Autologous matrix-induced chondrogenesis provides better outcomes in comparison to autologous minced cartilage implantation in the repair of knee chondral defects.

PURPOSE: In symptomatic mid-sized focal chondral defects, autologous matrix-induced chondrogenesis (AMIC) and minced cartilage implantation (MCI) offer two versatile treatment options. This study aimed to conduct a matched-patient analysis of patient-reported outcome measures to compare these two surgical treatment methods for focal chondral defects. METHODS: At the first centre, patients underwent a single-stage procedure in which autologous cartilage was hand-minced, implanted into the defect and fixed with fibrin glue. At the second centre, patients underwent AMIC, which was fixed in place with fibrin glue. All patients were seen 2-4 years postoperatively. Postoperative outcomes were assessed using the visual analogue scale for pain (VAS), the Lysholm score and the five domains of the knee osteoarthritis outcome score (KOOS). Patients from each surgical centre were matched by age, sex, defect size and defect localisation. RESULTS: In total, 48 patients from two surgical centres (24 from each site) were matched for sex, age (MCI 30.3 ± 14.9 years vs. AMIC 30.8 ± 13.7 years) and defect size (MCI 2.49 ± 1.5 cm2 vs. AMIC 2.65 ± 1.1 cm2). Significantly better scores in the AMIC cohort were noted for VAS (p = 0.004), Lysholm (p = 0.043) and the KOOS subscales for pain (p = 0.016) and quality of life (p = 0.036). There was a significantly greater proportion of positive responders for Lysholm in the AMIC group (92%) compared with the MCI group (64%). CONCLUSIONS: The AMIC procedure delivers superior patient outcomes compared with hand-minced autologous cartilage implantation. These are mid-term outcomes, with follow-up between 2 and 4 years. LEVEL OF EVIDENCE: Level III.

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians.

AIM: Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality. METHODS: Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle. RESULTS: 71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p = < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray. CONCLUSION: Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

The infraacetabular screw versus the antegrade posterior column screw in acetabulum fractures with posterior column involvement: a biomechanical comparison.

INTRODUCTION: Traditionally, plate osteosynthesis of the anterior column combined with an antegrade posterior column screw is used for fixation of anterior column plus posterior hemitransverse (ACPHT) acetabulum fractures. Replacing the posterior column screw with an infraacetabular screw could improve the straightforwardness of acetabulum surgery, as it can be inserted using less invasive approaches, such as the AIP/Stoppa approach, which is a well-established standard approach. However, the biomechanical stability of a plate osteosynthesis combined with an infraacetabular screw instead of an antegrade posterior column screw is unknown. MATERIAL AND METHODS: Two osteosynthesis constructs were compared in a synthetic hemipelvis model with an ACPHT fracture: Suprapectineal plate + antegrade posterior column screw (APCS group) vs. suprapectineal plate + infraacetabular screw (IAS group). A single-leg stance test protocol with an additional passive muscle force and a cyclic loading of 32,000 cycles with a maximum effective load of 2400 N was applied. Interfragmentary motion and rotation of the three main fracture lines were measured. RESULTS: At the posterior hemitransverse fracture line, interfragmentary motion perpendicular to the fracture line (p < 0.001) and shear motion (p < 0.001) and at the high anterior column fracture line, interfragmentary motion longitudinal to the fracture line (p = 0.017) were significantly higher in the IAS group than in the APCS group. On the other hand, interfragmentary motion perpendicular (p = 0.004), longitudinal (p < 0.001) and horizontal to the fracture line (p = 0.004) and shear motion (p < 0.001) were significantly increased at the low anterior column fracture line in the APCS group compared to the IAS group. CONCLUSIONS: Replacing the antegrade posterior column screw with an infraacetabular screw is not recommendable as it results in an increased interfragmentary motion, especially at the posterior hemitransverse component of an ACPHT fracture.

Impact of the medial displacement calcaneal osteotomy on foot biomechanics: a systematic literature review.

INTRODUCTION: Progressive collapsing foot deformity (PCFD), formally known as "adult-acquired flatfoot deformity" (AAFFD), is a complex foot deformity consisting of multiple components. If surgery is required, joint-preserving procedures, such as a medial displacement calcaneal osteotomy (MDCO), are frequently performed. The aim of this systematic review is to provide a summary of the evidence on the impact of MDCO on foot biomechanics. MATERIALS AND METHODS: A systematic literature search across two major sources (PubMed and Scopus) without time limitation was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria. Only original research studies reporting on biomechanical changes following a MDCO were included. Exclusion criteria consisted of review articles, case studies, and studies not written in English. 27 studies were included and the methodologic quality graded according to the QUACS scale and the modified Coleman score. RESULTS: The 27 included studies consisted of 18 cadaveric, 7 studies based on biomechanical models, and 2 clinical studies. The impact of MDCO on the following five major parameters were assessed: plantar fascia (n = 6), medial longitudinal arch (n = 9), hind- and midfoot joint pressures (n = 10), Achilles tendon (n = 5), and gait pattern parameters (n = 3). The quality of the studies was moderate to good with a pooled mean QUACS score of 65% (range 46-92%) for in-vitro and a pooled mean Coleman score of 58 (range 56-65) points for clinical studies. CONCLUSION: A thorough knowledge of how MDCO impacts foot function is key in properly understanding the postoperative effects of this commonly performed procedure. According to the evidence, MDCO impacts the function of the plantar fascia and Achilles tendon, the integrity of the medial longitudinal arch, hind- and midfoot joint pressures, and consequently specific gait pattern parameters.

App-based analysis of the femoral tunnel position in ACL reconstruction using the quadrant method.

PURPOSE: The purpose of this study was to examine the intra- and interobserver variability of an app-based analysis of the femoral tunnel position using the quadrant method in primary anterior cruciate ligament reconstruction. MATERIALS AND METHODS: Between 12/2020 und 12/2021 50 patients who underwent primary anterior cruciate ligament reconstruction were included in this retrospective study. Intraoperative strictly lateral fluoroscopic images of the knee with marked femoral tunnel were analyzed by four observers using the quadrant method. For retest reliability analysis, measurements were repeated once by 2 observers after 4 weeks. RESULTS: The femoral tunnel position of all included patients averaged 27.86% in the depth relation and 15.61% in the height relation. Statistical analysis showed an almost perfect intra- and interobserver reliability in the depth and height relation. The ICC was 0.92 in the depth relation and 0.84 in the height relation. The Pearson's correlation coefficient in the depth and height relation of observer 1 (0.94/0.81) was only slightly different from the Pearson's correlation coefficient of observer 2 (0.92/0.85). The app-based tunnel analysis took on average 59 ± 16 s per measurement. CONCLUSION: The femoral tunnel analysis with the app-based quadrant method has an almost perfect intra- and interobserver reliability. By smartphone camera, a fast and highly accurate, if necessary also intraoperative, control of the tunnel position can be performed. LEVEL OF EVIDENCE: Level 3-diagnostic retrospective cohort study.

Arthroscopic and open reconstruction of the posterolateral corner of the knee have equally good clinical results: first results of a prospective 12-month follow-up study.

PURPOSE: Arthroscopic reconstruction techniques for higher-grade posterolateral corner (PLC) injuries (Fanelli Type B, PoLIS LI-B) have not yet been validated in clinical studies. The open reconstruction technique described by Arciero is well-established and showed good restoration of joint stability in previous studies. This study aimed to compare clinical outcomes of this established open surgery technique to a newly developed arthroscopic technique in a prospective randomized clinical trial. METHODS: Between 2019 and 2021, this study focused on chronic high-grade PLC injuries (Fanelli Type B, PoLIS LI-B). Group A consisted of patients treated with conventional open surgery following Arciero's technique, while Group B included patients treated with Arciero's arthroscopic technique. All cases underwent additional PCL reconstruction. After a minimum 12-month follow-up, clinical scores and objective stability assessments were compared between the groups. RESULTS: In total, 26 (group A 12, group B 14) eligible patients with a mean follow-up of 14.9 ± 7.2 months were evaluated in the present study. Knee stability and patient-reported outcome scores (PROMS) were significantly improved when comparing pre- and post-operative values (p < 0.0001). No clinically relevant differences in PROMS (Lysholm: A 83.9 ± 11.4 vs. B 85.3 ± 13.8; IKDC: A 76.91 ± 12.6 vs. B 76.8 ± 15.7) were shown in both groups. Additionally, no statistically significant differences were detected between groups with respect to external rotation, range of motion and instrumental stability testing. Arthroscopic reconstruction showed significantly shorter operation time (p = 0.0109). There were no clinical failures or neurovascular complications of the surgical procedures. CONCLUSION: Both surgical techniques for isolated chronic PLC Fanelli Type B injuries significantly improved the knee stability, were equivalent with respect to PROMs and led to good clinical results. However, arthroscopic PLC reconstruction was associated with a shorter surgery time compared to open PLC reconstruction. Therefore, arthroscopic PLC reconstruction may be a viable option in the hands of an experienced surgeon. LEVEL OF EVIDENCE: Prospective cohort study, II.

Impact of body mass index on fracture severity, clinical, radiological and functional outcome in distal radius fractures: a retrospective observational study after surgical treatment.

INTRODUCTION: Distal radius fracture (DRF) is one of the three most common fractures of the human body with increasing incidences in all groups of age. Known causes of increasing incidence, such as ageing of the population or increased obesity, have been described and discussed. So far, literature reports ambivalent effects of body mass index (BMI) on bone physiology. It is worthwhile to examine the influence of BMI on the outcome of fractures more detailed. This study aims to investigate the influence of an abnormal BMI on fracture severity and treatment, as well as clinical, radiological, and functional outcome to improve clinical decision making. MATERIALS AND METHODS: A retrospective observational study was conducted on data obtained from patients, who underwent open reduction and internal fixation (ORIF) of a DRF at a local Level 1 Trauma Center between May 2018 and October 2021. Follow-up examinations were performed approximately 1 year after surgical fracture treatment, during which various questionnaires and functional measurements (CMS, DASH, NRS, ROM) were applied. In addition, postoperative complications were recorded and radiological examinations of the affected hand were performed. After excluding incomplete data sets and applying set exclusion criteria, the complete data of 105 patients were analyzed. RESULTS: 74 patients were female and 31 male with significant difference in mean BMI [p = 0.002; female: 23.8 (SD ± 3.3), men: 26.2 (SD ± 3.9)]. Patients with higher BMI had significantly more severe fractures (p = 0.042). However, there was no significant difference in surgery time for fracture management. At follow-up, patients with lower BMI showed a smaller difference in hand strength between the fractured and the other hand (p = 0.017). The BMI had no significant effect on the clinical and radiological outcome. CONCLUSION: Despite the ambivalent effects of BMI on the skeletal system, our findings indicate that a higher BMI is associated with more severe DRF. Thereby BMI does not correlate with surgery time for fracture treatment. Furthermore, no evidence of an influence on the clinical and radiological outcome could be detected.

The diagnostic accuracy of 332 incisional biopsies in patients with malignant tumors in the musculoskeletal system.

BACKGROUND: It is known that specimen collection followed by histopathological workup is the core of evidence-based medical therapy of musculoskeletal tumors. There exist many controversies about how a biopsy should be performed. While some centers recommend minimal invasive biopsy procedures, mostly the core needle biopsy (CNB), others prefer the incisional biopsy. PURPOSE OF THE STUDY: This study aimed to determine the accuracy of incisional biopsy for malignant tumors in the musculoskeletal system. Moreover, advantages and disadvantages to other biopsy methods are discussed. METHODS: This retrospective, single-center study about 844 incisional biopsies (benign and malignant) analysis the diagnostic accuracy of 332 malignant tumors, concerning the final histopathological result. In addition, surgical complications are analyzed to find the best way to plan and treat patients timely and correct. Secondary endpoints are the patients age, the pure operation time, as well as the type of tumor, and the subsequent therapy. RESULTS: In summary, incisional biopsy corresponded a sensitivity of 100% for malignancy in 844 incisional biopsies and a specificity of 97.6% in 332 malignant tumors, but it features greater operative expense (incision/suture 23.5 min) and the risk of general anesthesia. CONCLUSION: The method of biopsy should be tailored to the individual patient and the experience of the center performing the procedure.

Developments in the epidemiology and surgical management of patella fractures in Germany.

BACKGROUND: Patella fractures account for approximately 1% of all skeletal injuries. Treatment options are vast and no definitive conclusion on what option is the most beneficial could be made so far. Plate osteosynthesis appears to gain in importance. We aim to give insight into the more recent trends and developments as well as establish the epidemiology of patella fractures in Germany by analysing treatment and epidemiological data from a national database. METHODS: Anonymised data was retrieved form a national database. In the period of 2006 to 2020, all patients with patella fractures as defined in ICD-10 GM as their main diagnosis, who were treated in a German hospital were included. Patients were divided into subgroups based on gender and age. Age groups were created in 10-year intervals from 20 years old up to 80 years old with one group each encompassing all those above the age of 80 years old and below 20 years old and younger. Linear regression was performed were possible to determine statistical significance of possible trends. RESULTS: A total of 151,435 patellar fractures were reported. 95,221 surgical interventions were performed. Women were about 1.5 times more likely to suffer from patella fracture than men. The relative number of surgical interventions rose from about 50% in 2006 to 75% in 2020. Most surgical interventions are performed in those over the age of 50. The incidence of complex fractures and plate osteosynthesis has significantly increased throughout the analysed period. CONCLUSIONS: We found a clear trend for surgical treatment in Germany with an increase in surgical procedures. We could also show that this ratio is age-related, making it more likely for younger patients in the age groups from 0 to 70 years old to receive surgical treatment for their patella fracture.

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.

Video analysis of Achilles tendon ruptures in professional male football (soccer) reveals underlying injury patterns and provides strategies for injury prevention.

PURPOSE: In professional football (soccer), Achilles tendon ruptures are severe injuries. Video analysis promotes a better understanding of the underlying situational and biomechanical patterns, and provides a roadmap for future research to improve the management and prevention of Achilles tendon ruptures. The purpose of this study was to identify injury patterns contributing to acute Achilles tendon ruptures in professional male football players. METHODS: Professional male football players with an acute Achilles tendon rupture were identified using an online database. For every in-competition injury, the corresponding football match was detected. Video footage of the injury was accessed using Wyscout.com or publicly available video databases. Situational patterns and injury biomechanics of the injury frame were independently analysed by two reviewers using a standardised checklist and a motion analysis software. Finally, consensus was reached to describe the main injury patterns of Achilles tendon ruptures in professional male football players. RESULTS: The search identified video footage of 80 Achilles tendon ruptures in 78 players. Most injuries (94%) occurred through indirect or non-contact mechanisms. The kinematic analysis revealed characteristic joint positions at the time of injury consisting of hip extension, knee extension, ankle dorsiflexion, foot abduction, and foot pronation in most cases. The underlying direction of movement was from flexion to extension (knee) and from plantarflexion to dorsiflexion (ankle). Player actions identified as main injury patterns were stepping back (26%), landing (20%), running/sprinting (18%), jumping (13%), and starting (10%). CONCLUSION: Most Achilles tendon ruptures in professional male football players are closed-chain indirect or non-contact injuries. Sudden loading to the plantarflexor musculotendinous unit remains to be the main component for most cases. By achieving a better understanding of underlying injury mechanisms, this study provides new strategies for the prevention of Achilles tendon ruptures. LEVEL OF EVIDENCE: Level IV.

Clinical results after arthroscopic reconstruction of the posterolateral corner of the knee: A prospective randomized trial comparing two different surgical techniques.

INTRODUCTION: Arthroscopic reconstruction techniques of the posterolateral corner (PLC) of the knee have been developed in recent years. Reconstruction techniques for higher-grade PLC injuries have not yet been validated in clinical studies. This study aimed to compare clinical outcomes of two different techniques and to present results of the first prospective randomized clinical trial of patients to undergo these novel procedures. MATERIALS AND METHODS: 19 patients with Fanelli Type B posterolateral corner injuries and additional posterior cruciate ligament ruptures were included in this prospective study. They were randomly assigned to one of two novel arthroscopic reconstruction techniques, based on open surgeries developed by Arciero (group A) and LaPrade (group B). Follow-up was conducted at 6 and 12 months postoperatively and included clinical examinations for lateral, rotational and posterior stability, range of motion and subjective clinical outcome scores (IKDC Subjective Score, Lysholm Score, Tegner Activity Scale and Numeric Rating Scale for pain). RESULTS: At 6 and 12 months postoperative, all patients in both groups presented stable to varus, external rotational and posterior forces, there were no significant differences between the two groups. At 12-month follow-up, group A patients showed significantly higher maximum flexion angles (134.17° ± 3.76° vs. 126.60° ± 4.22°; p = 0.021) compared to patients of group B. Duration of surgery was significantly longer in Group B patients than in group A (121.88 ± 11.63 vs. 165.00 ± 35.65 min; p = 0.003). Posterior drawer (side-to-side difference) remained more reduced in group A (2.50 ± 0.69 mm vs. 3.27 ± 0.92 mm; p = 0.184). Subjective patient outcome scores showed no significant differences between groups (Lysholm Score 83.33 ± 7.79 vs. 86.40 ± 9.21; p = 0.621). CONCLUSIONS: This study indicates sufficient restoration of posterolateral rotational instability, varus instability and posterior drawer after arthroscopic posterolateral corner reconstruction without neurovascular complications. Increased postoperative range of motion and a shorter and less invasive surgical procedure could favor the arthroscopic reconstruction technique according to Arciero over LaPrade's technique in future treatment considerations.

Morphology of the acromioclavicular-joint score (MAC).

INTRODUCTION: To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection. MATERIALS AND METHODS: In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width < 2 mm in conjunction with an AC angle > 12°. A scoring system consisting of the measured morphologic factors was developed. RESULTS: Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%. CONCLUSION: Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: a systematic review.

PURPOSE: The purpose of this study is to systematically review multiligament knee injury (MLKI) outcome studies to determine definitions of arthrofibrosis (AF) and provide information about incidence, management as well as potential risk factors. METHODS: A systematic literature search was performed (PubMed and Cochrane library) following the PRISMA guidelines of operatively treated MLKI (Schenck II-IV) studies reporting the incidence of AF. Twenty-five studies met the inclusion criteria. Injury pattern, timing of surgery, surgical technique, treatment of AF, rehabilitation programs and PROMS were inquired. Risk of bias and quality of evidence were assessed using the Coleman methodological score. RESULTS: Twenty-five studies with a total of 709 patients with a mean age of 33.6 ± 4.8 years were included and followed 47.2 ± 32.0 months. The majority of studies (22/25) used imprecise and subjective definitions of AF. A total of 86 patients were treated for AF, resulting in an overall prevalence of 12.1% (range 2.8-57.1). Higher-grade injuries (Schenck III-IV), acute treatment and ROM (range of motion) limiting rehabilitation programs were potential risk factors for AF. The time from index surgery to manipulation anesthesia (MUA) and arthroscopic lysis of adhesions (LOA) averaged at 14.3 ± 8.8 and 27.7 ± 12.8 weeks. Prior to MUA and LOA, the ROM was 51.7° ± 23.5 and 80.2° ± 17.0, resulting in a total ROM gain after intervention of 65.0° ± 19.7 and 48.0° ± 10.6, respectively; with no reports of any complication within the follow-up. The overall methodological quality of the studies was poor as measured by the Coleman score with average 56.3 ± 12.5 (range 31-84) points. CONCLUSIONS: AF is a common but poorly defined complication particularly in high-grade MLKI. Early postoperative and intensified physiotherapy is important to reduce the risk of AF. MUA and LOA are very effective treatment options and result in good clinical outcome. Prospective studies with bigger study population are needed to optimize treatment algorithms of further patients after MLKI. The protocol of this systematic review has been prospectively registered with PROSPERO (CRD42021229187, January 4th, 2021).

Classifications of posterior malleolar fractures: a systematic literature review.

INTRODUCTION: Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS: The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS: A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartonícek/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS: None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartonícek/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.

Full endoscopic anterior intrapelvic plate osteosynthesis: a cadaveric feasibility study.

In this investigation, it was assumed that it must be possible to visualize the intrapelvic aspect as accustomed by pelvic surgeons using the anterior intrapelvic (modified Stoppa) approach. Moreover, it was hypothesized, that plate mountings will not only be possible for the symphysis but also at the supra- and infrapectineal aspect as well as to the posterior column. Ten anonymized cadaveric specimens were included in this study. A standard laparoscopic totally extraperitoneal (TEP) approach was used. A total of 10 landmarks were defined that are usually within reach in the open anterior intrapelvic (AIP) approach. Moreover, five different plate mountings were tested. The locations were chosen in accordance with the indication spectrum suitable for open surgery through the traditional AIP approach. It was possible to gain intrapelvic visibility in seven of ten cases. In all of those seven cases, it was technically possible to place plates to the symphysis, superior pubic ramus, as well as longer anterior column plates up to the aspect posterior of the acetabulum. In the last four of the seven cases, it was possible to mount plates to the infrapectineal aspect as well as the posterior column, too. The team, previously trained in arthroscopic surgical techniques as well as pelvic trauma surgery, observed a steep learning curve. This investigation demonstrated, that endoscopic anterior intrapelvic plate osteosynthesis was feasible in the majority of the cases in a series of ten cadaveric models. New instruments will be needed such as extra-long rasp elevators, ball-spikes as well as devices to hold and position plates and extra-long self-holding screwdrivers. With these, endoscopic pelvic surgery will likely be a realistic option for selected pelvic trauma cases in the future.

Osteoid osteoma in the bones of the hand: a systematic literature review.

INTRODUCTION: Osteoid osteoma (OO) is a common benign bone tumor. OO is observed most frequently in the long bones, especially in the tibia and femur. When occurring in the bones of the hand, OO can be a diagnostic and therapeutic challenge. The aim of this study was to provide a systematic review of occurrence, symptoms, diagnosis and treatment options regarding OO in hand bones. MATERIALS AND METHODS: We performed a systematic review of the literature. All studies from the online databases PubMed and SpringerLink, which reported cases of osteoid osteomas in the bones of the hand, were included. By summarizing the literature, we evaluated the localization within the hand as well as diagnostic and therapeutic options. RESULTS: We included 133 studies reporting 401 cases. OO was mostly common in the phalanges. The diagnosis was mostly made by CT (computed tomography) scan. Most of the OO were treated surgically by open curettage or en bloc resection. CONCLUSIONS: Osteoid osteomas in the bones of the hand are rare and a delayed diagnosis is common. In cases of pain combined with particular symptoms such as nail hypertrophy and swelling OO should be considered. Of the most used imaging methods, CT scans have the highest sensitivity.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review.

PURPOSE: To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare. METHODS: A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality. RESULTS: The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory. CONCLUSION: Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment. LEVEL OF EVIDENCE: Systematic Review of Level III and Level IV Studies, Level IV.

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.

Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study.

INTRODUCTION: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE: Level II.