Analysis of postoperative complications 5 years after osteosynthesis of patella fractures-a retrospective, multicenter cohort study.

PURPOSE: The study aims to investigate the influence of patient- and fracture-specific factors on the occurrence of complications after osteosynthesis of patella fractures and to compare knee joint function, activity, and subjective pain levels after a regular postoperative course and after complications in the medium term. METHODS: This retrospective, multicenter cohort study examined patients who received surgery for patella fracture at level 1 trauma centers between 2013 and 2018. Patient demographics and fracture-specific variables were evaluated. Final follow-up assessments included patient-reported pain scores (NRS), subjective activity and knee function scores (Tegner Activity Scale, Lysholm score, IKDC score), complications, and revisions. RESULTS: A total of 243 patients with a mean follow-up of 63.4 ± 21.3 months were included. Among them, 66.9% of patients underwent tension band wiring (TBW), 19.0% received locking plate osteosynthesis (LPO), and 14.1% underwent screw osteosynthesis (SO). A total of 38 patients (15.6%) experienced complications (TBW: 16.7%; LPO: 15.2%; SO: 11.8%). Implant-related complications of atraumatic fragment dislocation and material insufficiency/dislocation, accounted for 50% of all complications, were significantly more common after TBW than LPO (p = 0.015). No patient-specific factor was identified as a general cause for increased complications. Overall, particularly following complications such as limited range of motion or traumatic refracture, functional knee scores were significantly lower and pain levels were significantly higher at the final follow-up when a complication occurred. Implant-related complications, however, achieved functional scores comparable to a regular postoperative course without complications after revision surgery. CONCLUSION: The present study demonstrated that implant-related complications occurred significantly more often after TBW compared to LPO. The complication rates were similar in all groups.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment. / S2k-Leitlinie Tibiakopffraktur ­ Klassifikation, Diagnostik und Therapie.

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

2-year results of middle-aged patients with two-compartment cartilage lesions in one knee treated with two patient specific metal implants.

PURPOSE: Focal chondral lesions of the femur are currently treated with biological repair or arthroplasty. However, some patients are not suitable for either one due to lesion size, age, or prior biological treatment attempts. While singular patient-specific focal mini metal implants already showed good results, the outcomes of bicompartmental implantation of these implants have not been discussed in the literature yet. This study aims to evaluate clinical outcomes of patients who underwent bicompartmental implantation of two patient-specific implants. METHODS: This prospective, non-randomized, non-comparative pilot study evaluates results up to two years after bicompartmental implantation of two implants (Episealer Implant, Episurf, Stockholm, Sweden). A damage report is compiled using a special MRI program and patient specific implants are manufactured, including 3D-printed surgical instruments to provide exact placement of the implant. The patients were assessed repeatedly using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analogue Scale (VAS) for pain during the follow-up. RESULTS: The scores were evaluated three, 12, and 24 months after surgery and showed good results. The median in both scores improved from 37.7 for the KOOS5 preoperatively to 69.1 after 24 months and from 69 for the VAS for pain preoperatively to 9 after 24 months. CONCLUSION: Overall, for the small study group presented, the early results are promising. With noticeable improvement in KOOS and VAS for pain after two years, patient specific implants appear to become relevant in future standardized treatment of femoral chondral lesions. Especially with bicompartmental implantation, full arthroplasty can be delayed even further. LEVEL OF EVIDENCE: IV.

High degree of consensus amongst an expert panel regarding focal resurfacing of chondral and osteochondral lesions of the femur with mini-implants.

INTRODUCTION: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements. METHODS: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement. RESULTS: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus. CONCLUSION: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. LEVEL OF EVIDENCE: Level V.

Primary Proximal ACL Repair: A Biomechanical Evaluation of Different Arthroscopic Suture Configurations.

Purpose: Several suture techniques have been described in the past for direct ACL repair with poor healing capacity and a high re-rupture rate. Therefore, we investigated a refixation technique for acute primary proximal ACL repair. The purpose of this study is to compare the biomechanical properties of different suture configurations using a knotless anchor. Methods: In this study, 35 fresh-frozen porcine knees underwent proximal ACL refixation. First, in 10 porcine femora, the biomechanical properties of the knotless anchor, without the ligament attached, were tested. Then, three different suture configurations were evaluated to reattach the remaining ACL. Using a material testing machine, the structural properties were evaluated for cyclic loading followed by loading to failure. Results: The ultimate failure load of the knotless anchor was 198, 76 N ± 23, 4 N significantly higher than all of the tested ACL suture configurations. Comparing the different configurations, the modified Kessler-Bunnell suture showed significant superior ultimate failure load, with 81, 2 N ± 15, 6 N compared to the twofold and single sutures (50, 5 N ± 14 N and 37, 5 ± 3, 8 N). In cyclic loading, there was no significant difference noted for the different configurations in terms of stiffness and elongation. Conclusions: The results of this in vitro study show that when performing ACL suture using a knotless anchor, a modified Kessler-Bunnell suture provides superior biomechanical properties than a single and a twofold suture. Within this construct, no failure at the bone-anchor interface was seen. Clinical relevance: Since primary suture repair techniques of ACL tears have been abandoned because of inconsistent results, ACL reconstruction remains the gold standard of treating ACL tears. However, with the latest improvements in surgical techniques, instrumentation, hardware and imaging, primary ACL suture repair might be a treatment option for a select group of patients. By establishing an arthroscopic technique in which proximal ACL avulsion can be reattached, the original ACL can be preserved by using a knotless anchor and a threefold suture configuration. Nevertheless, this technique provides an inferior ultimate failure load compared to graft techniques, so a careful rehabilitation program must be followed if using this technique in vivo.

Comparable Instrumented Knee Joint Laxity and Patient-Reported Outcomes After ACL Repair With Dynamic Intraligamentary Stabilization or ACL Reconstruction: 5-Year Results of a Randomized Controlled Trial.

BACKGROUND: Technical innovation has led to the renaissance of anterior cruciate ligament (ACL) repair in the past decade. PURPOSE/HYPOTHESIS: The present study aimed to compare instrumented knee joint laxity and patient-reported outcomes (PROs) after ACL repair with those after primary ACL reconstruction for acute isolated ACL tears. It was hypothesized that ACL repair would lead to comparable knee joint stability and PROs at 5 years postoperatively in comparison with ACL reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair using dynamic intraligamentary stabilization (DIS) or primary ACL reconstruction with a semitendinosus tendon autograft. The primary outcome was the side-to-side difference in anterior tibial translation (ΔATT) assessed by Rolimeter testing at 5 years postoperatively. Follow-up examinations were performed at 1, 2, and 5 years. PROs were assessed using the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score, and the Lysholm score. Furthermore, the rates of recurrent instability, other complications, and revision surgery were recorded. A power analysis was performed a priori, and the Friedman test, Mann-Whitney U test, and Bonferroni correction were applied for statistical comparisons with significance set at P < .05. RESULTS: The mean age at inclusion was 28.3 ± 11.5 years in the ACL repair group and 27.1 ± 11.5 years in the ACL reconstruction group. At 5 years postoperatively, a total of 64 patients (ACL repair: n = 34 of 43 [79%]; ACL reconstruction: n = 30 of 42 [71%]) were available for follow-up. At 5 years, ΔATT was 1.7 ± 1.6 mm in the ACL repair group and 1.4 ± 1.3 mm in the ACL reconstruction group (P = .334). Preinjury PROs were restored as soon as 1 year after surgery and plateaued until 2 and 5 years postoperatively in both groups. At the 5-year follow-up, the mean Lysholm score was 97.0 ± 5.4 versus 94.5 ± 5.5 (P = .322), respectively, and the mean IKDC subjective score was 94.1 ± 9.9 versus 89.9 ± 7.8 (P = .047), respectively, in the ACL repair group versus ACL reconstruction group. At 5 years postoperatively, 12 patients in the ACL repair group (35%; age <25 years: n = 10/12; Tegner score ≥7: n = 10/12) had recurrent instability, of whom 10 underwent single-stage revision ACL reconstruction. In the ACL reconstruction group, there were 6 patients with recurrent instability (20%; age <25 years: n = 6/6; Tegner score ≥7: n = 5/6); however, in 5 patients, staged revision was required. Differences between both groups regarding recurrent instability (P = .09) or ACL revision surgery (P = .118) were not statistically significant. Recurrent instability was associated with age <25 years and Tegner score >7 in both groups. CONCLUSION: At 5 years after ACL repair with DIS, instrumented knee joint laxity and PROs were comparable with those after ACL reconstruction. Although no significant difference was found between repair and reconstruction, a critical appraisal of the rates of recurrent instability (35% vs 20%, respectively) and revision surgery (38% vs 27%, respectively) is needed. Young age and a high preinjury activity level were the main risk factors for recurrent instability in both groups. However, single-stage revision ACL reconstruction was possible in each case in the ACL repair group. Although ACL reconstruction remains the gold standard in the treatment of ACL tears, the present study supports the use of ACL repair with DIS as a feasible option to treat acute ACL tears in patients aged ≥25 years with low to moderate activity levels (Tegner score <7). REGISTRATION: DRKS00015466 (German Clinical Trials Register).

LOQTEQ® VA Periprosthetic Plate-A New Concept for Bicortical Screw Fixation in Periprosthetic Fractures: A Technical Note.

Internal fixation using angle stable plates is the treatment standard in periprosthetic fractures around stable implants. To provide instant postoperative full weight-bearing, bicortical screw fixation is advisable but often surgically demanding. This work presents the first clinical results of the LOQTEQ® VA Periprosthetic Plate (aap Implantate AG, Berlin, Germany), a new plate system to simplify screw placement around implants. This plate system uses insertable hinges that allow for variable angle screw anchorage. Data of 26 patients with a mean age of 80 years and a mean follow-up of 13.9 months were retrospectively collected. Patients were clinically and radiologically examined. Bony union was achieved in 14 out of 15 patients with no signs of non-union or implant loosening. One patient, however, presented with implant failure. Clinical scores demonstrated acceptable results. Since the hinge plates are easy to apply, the first results are promising.

Peri- and Interprosthetic Femoral Fractures-Current Concepts and New Developments for Internal Fixation.

Treatment of peri- and interprosthetic fractures represents a challenge in orthopedic trauma surgery. Multiple factors such as osteoporosis, polymedication and comorbidities impede therapy and the rehabilitation of this difficult fracture entity. This article summarizes current concepts and highlights new developments for the internal fixation of periprosthetic fractures. Since the elderly are unable to follow partial weight bearing, stable solutions are required. Therefore, a high primary stability is necessary. Numerous options, such as new angular stable plate systems with additional options for variable angle screw positioning, already exist and are in the process of being further improved. Lately, individually produced custom-made implants are offering interesting alternatives to treat periprosthetic fractures.

A New System for Periprosthetic Fracture Stabilization-A Biomechanical Comparison.

In recent years, an increase in periprosthetic femur fractures has become apparent due to the increased number of hip replacements. In the case of Vancouver type B1 fractures, locking plate systems offer safe procedures. This study compared the distal lateral femur plate (LOQTEQ®, aap Implantate AG) with a standard L.I.S.S. LCP® (DePuy Synthes) regarding their biomechanical properties in fixation of periprosthetic femur fractures after hip arthroplasty. We hypothesized that the new LOQTEQ system has superior stability and durability in comparison. Eighteen artificial left femurs were randomized in two groups (Group A: LOQTEQ®; Group B: L.I.S.S. LCP®) and tested until failure. Failure was defined as 10° varus deformity and catastrophic implant failure (loosening, breakage, progressive bending). Axial stiffness, loads of failure, cycles of failure, modes of failure were recorded. The axial stiffness in Group A with 73.4 N/mm (SD +/- 3.0) was significantly higher (p = 0.001) than in Group B (40.7 N/mm (SD +/- 2.8)). Group A resists more cycles than Group B until 10° varus deformity. Catastrophic failure mode was plate breakage in Group A and bending in Group B. In conclusion, LOQTEQ® provides higher primary stability and tends to have higher durability.

Patient-specific metal implants for focal chondral and osteochondral lesions in the knee; excellent clinical results at 2 years.

PURPOSE: Surgical treatment options for the management of focal chondral and osteochondral lesions in the knee include biological solutions and focal metal implants. A treatment gap exists for patients with lesions not suitable for arthroplasty or biologic repair or who have failed prior cartilage repair surgery. This study reports on the early clinical and functional outcomes in patients undergoing treatment with an individualised mini-metal implant for an isolated focal chondral defect in the knee. METHODS: Open-label, multicentre, non-randomised, non-comparative retrospective observational analysis of prospectively collected clinical data in a consecutive series of 80 patients undergoing knee reconstruction with the Episealer® implant. Knee injury and Osteoarthritis Outcome Score (KOOS) and VAS scores, were recorded preoperatively and at 3 months, 1 year, and 2 years postoperatively. RESULTS: Seventy-five patients were evaluated at a minimum 24 months following implantation. Two patients had undergone revision (2.5%), 1 declined participation, and 2 had not completed the full data requirements, leaving 75 of the 80 with complete data for analysis. All 5 KOOS domain mean scores were significantly improved at 1 and 2 years (p < 0.001-0.002). Mean preoperative aggregated KOOS4 of 35 (95% CI 33.5-37.5) improved to 57 (95% CI 54.5-60.2) and 59 (95% CI 55.7-61.6) at 12 and 24 months respectively (p < 0.05). Mean VAS score improved from 63 (95% CI 56.0-68.1) preoperatively to 32 (95% CI 24.4-38.3) at 24 months. The improvement exceeded the minimal clinically important difference (MCID) and this improvement was maintained over time. Location of defect and history of previous cartilage repair did not significantly affect the outcome (p > 0.05). CONCLUSION: The study suggests that at 2 years, Episealer® implants are safe with a low failure rate of 2.5% and result in clinically significant improvement. Individualised mini-metal implants with appropriate accurate guides for implantation appear to have a place in the management of focal femoral chondral and osteochondral defects in the knee. LEVEL OF EVIDENCE: IV.

[Current treatment standard for patella fractures in Germany]. / Aktueller Versorgungsstandard von Patellafrakturen in Deutschland.

BACKGROUND: The treatment of patella fractures is technically demanding. Although the radiological results are mostly satisfactory, this often does not correspond to the subjective assessment of the patients. The classical treatment with tension band wiring with K­wires has several complications. Fixed-angle plate osteosynthesis seems to be biomechanically advantageous. OBJECTIVE: Who is treating patella fractures in Germany? What is the current standard of treatment? Have modern forms of osteosynthesis become established? What are the most important complications? MATERIAL AND METHODS: The members of the German Society for Orthopedics and Trauma Surgery and the German Knee Society were asked to participate in an online survey. RESULTS: A total of 511 completed questionnaires were evaluated. Most of the respondents are specialized in trauma surgery (51.5%), have many years of professional experience and work in trauma centers. Of the surgeons 50% treat ≤5 patella fractures annually. In almost 40% of the cases preoperative imaging is supplemented by computed tomography. The classical tension band wiring with K­wires is still the preferred form of osteosynthesis for all types of fractures (transverse fractures 52%, comminuted fractures 40%). In the case of comminuted fractures 30% of the surgeons choose fixed-angle plate osteosynthesis. If the inferior pole is involved a McLaughlin cerclage is used for additional protection in 60% of the cases. DISCUSSION: The standard of care for patella fractures in Germany largely corresponds to the updated S2e guidelines. Tension band wiring is still the treatment of choice. Further (long-term) clinical studies are needed to verify the advantages of fixed-angle plates.

Periprosthetic fracture fixation in Vancouver B1 femoral shaft fractures: A biomechanical study comparing two plate systems.

INTRODUCTION: Periprosthetic fractures of the femur are an increasing problem in today's trauma and orthopaedic surgery. Owing to the hip stem, implant anchorage is very difficult in the proximal femur. This study compares two plate systems regarding their biomechanical properties and the handling in periprosthetic fracture fixation of the proximal femur. MATERIALS AND METHODS: Using eight pairs of fresh, frozen human proximal femora the Locking Compression Plate/Locking Attachment Plate construct (LCP/LAP) (group I, DePuy Synthes) was compared to the new LOQTEQ® periprosthetic distal lateral femur plate (group II, AAP Implantate AG). After implantation of press fit femoral hip stems a Vancouver B1 fracture model was used. Biomechanical testing was performed by cyclic axial loading with a constant increment of 0.1 N/cycle starting from 750 N axial loading. Every 250 cycles an a.p. x-ray was done to evaluate failure. RESULTS: The Group II showed significant higher axial stiffness (+42%) compared with Group I. In addition, Group II withstood significantly more load-cycles until failure (20%). The mode of catastrophic failure was plate breakage in Group II, whereas, in Group I, all plates showed an early bending followed by plate breakage. DISCUSSION AND CONCLUSION: Both plate systems enable screw placement around hip stems. The hinge plate showed superior biomechanical results compared with the locking compression plate/locking attachment plate construct. Furthermore, the hinge plate offers variable hinges and variable angel locking making bicortical screw placement around hip stems more comfortable and safe. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The results of this study can be directly transferred to patient care. With the innovative hinge plate, the surgeon has a biomechanically superior implant, which also offers improved options for screw placement compared to a standard locking plate.

Repair With Dynamic Intraligamentary Stabilization Versus Primary Reconstruction of Acute Anterior Cruciate Ligament Tears: 2-Year Results From a Prospective Randomized Study.

BACKGROUND: Anterior cruciate ligament (ACL) repair has once again become a focus of research because of the development of new techniques. PURPOSE/HYPOTHESIS: The purpose was to compare the functional results and recurrent instability rates in patients undergoing ACL repair with dynamic intraligamentary stabilization (DIS) versus primary ACL reconstruction (ACLR) for acute isolated ACL tears. The hypothesis was that functional results and knee joint stability after ACL repair with DIS would be comparable with that after ACLR. STUDY DESIGN: Randomized clinical trial; Level of evidence, 1. METHODS: A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair with DIS or primary ACLR. The preinjury activity level and function were recorded. Follow-up examinations were performed at 6 weeks and 6, 12, and 24 months postoperatively. Anterior tibial translation (ATT) was evaluated using Rolimeter testing. The Tegner activity scale, International Knee Documentation Committee (IKDC) subjective form, and Lysholm knee scoring scale scores were obtained. Clinical failure was defined as ΔATT >3 mm in combination with subjective instability. Recurrent instability and other complications were recorded. RESULTS: There were 83 patients (97.6%) who were successfully followed until 2 years. ATT was significantly increased in the DIS group compared with the ACLR group (ΔATT, 1.9 vs 0.9 mm, respectively; P = .0086). A total of 7 patients (16.3%) in the DIS group had clinical failure and underwent single-stage revision. In the ACLR group, 5 patients (12.5%) had failure of the reconstruction procedure; 4 of these patients required 2-stage revision. The difference in the failure rate was not significant (P = .432). There were 4 patients (3 in the DIS group and 1 in the ACLR group) who showed increased laxity (ΔATT >3 mm) without subjective instability and did not require revision. Recurrent instability was associated with young age (<25 years) and high Tegner scores (>6) in both groups. No significant differences between ACL repair with DIS and ACLR were found for the Tegner, IKDC, and Lysholm scores at any time. CONCLUSION: Whereas ATT measured by Rolimeter testing was significantly increased after ACL repair with DIS, clinical failure was similar to that after ACLR. In addition, functional results after ACL repair with DIS for acute tears were comparable with those after ACLR. The current study supports the use of ACL repair with DIS as an option to treat acute ACL tears. REGISTRATION: DRKS00015466 (German Clinical Trials Register).

Implant preloading in extension reduces spring length change in dynamic intraligamentary stabilization: a biomechanical study on passive kinematics of the knee.

PURPOSE: Dynamic intraligamentary stabilization (DIS) is a primary repair technique for acute anterior cruciate ligament (ACL) tears. For internal bracing of the sutured ACL, a metal spring with 8 mm maximum length change is preloaded with 60-80 N and fixed to a high-strength polyethylene braid. The bulky tibial hardware results in bone loss and may cause local discomfort with the necessity of hardware removal. The technique has been previously investigated biomechanically; however, the amount of spring shortening during movement of the knee joint is unknown. Spring shortening is a crucial measure, because it defines the necessary dimensions of the spring and, therefore, the overall size of the implant. METHODS: Seven Thiel-fixated human cadaveric knee joints were subjected to passive range of motion (flexion/extension, internal/external rotation in 90° flexion, and varus/valgus stress in 0° and 20° flexion) and stability tests (Lachman/KT-1000 testing in 0°, 15°, 30°, 60°, and 90° flexion) in the ACL-intact, ACL-transected, and DIS-repaired state. Kinematic data of femur, tibia, and implant spring were recorded with an optical measurement system (Optotrak) and the positions of the bone tunnels were assessed by computed tomography. Length change of bone tunnel distance as a surrogate for spring shortening was then computed from kinematic data. Tunnel positioning in a circular zone with r = 5 mm was simulated to account for surgical precision and its influence on length change was assessed. RESULTS: Over all range of motion and stability tests, spring shortening was highest (5.0 ± 0.2 mm) during varus stress in 0° knee flexion. During flexion/extension, spring shortening was always highest in full extension (3.8 ± 0.3 mm) for all specimens and all simulations of bone tunnels. Tunnel distance shortening was highest (0.15 mm/°) for posterior femoral and posterior tibial tunnel positioning and lowest (0.03 mm/°) for anterior femoral and anterior tibial tunnel positioning. CONCLUSION: During passive flexion/extension, the highest spring shortening was consistently measured in full extension with a continuous decrease towards flexion. If preloading of the spring is performed in extension, the spring can be downsized to incorporate a maximum length change of 5 mm resulting in a smaller implant with less bone sacrifice and, therefore, improved conditions in case of revision surgery.

Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction.

PURPOSE: Dynamic intraligamentary stabilization (DIS) has been introduced as a new technique to repair the torn anterior cruciate ligament (ACL) and to restore knee joint kinematics after an acute ACL tear. Aim of the present study was to compare the early post-operative activity, restoration of gait pattern and functional results after DIS in comparison with primary ACL reconstruction (ACLR) for acute ACL tears. It was hypothesized that functional results, post-operative activity and changes in gait pattern after DIS are comparable to those after ACLR. METHODS: Sixty patients with acute ACL tears were included in this study and underwent either DIS or ACLR with an anatomic semitendinosus autograft in a randomized manner. Patients were equipped with an accelerometric step counter for the first 6 weeks after surgery in order to monitor their early post-operative activity. 3D gait analysis was performed at 6 weeks and 6 months after surgery. Temporal-spatial, kinematic and kinetic parameters were extracted and averaged for each subject. Functional results were recorded at 6 weeks, 6 months and 12 months after surgery using the Tegner activity scale, International Knee Documentation Committee score and Lysholm score. RESULTS: Patients who underwent DIS showed an increased early post-operative activity with significant differences at week 2 and 3 (p = 0.0241 and 0.0220). No significant differences between groups were found for knee kinematic and kinetic parameters or the functional scores at any time of the follow-up. Furthermore, the difference in anterior tibial translation was not significantly different between the two groups (n.s.). CONCLUSION: Early functional results and changes in gait pattern after DIS are comparable to those of primary ACLR. Therefore, ACL repair may be an alternative to ACLR in this cohort of patients. LEVEL OF EVIDENCE: I.

Reverse total shoulder arthroplasty for type I fracture sequelae after internal fixation of proximal humerus fractures.

INTRODUCTION: Complications after internal fixation of proximal humerus fracture are common and may require surgical revision. Reverse total shoulder arthroplasty (RTSA) is frequently performed in such cases. The aim of the present study was to evaluate the functional results and complications after RTSA for the treatment of type I fracture sequelae after internal fixation of proximal humerus fractures. MATERIALS AND METHODS: 26 patients (18 female, 8 male) underwent surgical revision of type I fracture sequelae of the proximal humerus after locking plate (n = 22) or intramedullary nail (n = 4) fixation. The mean age of the patients at the time of the revision was 75 years (range 65-89). After a mean follow-up of 36 months (range 18-58), clinical examination was performed and the age- and gender-related Constant-Murley Score (CMS) and the Oxford Shoulder Score (OSS) were obtained from all patients and compared to the pre-revision values. RESULTS: The mean age- and gender-related CMS of the affected shoulder increased from 44% (range 17-65) to 73% (range 44-97). This difference was statistically significant (p < 0.001). The CMS of the unaffected shoulder was 93% (range 72-98). This relates to a ratio in the CMS of 78% between the affected and the contralateral shoulder. The mean OSS was 28 points (range 12-54) for the operated shoulder and 43 points (range 34-48) for the unaffected side, resulting in 66% ratio. Again, the OSS improved significantly when compared with the preoperative values (p < 0.001). A total of five complications including two periprosthetic fractures were observed and required surgical revision. CONCLUSION: Satisfying results can be obtained with RTSA as a salvage procedure for type I fracture sequelae after previous internal fixation of proximal humerus fractures.

Management of comminuted fractures of the distal humerus: clinical outcome after primary external fixation versus immediate fixation with locking plates.

OBJECTIVES: The surgical treatment of comminuted fractures of the distal humerus remains a challenging problem. The aim of the present study was to compare the clinical outcomes of primary external fixation with second-staged open reduction and internal fixation (ORIF) and initial definitive internal fixation in surgically treated patients with comminuted distal humerus fractures. DESIGN: Retrospective comparative study. SETTING: Level one trauma center. PATIENTS: A total of 24 patients (median age 52 years; range 14-84 years) were included: 15 patients were treated with initial definitive internal fixation with pre-contoured locking compression plates (group A), and 9 patients underwent surgical treatment with primary external fixation and second-staged ORIF (group B). Only patients with C3 fractures according to the AO classification were included in the study. MAIN OUTCOME MEASUREMENT: Disability of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS). INTERVENTION: External fixation internal fixation with locking plates. RESULTS: The median follow-up was 37 months for both groups. There was a significantly higher median elbow extension deficit in group B (39°) compared to group A (17°) (p = 0.048). The mean DASH score in group A was 14 and 12.5 in group B. MEPS showed that more patients in group A achieved excellent results; however, there was no significant difference compared to group B. CONCLUSIONS: Primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation. Thus, the use of primary external fixation in cases of comminuted distal humerus fractures appears to have a negative influence on the patient outcomes. LEVEL OF EVIDENCE: Therapeutic level III.

Cost-utility analysis of dynamic intraligamentary stabilization versus early reconstruction after rupture of the anterior cruciate ligament.

OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness of the dynamic intraligamentary stabilization (DIS) technique in comparison with reconstructive surgery (ACLR) in the treatment of isolated anterior cruciate ligament (ACL) ruptures from the perspective of the community of insured citizens in Germany. METHODS: Because of the specific decision problem at hand, namely that with DIS the procedure has to take place within 21 days after the initial trauma, a decision tree was developed. The time horizon of the model was set to 3 years. Input data was taken from official tariffs, payer data, the literature and assumptions based on expert opinion when necessary. RESULTS: The decision tree analysis identified the DIS strategy as the superior one with 2.34 QALY versus 2.26 QALY for the ACLR branch. The higher QALY also came with higher costs of 5,398.05 € for the DIS branch versus 4,632.68 € for the ACLR branch respectively, leading to an ICER of 9,092.66 € per QALY. Results were robust after sensitivity analysis. Uncertainty was examined via probabilistic sensitivity analysis resulting in a slightly higher ICER of 9,567.13 € per QALY gained. CONCLUSION: The DIS technology delivers an effective treatment for the ACL rupture at a favorable incremental cost-effectiveness ratio.