A Combined Cyto- and Histopathological Diagnostic Approach Reduces Time to Diagnosis and Time to Therapy in First Manifestation of Metastatic Spinal Disease: A Cohort Study.

Malignant spinal lesions (MSLs) are frequently the first manifestation of malignant disease. Spinal care, diagnostic evaluation, and the initiation of systemic therapy are crucial for outcomes in patients (pts) with advanced cancer. However, histopathology (HP) may be time consuming. The additional evaluation of spinal lesions using cytopathology (CP) has the potential to reduce the time to diagnosis (TTD) and time to therapy (TTT). CP and HP specimens from spinal lesions were evaluated in parallel in 61 pts (CP/HP group). Furthermore, 139 pts in whom only HP was performed were analyzed (HP group). We analyzed the TTD of CP and HP within the CP/HP group. Furthermore, we compared the TTD and TTT between the groups. The mean TTD in CP was 1.7 ± 1.7 days (d) and 8.4 ± 3.6 d in HP (p < 0.001). In 13 pts in the CP/HP group (24.1%), specific therapy was initiated based on the CP findings in combination with imaging and biomarker results before completion of HP. The mean TTT in the CP/HP group was 21.0 ± 15.8 d and was significantly shorter compared to the HP group (28.6 ± 23.3 d) (p = 0.034). Concurrent CP for MSLs significantly reduces the TTD and TTT. As a result, incorporating concurrent CP for analyzing spinal lesions suspected of malignancy might have the potential to enhance pts' quality of life and prognosis in advanced cancer. Therefore, we recommend implementing CP as a standard procedure for the evaluation of MSLs.

The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients.

BACKGROUND: Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients. METHODS: A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model. RESULTS: Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores. CONCLUSION: With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.

Does a prehospital applied pelvic binder improve patient survival?

INTRODUCTION: Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures. METHODS: This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients. RESULTS: 66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes. CONCLUSION: Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures.

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Areal bone mineral density is not associated with femoral stem subsidence in patients younger than 70 years undergoing total hip arthroplasty.

INTRODUCTION: Femoral stem subsidence is a known complication after uncemented total hip arthroplasty (THA). The purpose of this study was to determine the frequency of osteoporosis and to investigate the relationship between areal bone mineral density (aBMD) and subsidence in a cohort of patients younger than 70 years. METHODS: One hundred consecutive patients (age 60 ± 6 years; 52 female, 48 male) undergoing uncemented THA using a collarless press fit femoral stem were retrospectively reviewed. Dual-energy X-ray absorptiometry (DXA) was performed preoperatively at the proximal femur and lumbar spine, and if not feasible at these sites, at the distal radius. DXA results were compared to a cohort of 100 patients ≥ 70 years scheduled for cemented THA. Age, sex, and body mass index (BMI), canal flare index (CFI), and canal fill ratio (CFR) were assessed. Analysis of stem subsidence and migration was performed on standardized, calibrated radiographs obtained postoperatively and at follow-up. RESULTS: The frequency of osteoporosis was considerably lower in the study cohort compared to patients ≥ 70 years (7% vs. 19%, p = 0.02). Illustrated by the high CFR (mean 96 ± 4%) in the mid-stem region, a sufficient press fit was achieved. After a mean follow-up of 7.4 months, the mean stem subsidence was 0.9 ± 0.9 mm. Only two patients had subsidence greater than 3 mm, one of whom was morbidly obese and the other diagnosed with severe osteoporosis. There were no correlations between any of the parameters (CFI, CFR, age, sex, BMI) and femoral stem subsidence. In addition, aBMD T-scores showed no correlations with subsidence. CONCLUSION: aBMD by DXA does not appear to be associated with stem subsidence in patients younger than 70 years and with adequate press fit.

Influence of health literacy on health-related quality of life after total hip arthroplasty.

INTRODUCTION: Personal knowledge about the own disease, a key component of health literacy (HL), may have a considerable impact on treatment outcomes. The purpose of this study was to investigate whether the patients' knowledge about the surgical procedure, risks, and aftercare, as well as the satisfaction with the preoperative level of information, has an influence on the health-related quality of life (HRQoL) after primary total hip arthroplasty (THA). MATERIALS AND METHODS: A total of 176 patients (68.3 ± 10.3 years, 60.8% female) were evaluated. HRQoL was assessed prior to surgery as well as one and twelve months after THA using the 12-item Short Form Questionnaire. Following standardized surgical informed consent, HL was assessed preoperatively using a self-constructed quiz score, while information satisfaction was measured with a single-item rating scale. Sociodemographic and clinical characteristics, including pain (VAS), functionality (WOMAC), and psychological distress (PHQ-4), were also assessed at baseline. Multiple linear regression analyses were performed to examine whether HL, satisfaction with information, age, social class, WOMAC, VAS, and PHQ-4 predict HRQoL at one and twelve months post-surgery. RESULTS: The average HL quiz score was 23 ± 5.1 out of a possible 33 points. Social class index significantly influenced HL (p < 0.001). A weak correlation between HL and age (r = 0.23, p = 0.01) and no correlation between HL and psychological distress (p = 0.868) were observed. One month after THA, physical HRQoL was significantly predicted by the WOMAC index (p = 0.031) and subjective satisfaction with information (p = 0.022), but not by HL. After twelve months, only the WOMAC was a significant predictor (p < 0.001) of physical HRQoL. CONCLUSION: Although subjective satisfaction with the patient's preoperative level of information had a significant effect on the physical HRQoL at one month after THA, the influence of osteoarthritis severity outweighed this effect after twelve months. HL had no direct influence on HRQoL. These results suggest that patient satisfaction, rather than knowledge, predicts HRQoL.

Medium-term Results After Femoral Head Resection and Subtrochanteric Valgus Osteotomy in Children and Adolescents With Neuromuscular Disorders.

BACKGROUND: Various salvage surgical procedures for painful hip dislocation in adolescent patients with cerebral palsy exist. To date, no significant differences among these surgical techniques have been described. In our institution the McHale procedure is the standard of care for painful chronically dislocated hips with or without deformity of the femoral head in patients with cerebral palsy. This study focuses on mid-term results after surgical treatment. METHODS: Surgical reports and patient charts were analyzed retrospectively. All x-rays were evaluated and migration of the proximal femur and heterotopic ossification according to Brooker were recorded. In addition, we conducted a telephone interview with the caretakers with special reference to pain preoperatively and postoperatively and after implant removal, sitting tolerance, range of motion, mobility, quality of life, and personal hygiene. RESULTS: Fifty-two patients (65 hips) with a mean age of 13.5 ± 3.6 years (range: 4 to -20 y) were included. Mean surgery time was 178.4 ± 63.4 minutes (range: 45 to 380 min) and mean follow-up was 45.17 ± 30.6 months (range: 12 to 204 mo). A significant difference between preoperative and postoperative pain levels was found, P <0.001. Personal hygiene ( P =0.02) and quality of life ( P =0.013) improved significantly. Eighty-five percent of the caregivers would have the surgery performed on their child again and 81% of the caregivers would recommend the surgery to others. The removal of implants leads to a significant improvement in pain ( P =0.011). A total of 22 complications in 65 McHale procedures (33.9%) were related to the procedures. CONCLUSIONS: A significant reduction in pain and a significant improvement of hygiene as well as quality of life can be achieved with the McHale procedure in painful chronically dislocated hips in patients with cerebral palsy. Overall, the procedure is predominantly experienced as helpful by the caregivers and recommended to others. The removal of the implants improves pain significantly, but complications may occur in one third of the patients. LEVEL OF EVIDENCE: IV.

Comparison of Motion Grading in 1,000 Patients by First- and Second-Generation HR-pQCT: A Propensity Score Matched Cohort Study.

In-vivo bone microstructure measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) is gaining importance in research and clinical practice. Second-generation HR-pQCT (XCT2) shows improved image quality and shorter measurement duration compared to the first generation (XCT1). Predicting and understanding the occurrence of motion artifacts is crucial for clinical practice. We retrospectively analyzed data from HR-pQCT measurements at the distal radius and tibia of 1,000 patients (aged 20 to 89) evenly distributed between both generations of HR-pQCT. Motion artifacts were graded between 1 (no motion) and 5 (severe motion), with grades greater 3 considered unusable. Additionally, baseline characteristics and patients' muscle performance and balance were measured. Various group comparisons between the two generations of HR-pQCT and regression analyses between patient characteristics and motion grading were performed. The study groups of XCT1 and XCT2 did not differ by age (XCT1: 64.9 vs. XCT2: 63.8 years, p = 0.136), sex (both 74.5% females, p > 0.999), or BMI (both 24.2 kg/m2, p = 0.911) after propensity score matching. XCT2 scans exhibited significantly lower motion grading in both extremities compared to XCT1 (Radius: p < 0.001; Tibia: p = 0.002). In XCT2 motion-corrupted scans were more than halved at the radius (XCT1: 35.3% vs. XCT2: 15.5%, p < 0.001), and at the tibia the frequency of best image quality scans was increased (XCT1: 50.2% vs. XCT2: 63.7%, p < 0.001). The strongest independent predictor for motion-corrupted images is the occurrence of high motion grading at the other scanning site during the same consultation. The association between high motion grading in one scan and a corresponding high motion grading in another scan within the same session suggests a non-resting patient. Additionally, aged, female, and patients with smaller stature tend towards higher motion grading, requiring special attention to a correct extremity fixation.

Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial.

A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.

Apps in Clinical Practice: Usage Behaviour of Trauma Surgeons and Radiologists in Northern Germany.

Introduction: Apps, in general, are an integral part of our daily lives. To investigate the current usage behaviour of trauma surgeons and radiologists regarding medical apps in clinical practice and to find out if and how the current range of medical apps can be improved, we surveyed trauma surgeons and radiologists in northern Germany. Material and Methods. An online questionnaire was sent to 100 trauma surgeons and 100 radiologists in northern Germany. Participants were asked about the frequency of their use of medical apps in clinical practice, which apps were used most often, how useful participants thought apps were, and in which area they would like to see improvements. The most frequently mentioned apps were finally analyzed. Results: The survey study showed that 87.4% of the trauma surgeons and 67.4% of the radiologists use medical apps on a regular basis at work. It also revealed that trauma surgeons used medical apps much more often than radiologists and that young doctors were more likely to rely on medical apps than chief physicians. 80.0% of the participants would pay at least 5 euros for a medical app. Trauma surgeons see the greatest need for support in their daily work from medical apps in the area of treatment, while radiologists seek more support in the area of classification. Conclusion: The study underscored the broad acceptance of medical apps in everyday clinical practice. As the physicians are willing to spend money and stated a general interest and need for further developments, there is high potential for the future. This trial is registered with DRKS00026766.

The Use of Intraoperative Cell Salvage in Two-Stage Revision of Septic Hip Arthroplasties: A Double-Center Retrospective Study.

(1) Background: intraoperative cell salvage (ICS) devices can provide a valuable contribution to patient blood management. An infection of the surgical site presents a formal contraindication to the use of ICS. To date, there is no recommendation for the use of ICS in the context of reimplantation in two-stage septic exchange arthroplasty. (2) Methods: at two hospitals of maximum endoprosthetic care, a retrospective evaluation of patients who had received ICS blood during reimplantation of hip arthroplasties was performed. Patients' and surgical characteristics, intraoperative cultures, and the occurrence of septic complications in the short- and long-term follow-up were recorded. (3) Results: 144 patients were included. Detection of positive cultures during reimplantation occurred in 13 cases. A total of 127 patients showed no complication, 8 patients showed a non-specific septic complication, 6 patients a local persistence of infection, and 3 patients a possible bloodstream-associated infection. No significant correlation was found between the occurrence of complications and the detection of positive intraoperative cultures. (4) Conclusions: no clustering of septic complications due to the use of ICS during reimplantation was found. In the risk-benefit analysis, we considered the use of ICS during reimplantation to be indicated in terms of patient blood management, while the safety of the procedure during septic first-stage resection arthroplasty or septic one-stage exchange arthroplasty was not investigated. Given the paucity of comparative literature, further studies are needed on ideal patient blood management in the setting of septic revision arthroplasty.

Bi-planar calibration method for templating of hip joint arthroplasty: phantom study and proof of concept.

PURPOSE: Calibration of radiographs is a critical step in digital templating for hip arthroplasty. Calibration errors of > 1.5% lead to over- or undersizing of the templated implants and may affect logistics and patient safety. Contemporary calibration methods are known to be imprecise with average errors of 6.5% and wide variance. A novel bi-planar radiograph-based calibration method is proposed, and a phantom study was conducted as proof of concept. METHODS: A spherical external calibration marker (ECM) is placed in front of the pubic symphysis of a pelvic bone model at twelve different positions. For each marker position, standard anteroposterior radiographs and four corresponding lateral radiographs with different degrees of rotation (0°-30°) are taken (overall, 60 radiographs). Calibration factors are calculated for an internal calibration marker (ICM) at the centre of the right hip (reference) and the ECM using a novel algorithm. Rotation and marker positions simulate foreseeable use errors and misplacements and aim to test robustness of the method against these errors. RESULTS: ECM calibration factor was 125.9% (range 124.7-127.2), and the mean ICM calibration factor was 126.6% (range 126.2-127.1) ([Formula: see text]). Four images (8.3%) were beyond the 1% error threshold (all with 30° rotation). The mean difference was 0.79% (SD 0.49). CONCLUSION: The bi-planar method precisely predicts the true calibration factor of the hip joint plane under various conditions. In lateral radiographs, rotation of up to 20° did not adversely affect the precision and all images had calibration errors below the threshold for clinical significance.

Outcome of different reconstruction options using allografts in revision total hip arthroplasty for severe acetabular bone loss: a systematic review and meta-analysis.

INTRODUCTION: Several studies have reported good to excellent outcomes of revision total hip arthroplasty (rTHA) using allografts for treating severe acetabular bone defects. However, precise information on the impact of allograft type and reconstruction method is not available. MATERIAL AND METHODS: Systematic literature search was performed in Medline and Web of Science including patients with acetabular bone loss classified according to the Paprosky classification who underwent rTHA involving the use of allografts. Studies with a minimum follow-up of 2 years published between 1990 and 2021 were included. Kendall correlation was applied to determine the relationship between Paprosky grade and allograft type use. Proportion meta-analyses with 95% confidence interval (CI) were performed to summarize the success of various reconstruction options, including allograft type, fixation method, and reconstruction system. RESULTS: Twenty-seven studies met the inclusion criteria encompassing 1561 cases from 1491 patients with an average age of 64 years (range 22-95). The average follow-up period was 7.9 years (range 2-22). Structural bulk and morselized grafts were used in equal proportions for all Paprosky acetabular defect types. Their use increased significantly with the type of acetabular defect (r = 0.69, p = 0.049). The overall success rate ranged from 61.3 to 98.3% with a random effect pooled estimate of 90% [95% CI 87-93]. Trabecular metal augments (93% [76-98]) and shells (97% [84-99]) provided the highest success rates. However, no significant differences between reconstruction systems, allograft types and fixation methods were observed (p > 0.05 for all comparisons). CONCLUSION: Our findings highlight the use of bulk or morselized allograft for massive bone loss independent of Paprosky classification type and indicate similar good mid- to long-term outcomes of the different acetabular reconstruction options using allografts. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42020223093.

Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis.

OBJECTIVE: Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Peer-reviewed studies that reported site-specific RTS of BSIs in athletes. RESULTS: Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft. CONCLUSION: This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS. PROSPERO REGISTRATION NUMBER: CRD42021232351.

Does the COVID-19 personal protective equipment impair the surgeon's performance?

INTRODUCTION: Despite increasing vaccination rates, new viral variants of SARS-CoV-2 (severe acute respiratory syndrome coronavirus type 2) are advancing the COVID 19 (coronavirus disease 2019) pandemic and continue to challenge the entire world. Surgical care of SARS-CoV-2 positive patients requires special protective measures. We hypothesized that "COVID-19" personal protective equipment (PPE) during surgery of SARS-CoV-2 positive or potentially positive patients would negatively affect the surgeon and thus the surgical outcome. MATERIALS AND METHODS: Ten experienced trauma surgeons participated in the study. Each surgeon performed two simulated surgeries of a distal tibial fracture on a Sawbone® under standardized conditions either wearing regular PPE or special COVID-19 PPE. Baseline values at rest were acquired for heart rate, blood pressure, saturation of peripheral oxygen (SpO2), respiratory rate and capillary blood gas (CBG) analysis including capillary partial pressure of oxygen (pO2) and carbon dioxide (pCO2), followed by four different standardized tests of attentional performance (TAP). Subsequently, the surgeon performed the first surgery according to a randomly determined order, with regular or COVID-19 PPE conditions in an operation theatre. After each surgery vital signs were acquired and CBG and TAP were performed again. RESULTS: In our simulated surgical procedure heart rate, respiratory rate, systolic and diastolic blood pressure did not show relevant differences. Percutaneously measured SpO2 decreased with additional layers of PPE, while CBG parameters were not affected. TAP tests showed a significant impairment of attention if PPEs were compared to the baseline, but both PPEs had similar results and no meaningful differences could be measured. CONCLUSIONS: According to our results, for surgical procedures additional PPE required during COVID-19 pandemic does not relevant affect the surgeon's mental and physical performance. Surgeries under COVID-19 PPE conditions appear safe and do not increase patient risk. LEVEL OF EVIDENCE: Level I.

Chronic pain in osteoarthritis of the hip is associated with selective cognitive impairment.

INTRODUCTION: Chronic pain of various origin is known to be associated with selective cognitive impairment. Osteoarthritis (OA) of the hip is one of the leading causes of chronic pain in the adult population, but its association with cognitive performance has not been evaluated. Here, we investigate the effect of chronic pain due to unilateral OA of one hip and no further source of chronic pain on cognitive performance. MATERIALS AND METHODS: A neuropsychological test battery, consisting of the Mini-Mental State Examination, Rey-Osterrieth complex figure test, Rivermead behavioural memory test, d2 test of attention, and F-A-S test was applied in 148 patients and 82 healthy pain-free control individuals. The influence of potentially confounding factors such as depression and anxiety was examined. RESULTS: Patients with OA of the hip showed decreased performance in specific neuropsychological tests. Performance in verbal and visual short-term and long-term memory and selective attention tests was significantly poorer compared to healthy controls. Whereas the executive functions "updating", "set shifting", "response inhibition" and "reflection" appear intact, "problem solving" and "planning" were impaired. None of the confounders showed any influence on cognitive performance in both study groups. CONCLUSION: We conclude that chronic pain secondary to end-stage hip OA is associated with selective cognitive impairment. Future studies are required to investigate the effect of total hip arthroplasty on cognitive performance.

Localization and Likelihood of Chondral and Osteochondral Lesions After Patellar Dislocation in Surgically Treated Children and Adolescents.

Background: Patellar dislocation is a common injury in children and adolescents. There is a lack of information about concomitant osteochondral lesions in these patients. Hypothesis: We hypothesized that the likelihood of chondral or osteochondral lesions would increase with each prior patellar dislocation and that the appearance of lesions in surgically treated children and adolescents would be influenced by age, sex, injury mechanism, and body mass index (BMI). Study Design: Case-control study; Level of evidence, 3. Methods: Inclusion criteria were (1) age <18 years, (2) surgical treatment with diagnostic arthroscopy of the knee including description of chondral and osteochondral lesions, and (3) maximum time period between the last patellar dislocation and presentation in our department of 6 weeks and maximum of 4 weeks between presentation and surgery. A total of 153 children (173 knees) with a mean age of 13.0 ± 2.1 years were included. All surgical reports and intraoperative arthroscopic imaging were analyzed retrospectively for the location and severity of lesions. The likelihood of lesions was calculated with multiple stepwise regression models regarding injury mechanism, number of dislocations, sex, age, physeal closure, and BMI. Results: The regression model to predict femoral lesions was statistically significant (χ2[5] = 26.55; P < .001) and identified male sex, BMI ≥25, traumatic injury mechanism, and physeal closure as independent factors associated with the appearance of femoral lesions. The second regression model predicting the appearance of patellar lesions was also statistically significant (χ2[4] = 26.07; P < .001) and identified the traumatic injury mechanism as a single independent predictor for patellar lesions. Conclusion: BMI ≥25, male sex, and physeal closure were factors significantly associated with femoral chondral and osteochondral lesions in our cohort. In case of traumatic lateral patellar dislocation (LPD), the likelihood of patellar and femoral chondral and osteochondral lesions is significantly higher than in nontraumatic LPD. Early magnetic resonance imaging and surgical treatment should be considered in obese patients, male patients, and patients with physeal closure and after traumatic LPD.

Influence of Fracture Reduction on the Functional Outcome after Intramedullary Nail Osteosynthesis in Proximal Humerus Fractures.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013−2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either "anatomical", "acceptable" or as "malreduction". Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an "anatomic" reduction in 9 (21.4%), "acceptable" in 7 (16.6%) and a "malreduction" in 26 (62%) patients. Comparing the combined "anatomical" and "acceptable" reduction group with the "malreduction" group, worse scores were observed in the "malreduction" group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.

Evaluation of the patient-accompanying app "alley ortho companion" for patients with osteoarthritis of the knee and hip: study protocol for a randomized controlled multi-center trial.

BACKGROUND: Osteoarthritis (OA) is one of the most common disabilities in the elderly. When conservative management fails, total joint arthroplasty (TJA) is the treatment of choice for end-stage OA. Since quality and durability of implants has steadily improved, pre -and postsurgical processes moved into the focus of research. Hence, eHealth approaches offer an opportunity to provide a more available continuity of care. Regarding individualized pre-, peri-, and postsurgical stages, eHealth is expected to improve patient engagement, self-care, and outcomes across the surgical pathway. Aim of this study is to evaluate the effectiveness of the eHealth application "alley" as an adjuvant intervention to TJA. The app provides comprehensive information to empower patient with hip or knee OA to prepare and accompany them for their TJA surgery. Our primary hypothesis is that the pre- and postoperative adjuvant use of the eHealth application "alley" (intervention group, IG) leads to improved functional outcome. METHODS: Prospective, randomized, controlled, multi-center trial including n = 200 patients diagnosed with hip and n = 200 patients with knee OA (n = 200) scheduled for TJA. Patients of both groups will be randomly assigned to one of two study arms. Patients in the intervention group will receive access to the functions of the "alley" app. The app presents informative (e.g., information about osteoarthritis), organizational (e.g., information about medical rehabilitation), and emotional/empowerment (e.g., information about the relationship between mood and pain) content. Patients evaluate their condition and functional level by means of standardized digitally questionnaires. Patients in the control group will not receive any functions of the app. Assessments will be performed at baseline before, 10 days after, 1 months after, 3 months after, 6 months after, and 12 months after TJA. Primary outcome is change from baseline measured by the Hip Osteoarthritis Outcome Score or Knee injury and Osteoarthritis Outcome Score 3 months after TJA. The statistical analysis (t-test for independent variables with effect size Cohen's d) is performed separately for patients with TKA and THA. DISCUSSION: Overall, the study aims to improve the understanding of the benefits of eHealth applications in the treatment of elderly patients with knee or hip arthroplasty. The approach is novel since a health care companion is combined with a digital information platform enabling direct and continuous feedback from the patients to the therapeutic treatment team. As the study investigate the effectiveness under everyday conditions, it is not feasible to control whether the patients in the IG read the educational information of the app respectively the control group consume additional information from other sources. However, this increases the external validity of the study if significant effects for the app can be demonstrated. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00025608. Registered on 21 June 2021.