Current Trends in Orthopaedics and Trauma in Germany.

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

[Evaluation of the current research structures in trauma surgery : A survey of the scientific committee of the German Society for Trauma Surgery]. / Erhebung der Forschungsstrukturen in der Unfallchirurgie : Eine Umfrage des Wissenschaftsausschusses der DGU.

BACKGROUND: To improve research in orthopedics and traumatology (O&T) in Germany, the implementation of comprehensive research collaborations and enhanced communication pathways among different institutions are necessary. This survey was initiated to collect data regarding the current research structures in O&T. MATERIAL AND METHODS: A subject-specific questionnaire was sent via email to collect data regarding demographics, on-going and past research activities and the funding. Naming of current and future research topics and problems regarding realization of projects were determined. All results were submitted electronically, anonymously and voluntarily. RESULTS: Of 229 participants, 83% worked as clinicians and 59.6% of the participants were working in departments with joint structures (O&T). Industry and universities were found to be the essential funding sources. Future research topics tend to concentrate on digital health issues (artificial intelligence, big data, 3D-printing). Resource scarcity in time and staff as well as administrative barriers but also insufficient funding were identified as major impediments of research activity. CONCLUSION: Future research development in O&T will cause an expansion of techniques and methods. At the same time aggravated personnel, financial, administrative and legal framework conditions can only be managed with an intensively increased effort. Cooperation projects and collaborative research structures might be a solution to these challenges.

[Triangular minimally invasive spinopelvic stabilization for type C pelvic fractures according to AO/OTA and type IV according to FFP]. / Trianguläre minimal-invasive spinopelvine Stabilisierung bei Beckenfrakturen Typ C nach der Klassifikation der Arbeitsgemeinschaft für Osteosynthesefragen (AO/OTA) und Typ IV nach den Fragilitätsfrakturen (FFP).

INTRODUCTION: Spinopelvic instability is common in type IV fragility fractures of the pelvic ring (FFP) and type C traumatic pelvic fractures. This results in the indications for operative stabilization using a spinopelvic support. Due to the variety of surgical techniques for spinopelvic support it is unclear what importance a minimally invasive spinopelvic screw-rod osteosynthesis can have. MATERIAL AND METHODS: In the retrospective clinical study over a period of 2 years, 23 patients (median age 67 years, 5 male and 18 female) with unstable pelvic fractures (FFP type IV: n = 12, AO/OTA type C: n = 11) treated by triangular minimally invasive spinopelvic stabilization (TMSS) were included in the study. The patient data were examined with respect to the parameters gender, age, fracture morphology, intraoperative blood loss, operating time, postoperative infection, postoperative reduction result in the computed tomography (CT) imaging and screw loosening. RESULTS: The average age of the 11 type C fractures was 43 years and that of the 12 FFP type IV fractures was 80 years. The follow-up period was on average 12.2 months. The average operation time was 67 min, the blood loss was 70 ml, there were 2 postoperative infections and 4 cases of screw loosening. The reduction according to Matta was < 4 mm for all FFP and between 4-20 mm for traumatic pelvic fractures. Symptomatic pseudarthroses occurred in 3 cases. CONCLUSION: The triangular minimally invasive spinopelvic stabilization (TMSS) showed a stable and sufficient treatment of the type IV fragility fractures and in the slightly displaced type C traumatic pelvic fractures. Coarse fracture dislocations limit the procedure.

Can a Balance Wristband Influence Postural Control?

Eichhorn, S, Foerster, S, Friemert, B, Willy, C, Riesner, H-J, and Palm, H-G. Can a balance wristband influence postural control? J Strength Cond Res 34(12): 3416-3422, 2020-Top sports performances cannot be achieved without a high level of postural control. Balance wristbands purport to improve the mental and physical balance of the wearer. It is still unclear, however, whether these wristbands can indeed enhance postural control. Our aim was to ascertain through computerized dynamic posturography whether balance wristbands can improve postural stability. In this randomized controlled single-blind clinical study, posturography was used to assess postural control in 179 healthy subjects with or without a balance wristband. Tests were also performed with the subjects blinded to whether they were wearing an intact or a defective wristband. Analysis of variance (ANOVA) was used to detect significant differences (p ≤ 0.05). Stability indexes did not reveal significant differences in postural control between wearing and not wearing a wristband. Our study did not provide evidence of an improvement in postural stability. Because the single-blind trials too revealed no significant differences, a placebo effect could be ruled out.

Dual-energy CT as an innovative method for diagnosing fragility fractures of the pelvic ring: a retrospective comparison with MRI as the gold standard.

INTRODUCTION: As the average age of society increases, so does the number of cases of fragility fractures of the pelvis (FFP). Magnetic resonance imaging (MRI) can visualise associated oedema and is thus the gold standard for diagnosing such fractures. MRI, however, is costly, not always available, and involves certain exclusion criteria. Dual-energy computed tomography (DECT) appears to be a promising alternative. It is unclear, however, whether it could be used for diagnosing FFP with similar sensitivity/specificity. The aim of our study was thus to compare conventional CT and DECT with MRI in cases of suspected FFP. MATERIALS AND METHODS: A total of 46 patients with suspected FFP underwent MRI, CT and DECT scans. There were three comparison groups for each of these patients: conventional CT image analysis without dual-energy modification (Arm 1), DECT analysis (Arm 2) and MRI as the gold standard (Arm 3). Diagnosis and FFP classification were performed by a radiologist in random order and without clinical information. The sensitivity and specificity of conventional CT and DECT were calculated in comparison with MRI as the reference standard. RESULTS: With 100% sensitivity and specificity, DECT is on par with MRI when it comes to diagnosing fragility fractures of the pelvis and is superior to conventional CT (90.3% sensitivity, 100% specificity). In terms of classification as well, there were no differences between DECT and MRI. On conventional CT, on the other hand, 16 patients were classified differently than they were on MRI. CONCLUSIONS: Our study shows DECT to be reliable and superior to conventional CT in terms of oedema detection and specific fracture classification in FFP. DECT thus combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures).

[Internal meniscus resections do not affect anterior knee joint stability]. / Innenmeniskusresektionen beeinflussen nicht die anteriore Kniegelenksstabilität.

BACKGROUND: Meniscus injuries lead to increased knee joint instability. Currently, however, it is unclear whether a relevant medial meniscus part resection leads to an increased ventral tibia translation with intact anterior cruciate ligament. The aim of our study was therefore to clinically examine the stabilizer function of at least 30% resected medial meniscus for anterior tibial translation. MATERIALS AND METHODS: In this prospective study, 18 patients with unilateral medial meniscus lesion were treated before and after arthroscopic medial meniscus resection. They were treated on the healthy and on the sick leg through the use of two different apparatus methods (dynamic translation measurement using hamstring reflex apparatus and KT-1000 arthrometers) as well as a functional test (computer-supported dynamic posturography (CDP)) and a clinical hop test. Further, the mean values for significance using non-parametric Wilcoxon test. RESULTS: After completing all the studies, we were not able to detect any significant differences in our study that would indicate increased ventral instability in the knee joint after arthroscopic medial meniscus resection. CONCLUSIONS: Inner meniscal partial resection does not lead to increased ventral knee instability in intact VKB. Whether in patients with instability (feeling) after partial meniscus resection, a rotation instability is the cause or whether further injuries or disturbances in the capsular ligament apparatus are present, must be examined in further studies. Anterior knee joint instability cannot be adequately explained according to our study.

Striking a new path in reducing cartilage breakdown: combination of antioxidative therapy and chondroanabolic stimulation after blunt cartilage trauma.

Cartilage injury can trigger crucial pathomechanisms, including excessive cell death and expression of matrix-destructive enzymes, which contribute to the progression of a post-traumatic osteoarthritis (PTOA). With the intent to create a novel treatment strategy for alleviating trauma-induced cartilage damage, we complemented a promising antioxidative approach based on cell and chondroprotective N-acetyl cysteine (NAC) by chondroanabolic stimulation. Overall, three potential pro-anabolic growth factors - IGF-1, BMP7 and FGF18 - were tested comparatively with and without NAC in an ex vivo human cartilage trauma-model. For that purpose, full-thickness cartilage explants were subjected to a defined impact (0.59 J) and subsequently treated with the substances. Efficacy of the therapeutic approaches was evaluated by cell viability, as well as various catabolic and anabolic biomarkers, representing the present matrix turnover. Although monotherapy with NAC, FGF18 or BMP7 significantly prevented trauma-induced cell dead and breakdown of type II collagen, combination of NAC and one of the growth factors did not yield significant benefit as compared to NAC alone. IGF-1, which possessed only moderate cell protective and no chondroprotective qualities after cartilage trauma, even reduced NAC-mediated cell and chondroprotection. Despite significant promotion of type II collagen expression by IGF-1 and BMP7, addition of NAC completely suppressed this chondroanabolic effect. All in all, NAC and BMP7 emerged as best combination. As our findings indicate limited benefits of the simultaneous multidirectional therapy, a sequential application might circumvent adverse interferences, such as suppression of type II collagen biosynthesis, which was found to be reversed 7 days after NAC withdrawal.

Correction to: In vivo performance of a novel silk fibroin scaffold for partial meniscal replacement in a sheep model.

The author would like to correct the errors in the publication of the original article. The corrected details are given below for your reading.

Application of a Parallelizable Perfusion Bioreactor for Physiologic 3D Cell Culture.

It is crucial but challenging to keep physiologic conditions during the cultivation of 3D cell scaffold constructs for the optimization of 3D cell culture processes. Therefore, we demonstrate the benefits of a recently developed miniaturized perfusion bioreactor together with a specialized incubator system that allows for the cultivation of multiple samples while screening different conditions. Hence, a decellularized bone matrix was tested towards its suitability for 3D osteogenic differentiation under flow perfusion conditions. Subsequently, physiologic shear stress and hydrostatic pressure (HP) conditions were optimized for osteogenic differentiation of human mesenchymal stem cells (MSCs). X-ray computed microtomography and scanning electron microscopy (SEM) revealed a closed cell layer covering the entire matrix. Osteogenic differentiation assessed by alkaline phosphatase activity and SEM was found to be increased in all dynamic conditions. Furthermore, screening of different fluid shear stress (FSS) conditions revealed 1.5 mL/min (equivalent to ∼10 mPa shear stress) to be optimal. However, no distinct effect of HP compared to flow perfusion without HP on osteogenic differentiation was observed. Notably, throughout all experiments, cells cultivated under FSS or HP conditions displayed increased osteogenic differentiation, which underlines the importance of physiologic conditions. In conclusion, the bioreactor system was used for biomaterial testing and to develop and optimize a 3D cell culture process for the osteogenic differentiation of MSCs. Due to its versatility and higher throughput efficiency, we hypothesize that this bioreactor/incubator system will advance the development and optimization of a variety of 3D cell culture processes.

Biomechanical in vitro comparison of radiofrequency kyphoplasty and balloon kyphoplasty.

PURPOSE: Balloon kyphoplasty (BK) has emerged as a popular method for treating osteoporosis vertebral compression fractures (OVCFs). In response to several shortcomings of BK, alternative methods have been introduced, among which is radiofrequency kyphoplasty (RFK). Biomechanical comparisons of BK and RFK are very sparse. The purpose of this study was to perform a biomechanical study in which BK and RFK are compared. METHODS: Each of the two study groups comprised six specimens prepared from two functional spinal units (FSUs) cut from fresh-frozen cadaveric spines (3 of T9-T11 and 3 of T12-L2). VCFs (A1.2 type) were created in the middle VB of each of the FSUs, with a height loss of 30% of the VB. After that, the specimens were subjected to cyclic compression-compression loading. The following parameters were determined: range of motion (ROM), height of the middle VB, augmentation time, cement interdigitation and cement distribution. Also, the cement layer, the trabecular bone in the augmented VB and the bone-cement interface were examined for cracks. All of these parameters were determined at various stages, namely in the intact middle VB and after its fracture, cement augmentation and subject to the cyclic loading protocol. RESULTS: Fractures caused a significant increase in median ROM and a significant reduction in the height of fractured VB. Cement augmentation significantly stabilized the fractures and led to partial height restoration. ROM and vertebral height, however, were not restored to the intact levels. Cyclic loading led to a further significant increase in ROM and a significant height reduction. There were no significant differences between BK and RFK in terms of any of these parameters. CONCLUSIONS: BK and RFK achieved similar results for fracture stabilization and restoration of the height of the fractured VB. RFK involved shorter cement augmentation time and less damage to the trabecular bone.

[The Relevance of Surgeon-performed Ultrasound For the Detection of Acute Appendicitis: a Review of the Literature and a Practical Diagnostic Algorithm]. / Stellenwert der chirurgischen Sonografie in der Diagnostik der akuten Appendizitis: Literaturübersicht und ein praxisnaher Diagnosealgorithmus.

Background The relevance of ultrasound (US) in diagnosing acute appendicitis is controversial. The validity of US in comparison with other imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), is unclear, as is the difference between surgeon-performed ultrasound (SPUS) and radiologist-performed ultrasound (RPUS). On the basis of a review of current literature, our study aimed to develop a US-based algorithm to simplify the choice between additional diagnostic measures and surgery. Methods MEDLINE (PubMed®) was searched for literature published between 2010 and 2016. A total of 53 relevant full-text articles were eventually evaluated. Results Ultrasound (US) is an established part of algorithms used to diagnose acute appendicitis and has already replaced CT as the imaging technique of choice. The differences between SPUS and RPUS with regard to sensitivity, specificity, and positive and negative predictive values (PPV, NPV) are not statistically significant. The benefit of SPUS over RPUS is the simultaneous clinical assessment of the patient by the surgeon while the sonogram is performed (sonopalpation), which can increase diagnostic accuracy even further. Radiation exposure as a result of CT could be avoided or significantly reduced through the routine use of US, which is increasingly being used and is widely available. Conclusions SPUS should be the first imaging technique used to diagnose patients with suspected appendicitis. Additional diagnosis using CT or MRI is only recommended if sonographic imaging of the appendix is impossible in combination with specific clinical and laboratory criteria. A structured diagnostic approach with obligatory use of (SP)US, as described in the diagnostic algorithm, should be used for detection of acute appendicitis.

Vacuum-Assisted Closure in the Management of Degloving Soft Tissue Injury: A Case Report.

We report the case of a patient with an extensive degloving injury to his right foot involving severe subcutaneous soft tissue disruption and contamination. The initial treatment consisted of debridement, which was kept to a minimum, copious irrigation, primary wound closure at a few sites, and coverage of the remaining skin defects with vacuum-assisted closure (VAC) dressings. After a few weeks of VAC therapy for wound bed preparation, definitive coverage with a meshed skin graft was possible. Additional plastic surgical procedures were not required. At the last follow-up visit, the patient had no complaints and was able to participate in normal social life without limitations. Wounds that are grossly contaminated or associated with extensive soft tissue defects often require a multistage approach before delayed primary wound closure or plastic surgical procedures can be performed. Vacuum therapy can be used for temporary soft tissue coverage and has been shown to improve bacterial clearance, to increase local blood flow, and to promote granulation tissue formation. In contrast, plastic surgical procedures initially achieve safe and stable wound closure; however, the absence of sensitivity can lead to secondary problems. This is of particular relevance if the graft recipient site is subject to heavy stress and the restoration of function is of paramount importance, such as in the present case. Vacuum therapy is an effective and safe treatment of degloving injuries. We achieved a very good functional outcome, which was particularly important in view of the high stresses and strains to which a foot is exposed.

In vivo performance of a novel silk fibroin scaffold for partial meniscal replacement in a sheep model.

PURPOSE: Due to the negative effects of meniscectomy, there is a need for an adequate material to replace damaged meniscal tissue. To date, no material tested has been able to replace the meniscus sufficiently. Therefore, a new silk fibroin scaffold was investigated in an in vivo sheep model. METHODS: Partial meniscectomy was carried out to the medial meniscus of 28 sheep, and a scaffold was implanted in 19 menisci (3-month scaffold group, n = 9; 6-month scaffold group, n = 10). In 9 sheep, the defect remained empty (partial meniscectomy group). Sham operation was performed in 9 animals. RESULTS: The silk scaffold was able to withstand the loads experienced during the implantation period. It caused no inflammatory reaction in the joint 6 months postoperatively, and there were no significant differences in cartilage degeneration between the scaffold and sham groups. The compressive properties of the scaffold approached those of meniscal tissue. However, the scaffolds were not always stably fixed in the defect, leading to gapping between implant and host tissue or to total loss of the implant in 3 of 9 cases in each scaffold group. Hence, the fixation technique needs to be improved to achieve a better integration into the host tissue, and the long-term performance of the scaffolds should be further investigated. CONCLUSION: These first in vivo results on a new silk fibroin scaffold provide the basis for further meniscal implant development. Whilst more data are required, there is preliminary evidence of chondroprotective properties, and the compressive properties and biocompatibility are promising.

[Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18 months ]. / Versorgung von Kriegsverletzten aus der Ukraine in den Traumanetzwerken der DGU ­ Anspruch, Wirklichkeit und Motivation im Verlauf von 18 Monaten .

BACKGROUND: The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented a challenge for more than 15 months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a 2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. MATERIAL AND METHODS: An online survey of senior physicians of the trauma network hospitals was carried out with a semistructured written questionnaire in December 2022 and a follow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. RESULTS: Of the questionnaires 113 could be evaluated in December 2022 and 70 completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7 patients were treated in all participating hospitals up to December and up to September no more than 5 in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. CONCLUSION: The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in a long course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

Improved gait parameters following surgical revascularization in patients with intermittent claudication.

Objective: Intermittent claudication (IC) is known to be associated with impaired gait parameters, with a higher incidence of falls and higher oxygen consumption due to uneconomic walking. However, the influence of arterial disobliteration in patients with IC on their gait pattern has rarely been investigated to date. The aim of this study was to examine the gait patterns before and after inflow revascularization by surgical disobliteration of pelvic and inguinal arteries (ie, common iliac artery, external iliac artery, common femoral artery, profound femoral artery, superficial femoral artery) in IC patients. Successful surgical disobliteration of inflow arteries (improvement of ankle brachial pressure index of ≥0.2 and patent common iliac, external iliac, common femoral, profound femoral, and superficial femoral arteries) is known to improve the painless walking distance for patients with IC due to peripheral arterial disease; however, its influence on gait parameters is unclear. We hypothesized that the gait parameters would also improve after surgery. Improved gait parameters can lead to a more economic walking process, lower oxygen consumption, a lower risk of falls, and a higher quality of life. Methods: In a single-center, exploratory, longitudinal study, we examined the gait parameters of 20 IC inpatients of our hospital before and after surgical disobliteration of pelvic and inguinal arteries. Spatiotemporal parameters such as range of motion of the hip and knee joint, stance phase, cadence, and foot rotation were obtained using the Diers 4Dmotion Lab (Diers International). The gait parameters were obtained under painful walking conditions preoperatively and with the patients walking pain free at the same speed postoperatively. Results: A total of 20 patients were examined. Surgical revascularization led to a higher walking cadence (mean, plus 7.88 steps; 95.5 steps/min vs 87.6 steps/min; P = .024), an increased range of motion of the hip joint (mean, plus 2.0°; 35.1° vs 33.1°; P = .038), and improved foot rotation (mean, plus 2.0°; 11.0° vs 9.0°; P = .02). Regarding other parameters such as step length, stance phase, and step duration, smaller differences were detected in this study. Conclusions: In this exploratory study, we found that surgical revascularization of pelvic and inguinal arteries in IC patients improved certain gait parameters. Further studies with larger patient numbers are needed to confirm these data and provide more evidence on this subject.

A prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears.

BACKGROUND: This pilot study evaluates the outcome after occupational therapy, compared to home-based exercises in the conservative treatment of patients with full thickness rotator cuff tears. METHODS: Forty-three adult subjects (range, 18-75 years), who had a full thickness rupture of the rotator cuff which was verified by magnetic imaging tomography, with clinical signs of a chronic rotator cuff impingement, and who were available for follow-up, were randomized to occupational therapy or to independent home-based exercises using a booklet. After drop-out, 38 patients were available for full examination at follow-up. Before therapy and after 2 months of conservative treatment, pain intensity, the Constant-Murley score, isokinetic strength testing in abduction and external rotation, functional limitation, clinical shoulder tests and health-related quality of life (EQ-5D) were evaluated. RESULTS: Two-thirds of the patients improved in clinical shoulder tests, regardless of the therapy group. There were no significant differences between the groups with reference to pain, range of motion, maximum peak force (abduction, external rotation), the Constant-Murley score, and the EQ-5D index. The only significant difference observed was the improvement in the self-assessed health- related quality of life (EQ-5D VAS) favoring home-based exercises. CONCLUSION: Home-based exercise, on the basis of an illustrated booklet with exercises twice a day, supplies comparable results to formal occupational therapy in the conservative treatment of rotator cuff tears. The results of this pilot study suggest some potential advantages related to psychological benefits using home-based treatment.