testing methods and the post-market surveillance required by the legal regulation. Arthroplasty registers are very effective tools to document the long-term clinical performance of implants and implantation techniques such as fixation methods in combination with patient characteristics. Revisions due to implant failure are initially not reflected by the registries due to their small number. Explant analysis including patient, clinical and imaging documentation is crucial to identify failure mechanisms early enough to prevent massive failures detectable in the registries. In the past, early reaction was not always successful, since explant analysis studies have either been performed late or the results did not trigger preventive measures until clinical failures affected a substantial number of patients. The identification of implant-related problems is only possible if all failures are reported and related to the number of implantations. A system that analyses all explants from revisions attributed to implant failure is mandatory to reduce failures, allowing improvement of risk assessment in the regulatory process.

[Reconstruction of the extensor apparatus with advanced structural defects in knee revision arthroplasty]. / Rekonstruktion des Streckapparates bei fortgeschrittenen Defekten in der Knierevisionsendoprothetik.

OBJECTIVE: Restoration of the extensor apparatus in the case of advanced tendon defects as part of revision total knee arthroplasty (TKA). Reconstruction and augmentation using vascularized gastrocnemius muscle and tendon. INDICATIONS: Advanced degeneration of the extensor apparatus (patella tendon; quadriceps tendon) with or without discontinuity, following revision arthroplasty. CONTRAINDICATIONS: Persistent infection or pending TKA revision. Damaged gastrocnemius or soleus muscle or Achilles tendon. SURGICAL TECHNIQUE: Extension of the surgical TKA-access medial-distally. Separation of the medial gastrocnemius muscle along the raphe and preparation of the distal tendon from the soleus portion. Transposition into the defect site, augmentation or reconstruction of the defect by double turn of the gastrocnemius tendon. The muscle belly serves to adequately cover the tendon as well as the ventral knee joint. Mesh coverage of the muscle. POSTOPERATIVE MANAGEMENT: Immobilization of the knee and ankle for 10 days until mesh graft healing. Stepwise increasing flection of the knee with 30°/60°/90° every 2 weeks. Total weight bearing with secured full extended knee, no weight bearing with flexed knee for 6 weeks. RESULTS: In 9 patients, 3 with complete rupture of the patellar tendon, 5 with destruction of the extensor apparatus, and 1 patient with rupture of the quadriceps tendon following TKA revision, good functional results were achieved with active extension of the knee joint and standing/gait stability 6 months after surgery.

Evaluation of a new computer-assisted surgical planning and navigation system based on two-dimensional fluoroscopy for insertion of a proximal femoral nail: an experimental study.

Pertrochanteric femoral fractures are common and intramedullary nailing is an accepted method for their surgical treatment. Accurate placement of the implant is essential to ensure fixation. The conventional technique can require multiple guide wire passes, and relies heavily on fluoroscopy. A computer-assisted planning and navigation system based on two-dimensional fluoroscopy for guide wire placement in the femoral neck has been developed, in order to perform intramedullary pertrochanteric fracture fixation using the proximal femoral nail (PFNA). The planning process was supported by a 'zero-dose C-arm navigation' system. The PFNA was inserted into 12, intact, femoral sawbones guided by the computer-based navigation, and into 12, intact, femoral sawbones using a conventional fluoroscopic-assisted technique. Guide wire and subsequent blade placement in the femoral neck was evaluated. The computer-assisted technique achieved a significant decrease in the number of required fluoroscopic images and in the number of guide wire passes. The obtained average blade placement accuracy in the femoral neck was equivalent to the conventional technique. The operation time was significantly longer in the navigation-assisted group. The addition of computer-assisted planning and surgical guidance to the intramedullary nailing of pertrochanteric femoral fractures offers a number of clinical benefits based on the results of this sawbone study. Further studies including fractured sawbones and cadaver models with extension of the navigation process to all steps of PFNA introduction and with the goal of reducing operation time are indispensable before integration of this navigation system into clinical practice.