Risk Factors and Clinical Outcomes after Antegrade Intramedullary Nailing in Proximal Humeral Fractures: Insights and Implications for Patient Satisfaction.

BACKGROUND: Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs. METHODS: A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging. RESULTS: Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (-11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures. CONCLUSION: The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up.

The Rising Problem of Hip Fractures in Geriatric Patients-Analysis of Surgical Influences on the Outcome.

BACKGROUND: Hip fractures in geriatric patients often have a poor outcome in terms of mortality, mobility as well as independence. Different surgical influence factors are known that improve the outcome. METHODS: In this observational cohort study, 281 patients of a geriatric trauma unit were analyzed prospectively. Demographic factors, as well as data regarding the trauma mechanism and perioperative treatment, were recorded. The nutritional status was also analyzed. The follow-up was set to 120 days. RESULTS: The key conclusion of this study is that a high ASA classification, the use of anticoagulatory medicine and malnutrition are significantly associated with higher mortality together with worse independence (p < 0.05). There is no significant difference in outcome concerning the time to surgery within the first 24 h. CONCLUSIONS: Malnutrition seems to be an important risk factor for an adverse outcome of geriatric patients and therefore warrants a focus in multidisciplinary treatment. The risk factor ASA cannot be improved during the pre-surgery phase, but requires intensified care by a multidisciplinary team specialized in orthogeriatrics.

Mid- to Long-Term Survival of Geriatric Patients with Primary Septic Arthritis of the Shoulder: A Retrospective Study over a Period of 20 Years.

Septic arthritis of the shoulder is an urgent medical emergency that often occurs in elderly patients and is associated with high morbidity and mortality. Retrospectively, 56 patients aged ≥60 years, treated for primary septic monoarthritis of the shoulder at a maximum care hospital between 1 July 2001, and 30 July 2022, were included in this study. The primary aim of the study was analyzing survival rates and different bacteria in these patients. For statistical analysis, Kaplan-Meier curves were used for survival probability and the log-rank test was used to compare a survival probability of 5 years. The mean patient age was 78.7 years and a mean follow-up time of 3011.8 days. The mean survival of the entire study population was 920.3 days or 2.5 years. Significantly impaired 5-year survival was found only with increasing age and higher American Society of Anesthesiologists (ASA) physical status (PS) classification scores. Eight different types of bacteria were detected in the synovial fluid cultures. A total of 42 of 48 overall pathogens was Gram-positive and 6 were Gram-negative bacteria. Staphylococcus aureus was identified as the most frequent variant. We conclude that the mean survival is significantly shortened within the first 5 years with increasing age and ASA PS classification.

MRI Characteristics and Alterations in Patellar Height in Patients with Patellar Tendinopathy-A Retrospective Study.

(1) Background: Patellar tendinopathy (PT) is an overuse condition of the knee extensor mechanism characterized by ventral knee pain at the lower pole of the patella and limited functionality. (2) Methods: In this retrospective study, a group of patients with PT (n = 41) was compared with a control group (n = 50) in terms of patient-related data and magnetic resonance imaging (MRI) characteristics. (3) Results: Patellar height was higher in the PT patient group and there was a significant difference in Caton-Deschamps index (CD) compared to the control group (p = 0.021). Patients with PT showed a lower patella-patellar tendon angle (PPTA) (p = 0.011). The patellar tendon thickness (PTT) in the proximal (PTTprox), middle (PTTmid) and distal (PTTdistal) part of the tendon was significantly thickened (p < 0.001). Increased signal intensity in MRI was detected in symptomatic tendons over 6 months compared to a duration of less than 6 months (p = 0.025). A significant relationship between the PTTprox and an increased signal intensity was observed (p < 0.001). (4) Conclusions: Patients with PT showed a significant difference in the patellar height and PPTA. With persistence of symptoms over 6 months, MRI seems suitable to detect the morphologic tendon changes and further identify patients suitable for surgical procedures.

Arthrodesis of the Proximal Interphalangeal Joint of the Finger-A Biomechanical Study of Primary Stability.

BACKGROUND: Osteoarthritis of the proximal interphalangeal (PIP) joint of the finger often leads to global hand-function detriment. Different techniques for the arthrodesis of the proximal interphalangeal joint have been described that all lead to union in a reasonable percentage of patients and period of time. This biomechanical study aims to analyze and compare the primary stability of different techniques of arthrodesis to render postoperative immobilization unnecessary. METHODS: Arthrodeses of 40° of composite cylinders were tested with different techniques in four-point bending for stability in extension as well as flexion. RESULTS: In extension, the compression screw and the compression wires showed the highest stability-whereas in flexion, plate fusion was superior. Tension band, cerclage or compression screw fusion showed the best compromise in flexion/extension stability. CONCLUSIONS: Fusion techniques that apply compression to the fusion show superior stability. Cerclage, tension band and compression screws might be able to provide enough stability to withstand the forces exerted during unencumbered activities of daily living. Arthrodesis with plates should be limited to patients with special indications and require immobilization during consolidation.

Quadriceps Tendon Ruptures in Middle-Aged to Older Patients: A Retrospective Study on the Preoperative MRI Injury Patterns and Mid-Term Patient-Reported Outcome Measures.

(1) Quadriceps tendon rupture (QTR) is a rare pathology, usually occurring in elderly patients with comorbidities, requiring surgical therapy. The aim of this study was to analyze rupture patterns and concomitant injuries using preoperative magnetic resonance imaging (MRI) and to evaluate patient-reported outcome measures. (2) In this retrospective cross-sectional study, 113 patients with QTR were screened and rupture patterns/concomitant injuries (n = 33) were analyzed via MRI. Clinical outcome was assessed in 45 patients using the International Knee Documentation (IKDC) and Lysholm score with a mean follow-up of 7.2 (±5.0) years. (3) The evaluation of preoperative MRIs showed multiple ruptures of subtendons in 67% with concomitant knee injuries in 45%. The most common associated pathology detected using MRI was pre-existing tendinosis (31.2%). Surgical refixation demonstrated good results with a mean post-operative IKDC score of 73.1 (±14.1) and mean Lysholm score of 84.2 (±16.1). Patient characteristics and individual radiologic rupture patterns did not significantly affect the clinical outcome of patients. (4) Acute QTRs are complex injuries with common involvement of multiple subtendons. MRI imaging can be useful for achieving an accurate diagnosis as pre-existing tendinosis as well as concomitant injuries are common, and might be useful for providing an individual surgical strategy and improving outcomes.

CT scan and conventional x-ray in multiple injured patient care: diagnostic strategies and outcomes analysed from the TraumaRegister DGU®.

PURPOSE: To evaluate the current practice regarding the prevalence and sequence of x-ray and CT scan in diagnostic algorithms for multiple injured patients. METHODS: All primarily treated patients with ISS ≥ 9 were selected from the TraumaRegister DGU® (years 2008-2015; n = 109,257). Four subgroups of diagnostic algorithm were defined: CT only (group C; n = 63,763), CT before x-ray (group CX; n = 3711), x-ray followed by CT (group XC; n = 33,590), and x-ray only (group X, n = 8193). We analysed the type and sequence of diagnostic procedures and their association with hospital mortality and length-of-stay in the emergency room (ER-LOS). RESULTS: Predominant strategies were CT only (58.4%) and x-ray followed by CT (30.7%). Overall mortality was between 10 and 12% in all subgroups involving CT, and 6.6% in the x-ray only group. Expected mortality was within the 95% confidence of observed mortality except for the CX group (observed 10.0%; CI95 8.9-11.0; expected 11.1%). Mean / median length of stay in the emergency room was shortest in the CT only subgroup: (60 / 50 min). Prior x-ray diagnostic resulted in additional 3 min (group XC). The use of additional x-ray diagnostic decreased from 51.6% (in 2008) to 35.4% (in 2015). CONCLUSIONS: ER-LOS is significantly affected by diagnostic pathway. CT scan alone accelerates ER-LOS, which however was not associated with lower mortality rates. Performing completive x-ray examinations after an initial CT scan seems not to deteriorate mortality rates.

Risk and Influence Factors of Fall in Immobilization Period after Arthroscopic Interventions.

Knee injuries are one of the most common injuries. Falls during the immobilization period can deteriorate the postoperative outcome. The risk factors causing falls after initial injury and the question of whether a rigid orthosis serves as a protective factor remain unclear. The primary aim of the study was to record the fall rate in the first six weeks after arthroscopic intervention. The secondary aim was to assess the influences of risk factors and protective factors on these fall ratios. Different scores were examined and compared in the groups 'fall event' and 'no fall'. Data from 51 patients (39 males, 12 females) with a mean age of 31.2 years (19-57 years) were collected. A total of 20 patients suffered at least one fall event within the observation period. A total of 18 of 23 fall events happened within the first three weeks postoperatively. The Extra Short Musculoskeletal Function Assessment Questionnaire (XSMFA) showed a significant difference between the groups (p = 0.02). People with multiple injuries to the knee joint were more likely to suffer fall events. Conclusively, patients with limited knee functions appeared to fall more frequently within the first three weeks postoperatively. Therefore, appropriate measures should be taken to protect the postoperative outcome. Physical therapy and patient behavioural training should be practiced perioperatively in patients at risk.

Specific Radiologic Risk Factors for Implant Failure and Osteonecrosis of the Humeral Head after Interlocking Nailing with the Targon PH+ of Proximal Humeral Fractures in a Middle to Old Population.

Background: Operative management of proximal humeral fractures is still challenging. While antegrade nailing has become a valid option in fracture fixation, risk factors for adverse events, and failure have not been sufficiently clarified. Methods: All patients of a single trauma center undergoing surgery for proximal humeral fractures with the Targon PH+ nail between 2014 and 2021 were evaluated retrospectively. This included complications, revisions, and failures. Pre- and postoperative radiographic imaging were assessed regarding fracture's complexity, anatomic reduction, reconstruction of the medial hinge, metaphyseal head extension, and fixation of the implant in the calcar region. Follow-up was at a minimum of 12 months. Results: A total number of 130 patients with a mean age of 74.5 years (range 63−94, SD ± 8.2) are included in this study. Two- and three-part fractures were found in 58 patients, while 14 patients showed four-part fractures. Overall, a complication rate of 34.2% and an implant failure rate of 15.4% was found. Four-part fractures showed a significantly higher complication rate than two- and three-part fractures. Four-part fractures also showed significantly higher revisions (p = 0.005) and implant failures (p = 0.008). The nonsufficient anatomical reduction was found to be a risk factor for complications (p < 0.0001), implant failures (p < 0.0001), and later humeral head osteonecrosis (p < 0.0001). Insufficiently reconstructed medial hinges (p = 0.002) and a metaphyseal head extension of under 8 mm (p = 0.005) were also demonstrated as risk factors for osteonecrosis of the humeral head. Conclusions: Four-part fractures in an elderly population show high complication, revision, and implant-failure rates. Therefore, demonstrated radiologic risk factors should be evaluated for improvements. Anatomical reduction and fixation near the calcar proved to be vital for successful antegrade nailing of complex fractures. To prevent osteonecrosis of the humeral head, reconstruction of the medial hinge and metaphyseal head extension should be evaluated.

Complement Proteins C5/C5a, Cathepsin D and Prolactin in Chondrocytes: A Possible Crosstalk in the Pathogenesis of Osteoarthritis.

INTRODUCTION: Both increased activity of the complement system (CS) and the role of the pituitary hormone prolactin (PRL) are implicated in osteoarthritis (OA) pathogenesis. Besides, Cathepsin D (CatD) activity is increased in the context of OA and can exert not only proteolytic but also non-proteolytic effects on cells. For the first time, possible crosstalk between two separate humoral systems: the CS and the PRL hormone systems in chondrocytes are examined together. METHODS: Primary human articular chondrocytes (hAC) were stimulated with complement protein C5 (10 µg /mL), PRL (25 ng/mL), CatD (100 ng/mL), or anaphylatoxin C5a (25 ng/mL) for 24 h or 72 h, while unstimulated cells served as controls. In addition, co-stimulations of C5 or PRL with CatD were carried out under the same conditions. The influence of the stimulants on cell viability, cell proliferation, and metabolic activity of hAC, the chondrosarcoma cell line OUMS-27, and endothelial cells of the human umbilical cord vein (HUVEC) was investigated. Gene expression analysis of C5a receptor (C5aR1), C5, complement regulatory protein CD59, PRL, PRL receptor (PRLR), CatD, and matrix metal-loproteinases (MMP)-13 were performed using real-time PCR. Also, collagen type (Col) I, Col II, C5aR1, CD59, and PRL were detected on protein level using immunofluorescence labeling. RESULTS: The stimulation of the hAC showed no significant impairment of the cell viability. C5, C5a, and PRL induced cell growth in OUMS-27 and HUVEC, but not in chondrocytes. CatD, as well as C5, significantly reduced the gene expression of CatD, C5aR1, C5, and CD59. PRLR gene expression was likewise impaired by C5, C5a, and PRL+CatD stimulation. On the protein level, CatD, as well as C5a, decreased Col II as well as C5aR1 synthesis. CONCLUSIONS: The significant suppression of the C5 gene expression under the influence of PRL+CatD and that of CD59 via PRL+/-CatD and conversely a suppression of the PRLR gene expression via C5 alone or C5a stimulation indicates an interrelation between the two mentioned systems. In addition, CatD and C5, in contrast to PRL, directly mediate possible negative feedback of their own gene expression.

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival.

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan-Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes.

Foot and Ankle Injuries in Elite Taekwondo Athletes: A 4-Year Descriptive Analysis.

BACKGROUND: Foot and ankle injuries are a common but underestimated problem in taekwondo. Detailed data on injury incidence rates (IIRs), patterns, and injury mechanism are missing. PURPOSE: The primary aims were to evaluate the prevalence of foot and ankle injuries and the exposure-adjusted IIR of elite taekwondo athletes during matches while training (ie, sparring) and in competitions. The secondary aims were to evaluate injury site, type, sport-specific mechanism, and time loss. STUDY DESIGN: Descriptive epidemiology study. METHODS: Athletes from a single national Olympic taekwondo training center were assessed prospectively for foot and ankle injuries over 4 years (between January 1, 2016, and December 31, 2019). Data were collected regarding number and type of injuries, anatomic location, and total exposure time during training and competition for each athlete. Injury mechanism and dominant foot were assessed via personal interview. Time loss from sport was analyzed retrospectively. The injury prevalence and IIR were calculated. Correlation between mechanism and injury type, location, and dominant foot was evaluated. Time loss according to location and injury type was assessed. The chi-square test and Fisher exact test were used to test for differences in sex, age, and taekwondo experience and for comparison of injury location and type, injury mechanism, and side dominance, respectively. Training and competition IIRs and prevalence were calculated with 95% CIs (for Poisson rates). RESULTS: From an initial 107 athletes, 79 (73.8%) were included in the final data set. Of these athletes, 38 were injured (n = 112 injuries) for a prevalence of 48.1% (95% CI, 43%-52%). The overall IIR of the ankle joint was 13.14 injuries per 1000 athletes (95% CI, 1.5-25.9) and was significantly higher during competition versus training (P < .001). Ankle joint injuries were most common (n = 71; 63%). Significantly more noncontact versus contact ankle ligament injuries (n = 46; 83%) occurred (P < .001). The forefoot (n = 18; 66%) was mainly affected by contact injuries (P < .001). Time loss was the highest for midfoot fractures (mean ± SD, 23.0 ± 0.6 days; range, 23-24 days). CONCLUSION: Noncontact ligamentous ankle injuries were most common, with a higher incidence during competition. Improvement of strength, endurance, and postural stability under strain is recommended for prevention.

[Analysis of muscle injuries and return-to-training in elite Taekwondo athletes: results of a prospective cohort study over a period of five years]. / Analyse von Muskelverletzungen und "Return-to-Training" im Elite-Taekwondo ­ Ergebnisse einer prospektiven Kohortenstudie über einen Zeitraum von 5 Jahren.

BACKGROUND: Muscle injuries frequently occur in sports involving explosive movement patterns, and they can cause considerable downtime. There is a lack of detailed data on muscle injuries in Olympic elite Taekwondo. METHODS: All injuries sustained by 76 elite Taekwondo athletes from a national Olympic training centre during training and competition were prospectively recorded over a period of five years. Data on muscle injuries, including location and time elapsed until return-to-training, were extracted from medical records. Injuries were diagnosed by means of MRI and were classified according to the British Athletes Muscle Injury System. The relationship between MRI classification subgroups and time elapsed until return-to-training was assessed. RESULTS: Mean age of athletes was 22.5 ±â€Š3.2 (16-27) years with an average Taekwondo experience of 12.1 ±â€Š4.0 (7-20) years. Hamstring muscles were most commonly injured (48.4 %), followed by quadriceps muscles (32.3 %) and calf muscles (9.6 %). The analysis of MRI injury subgroups showed grade 1 (32.2 %) and grade 2 (41.9 %) injuries in most cases. A positive correlation was found between injury groups and return-to-training (r = 0.56). The comparison between different injury groups and time elapsed until return-to-training also revealed significant differences (p < 0.0001). CONCLUSION: Hamstring muscles are the most injured muscles in Taekwondo besides the quadriceps femoris muscle. Most injuries were mild to moderate (grade 1-2). The time needed for return-to-training increased significantly with the severity of injuries diagnosed by MRI.

Intramedullary nailing as a safe and efficient treatment option for all types of displaced proximal humeral fractures in geriatric patients: A retrospective evaluation of 49 patients treated with the new Targon PH+ nail.

BACKGROUND: Implant specific complications and outcome for the use of proximal humeral nails in different fracture types are not well described. OBJECTIVE: Evaluation of adverse effects and outcome of patients treated with the new Targon PH+ implant for proximal humeral fractures in a geriatric population. METHODS: A consecutive series of patients from a single institution was retrospectively evaluated. Adverse events (AE) were assessed from patients' files and during follow-up examination. Current pain level was evaluated using the Visual Analogue Scale (VAS). The disability score of arm, shoulder and hand (DASH) as well as the Constant-Murley score were assessed. Patient satisfaction was evaluated by questionnaire. RESULTS: Forty-nine patients with a mean age of 72.0 ± 10.0 years were included with a follow-up of 2.2 years. Five patients showed twopart fractures (10%), 24 threepart fractures (50%) and 20 fourpart fractures (40%). Additional shaft fracture occurred in twelve cases (24%). Implant-related AE were recorded in six cases (12%). Pain under strain was moderate with a mean of 27.6 ± 27.1 mm. DASH score showed a mean of 25.9 ± 24.9. Constant score of the affected shoulder was 57 ± 23.8 with a mean difference of 16 points compared to reference shoulder. No significant differences in AE, VAS, DASH or Constant score could be found according to fracture groups. Most patients were satisfied with the surgical outcome (84%). CONCLUSIONS: The Targon PH+ nail demonstrated good functional results and low adverse events in geriatric patients. Additional studies including less experienced centres are required to further evaluate the possible benefits of this implant.

IL-10 Could Play a Role in the Interrelation between Diabetes Mellitus and Osteoarthritis.

The association between osteoarthritis (OA), obesity and metabolic syndrome suggests an interrelation between OA and diabetes mellitus (DM). Little is known about the role of anti-inflammatory cytokine interleukin (IL)-10 in the interrelation between OA and DM. Hence, the effects of IL-10 under hyperglycemia (HG) and hyperinsulinemia (HI) in human articular chondrocytes (hAC) and chondrosarcoma cell line Okayama University Medical School (OUMS)-27 were examined. HAC and OUMS-27, cultured in normoglycemic (NG) and HG conditions were stimulated with insulin and/or IL-10. Cell survival, metabolic activity, proliferation and extracellular matrix (ECM) synthesis were immunocytochemically examined. No significant differences in vitality of hAC neither in pure NG (NGw/o) nor HG (HGw/o) conditions were found. Applying HI and/or IL-10 in both conditions reduced significantly the vitality of hAC but not of OUMS-27. HG impaired significantly hAC metabolism. When combined with HI + IL-10 or IL-10 alone it decreased also significantly hAC proliferation compared to NGw/o. In OUMS-27 it induced only a trend of impaired proliferation compared to NGw/o. hAC but not OUMS-27 reduced significantly their collagen type (col) I, SOX9 and proteoglycan (PG) synthesis in HG combined with HI +/- IL-10 compared to NGw/o. IL-10 could not moderate HI and HG effects. In contrast to hAC OUMS-27 showed limited sensitivity as DM model.