Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score.

BACKGROUND: The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF). MATERIALS AND METHODS: A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle. RESULTS: Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%. CONCLUSION: Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.

Osseoperception in transcutaneous osseointegrated prosthetic systems (TOPS) after transfemoral amputation: a prospective study.

BACKGROUND: Endo-exo prosthetics (EEP), which belongs to the transcutaneous osseointegrated prosthetic systems (TOPS), provides an alternative bone-anchored rehabilitation method for transfemoral amputees. It led to the question of whether transmitted forces from prosthetic feet are perceptible by osseoperception resulting in proprioceptive feedback of ground conditions. OBJECTIVES: The following hypotheses emerged for our trial with the null hypothesis: EEP fitting after transfemoral amputation does not influence osseoperception. Alternative hypothesis 1: EEP patients achieve better osseoperception results than transfemoral amputees fitted with socket prosthesis. Alternative hypothesis 2: EEP carriers achieve comparable results with regards to their osseoperception as non-amputees. METHODS: N = 25 patients with EEP (mean age = 50,6 ± 9,4, male/female = 15/10) N = 25 patients with socket prostheses (mean age = 52,6 ± 13,1, male/female = 19/6) and N = 25 healthy volunteers were included in the experimental case-control study. In three blinded test modules (V1, V2, V3), the participants had to identify different degrees of shore hardness (c) of different materials (rubber balls (shore = 5-25c), foam cushions (shore = 5-30c), foam mats (shore = 5-30c) with their prosthetic foot (or a personally defined foot in healthy volunteers) without footwear and had to rank them into the correct order according to their tactile sensation and the degree of hardness. A maximum of 10 points could be scored per run. RESULTS: This experimental observational study included N = 75 participants. The mean age for the entire cohort was 42.8 ± 16.6 years and the BMI was 26.0 ± 4.8. Our results show a significant level of differences in tactile osseoperception between all groups (p < 0.001). A correlation between the mean values of V1-3 and the PMQ2.0 as well as the mean values of K-Level and the prosthesis wearing time per day showed for PMQ (r = 0.387, p = 0.006) and K-level (r = 0.448, p = 0.001) which is a moderate effect according to Cohen. CONCLUSION: Our study results suggest that the EEP treatment can lead to an improvement in tactile sensory perception via the bone-anchored implant, which can lead to an increase in quality of life and improved gait safety.

Influence of age on stem cells depends on the sex of the bone marrow donor.

Ageing is often accompanied by an increase in bone marrow fat together with reduced bone volume and diseases of the bone such as osteoporosis. As mesenchymal stem cells (MSCs) are capable of forming bone, cartilage and fat tissue, studying these cells is of great importance to understand the underlying mechanisms behind age-related bone diseases. However, inter-donor variation has been found when handling MSCs. Therefore, the aim of this study was to investigate the effects of donor age and sex by comparing in vitro characteristics of human bone marrow-derived MSCs (hBMSCs) from a large donor cohort (n = 175). For this, hBMSCs were analysed for CFU-F capacity, proliferation, differentiation capacity and surface antigen expression under standardized culture conditions. The results demonstrated a significantly reduced CFU-F number for hBMSCs of female compared to male donors. Furthermore, there was a significant decrease in the proliferation rate, adipogenic differentiation potential and cell surface expression of SSEA-4, CD146 and CD274 of hBMSCs with an increase in donor age. Interestingly, all these findings were exclusive to hBMSCs from female donors. Further research should focus on postmenopausal-related effects on hBMSCs, as the results imply a functional loss and immunophenotypic change of hBMSCs particularly in aged women.

Conflicts of interest among patients: do they exist and can they bias patient-reported outcome measures? A survey of shoulder and elbow patients.

BACKGROUND: Potential conflicts of interest (COIs) are common among physicians and may bias physician-reported outcome assessment in orthopedic research. It is unclear whether patients have COIs and whether these COIs could affect patient-reported outcome measures (PROMs). The purposes of this study were to investigate (1) the existence of COIs among patients and (2) the potential of these COIs to bias PROMs with a pseudonymized survey among consecutive shoulder and elbow patients. MATERIALS AND METHODS: Between February and May 2021, 144 shoulder and elbow patients who underwent consultation at our outpatient clinic were included in the survey study. Of these patients, 79.2% (n = 114) completed the 11-item questionnaire. Variables including sex, existence of chronic diseases, level of education, and economic status were also assessed to investigate any association between these variables and patients' perceptions of COIs. RESULTS: Whereas 33.3% of respondents (n = 38) believe that COIs exist among patients and 28.1% (n = 32) believe that COIs could bias PROMs in general, fewer patients admit to personal COIs (24.6%, n = 28) and COIs biasing their self-assessment (23.7%, n = 27). Patients more frequently suggest COIs in their personal environment, such as among family members or friends (27.2%, n = 31), than in their own medical treatment. Financial factors such as sick pay (34.2%, n = 39) are thought to be the most likely reason for having COIs, followed by interpersonal reasons such as maintaining medical affection or bonds (29.8%, n = 34). Of respondents, 42.1% (n = 48) believe that sole usage of PROMs poses risks in treatment evaluation and only 21% (n = 24) consider PROMs reliable. In addition, 43% of respondents (n = 49) believe that patients should disclose COIs routinely in medical treatment. Multinomial logistic regression analysis revealed that wealthier patients are more likely to believe COIs could bias PROMs (odds ratio for poor vs. middle class, 0.23 [95% confidence interval, 0.053-0.963]; odds ratio for lower-middle class vs. middle class, 0.19 [95% confidence interval, 0.052-0.677]). CONCLUSIONS: Although the majority of shoulder and elbow patients deny having self-experienced COIs and deny biased PROMs due to COIs in their own medical treatment, a considerable number of patients admit to having experienced both. Further studies might be justified to investigate the actual clinical relevance of patients' COIs and their impact on value-based health care.

Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial.

INTRODUCTION: Comparable data of functional outcomes of anterior cruciate ligament reconstruction using either hamstring- or quadriceps tendon grafts is controversial. This prospective, randomized controlled trial aims to provide data comparing both grafts regarding the functional outcome. MATERIALS AND METHODS: A two centre trial involving symptomatic patients 18 years of age or older with an anterior cruciate ligament tear was conducted. We randomly assigned 27 patients to quadruple hamstring tendon reconstruction and 24 to quadriceps tendon reconstruction. The patients were evaluated preoperatively, at 3, 6, 12 and 24 months post-surgery. The primary outcome parameter was the side-to-side knee laxity measured with an arthrometer. Secondary outcomes included results in the International Knee Documentation Committee (IKDC) and Lysholm Scores and isokinetic testing of strength in knee extension and flexion. RESULTS: Forty-four patients (86%) completed the 2-year follow-up. There was significantly improved knee stability at all time intervals with no difference between the two study groups. The manual side-to-side displacement improved by 4.7 ± 3.0 mm in patients with hamstring tendon reconstruction and 5.5 ± 2.9 mm in patients with quadriceps tendon reconstruction. In addition, muscle strength and outcome scores (IKDC and Lysholm Score) did not show any differences between the hamstring tendon group and the quadriceps tendon group. Patients in the hamstring tendon group returned to their pre-injury activity level after 95.2 ± 45.5 days while patients in the quadriceps tendon group needed 82.1 ± 45.6 days. CONCLUSION: Quadriceps and hamstring tendon autografts yield comparably good results in primary anterior cruciate ligament reconstruction.

Management, outcome, and novel classification system of periprosthetic fractures in patients with transcutaneous osseointegrated prosthetic systems (TOPS)-a retrospective cohort analysis.

INTRODUCTION: Transcutaneous osseointegrated prosthetic systems (TOPS) are anchored prosthetic systems for major limb loss. Sometimes TOPS patients suffer from periprosthetic fractures. The aim of this study was to analyze the management and outcomes of periprosthetic fractures in patients with TOPS and to introduce a novel classification system for this entity. MATERIAL/METHODS: Since 2010, 140 patients were treated with TOPS after transfemoral amputation in two centers in Germany. Fifteen patients sustained periprosthetic fractures, with five intra- and ten postoperative fractures. The outcome was analyzed by Prosthesis Mobility Questionnaire (PMQ), K-level and prosthesis wear time per day. A subgroup analysis for the body mass index (BMI) was performed. RESULTS: All postoperative fractures were treated with implant-retaining osteosynthesis. Fourteen fractures healed without complications after a mean of 3 months. One postoperative fracture developed a clinically asymptomatic firm non-union. No Endo-Fixstem had to be removed. For the fracture and control group, a significant increase of the PMQ (p < 0.001) and K-level (p < 0.001) was observed after TOPS treatment compared to the preoperative baseline. Furthermore, the subgroup analysis showed a significant increase of the PMQ and K-level for both normal weight (p = 0.002) and overweight patients (p < 0.001). Of interest, overweight patients even showed a significantly higher increase in scores compared to normal weight patients, regardless of periprosthetic fracture. CONCLUSION: Periprosthetic fractures do not necessarily worsen outcomes of TOPS treatment. Proper classification and standardized appropriate treatment strategies according to fracture morphology are paramount for reliably good outcomes. We recommend to not remove or exchange the implant (Endo-Fixstem) even if it is assembly. Higher BMI did not have an impact onto rehabilitation success after TOPS to major limb loss of the lower extremity.

[3D printing in the field of shoulder surgery]. / 3D-Druck im Bereich der Schulterchirurgie.

The 3D printing technology is a relatively new procedure with a high potential, especially in the field of shoulder surgery. The 3D printing procedures are increasingly being developed and also gaining new users. Principally, 3D printing procedures can be applied preoperatively in planning the surgical procedure, patient clarification and in teaching; however, the technology is increasing being used intraoperatively. In addition to intraoperative visualization of the models, 3D printing permits the use of individual and specific instruments and implants. This allows the precise transfer of the preoperative planning to the surgical procedure. Inaccuracies are mainly caused by soft tissues. The 3D printing can be beneficial in the fields of arthroplasty, shoulder instability as well as orthopedic trauma. The literature shows promising results in relation to duration of surgery, blood loss and clinical results of the procedure. On the other hand, it is still unclear which indications warrant the use of 3D printing. Other aspects that raise questions are the time of planning, the production time and the additional cost that the use of 3D printing entails. Nonetheless, 3D printing represents a meaningful enhancement of the portfolio of surgeons, which becomes highly beneficial and useful in complex situations. Furthermore, this procedure enables a certain amount of flexibility when reacting to certain circumstances.

[Management of fracture-related infections]. / Management von frakturassoziierten Infektionen.

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.

[Transcutaneous osseointegrated prosthetic systems after major amputation of the lower extremity : A retrospective 3-year analysis]. / Transkutane osseointegrierte Prothesensysteme (TOPS) nach Majoramputation der unteren Extremität : Eine retrospektive 3-Jahres-Analyse.

INTRODUCTION: Transcutaneous osseointegrated prosthetic systems (TOPS) are an established optional procedure for the prosthetic treatment of amputations. Under the term endo-exo-prosthesis (EEP), the endosteal adapted exo-prosthesis (Dr. Grundei®) is currently used as the only standard prosthesis for clinical application in Germany. The prosthetic treatment with EEP involves a two-stage surgical procedure. In a first surgical step, the endo-fixed stem is implanted into the bone; in a second operation, approx. 2-6 weeks later, the skin/soft tissue stoma is created, through which the exoprosthetic components can be coupled transcutaneously. AIM: The aim of this manuscript was to retrospectively collect descriptive 3­year statistics (2017-2019) from clinical follow-ups and to analyze them with regard to possible effects of TOPS on the mobility level measured by k­levels. In addition, a brief description of the current standard of care in Germany regarding TOPS will be given. METHODS: All patients who underwent EEP after major amputation from February 2017 to December 2019 (n = 72, with 76 implants) were included in this study. The data of the EEP patients were collected in standardized follow-ups. K­levels were compared preoperatively to 6 months postoperatively. RESULTS: A total of N = 72 patients (N = 76 implantations) was analyzed in the described period. The main cause of amputations was trauma (68.9%). Main complications were myofascial complaints. Implant loosening and deep infections were observed in two cases (2.7%) during this period. Stoma problems occurred with a 3-year average of 25.7%. In terms of K­levels, there was a high significant increase from preoperative 1.8 ± 0.8 to 3.0 ± 0.4 after a 6-month period. CONCLUSION: TOPS is an established optional procedure for the treatment of limb loss. In Germany, only one implant is currently regularly implanted (endo-exo prosthesis), and the restoration is currently focused on the lower limb. The restoration of patients with major amputation of the lower extremity by means of TOPS can lead to an increase in mobility and, thus, to an increase in daily activities and participation in daily living.

[Transosseous reconstruction of triceps tendon rupture : Surgical technique]. / Die transossäre Rekonstruktion der Trizepssehnenruptur : Operationstechnik.

OBJECTIVE: Transosseous reconstruction of the triceps tendon. INDICATIONS: All tears of the triceps tendon that allow a tension-free reconstruction. CONTRAINDICATIONS: Retracted triceps tendon tears that do not allow a tension-free reconstruction after mobilization. SURGICAL TECHNIQUE: Two nonabsorbable sutures are threaded through two crossing transosseous canals. In addition, an anchor is placed directly in the footprint. Using the first nonabsorbable suture the tendon is sutured using the Krackow technique and subsequently shuttled transosseously distally and knotted there with its other part. Using the first suture pair of the anchor the tendon is sutured in a similar manner and knotted within the tendon. With the second pair pressure to the avulsion fragment can be increased by knotting it distally to the first knot. Alternatively, sutures of the suture anchor can be used with a Mason-Allen technique. POSTOPERATIVE MANAGEMENT: For the first 6 weeks a ROM brace is applied with gradual release of flexion. Free flexion after 6 weeks is allowed. Beginning of strengthening exercises after 12 weeks. RESULTS: Authors have reported good results after surgical treatment of triceps tendon ruptures. Regardless of possible extension deficits described in the literature, in the case presented an excellent postoperative outcome with a free range of motion was achieved.

[Open fractures]. / Offene Frakturen.

Open fractures are associated with a higher rate of infections and delayed fracture healing; therefore, in addition to fracture fixation, infection prevention and soft tissue management are also important. Administration of antibiotics should be carried out as early as possible and over 24-72 h depending on the injury. The initial debridement and assessment of the severity of injury determine the treatment strategy. Fracture fixation follows the general traumatological principles. Simple injury patterns can be treated by primary fixation and wound closure. With substantial contamination, loss of bone or extensive soft tissue damage, temporary fixation and temporary wound closure are carried out. The definitive treatment with soft tissue coverage should be performed within 72 h in order to reduce the risk of fracture-related infections. For osseous segmental defects, different approaches are available to restore bone continuity, depending on the size and soft tissue situation.

[Treatment strategies for tumor-related pathological fractures of the extremities]. / Versorgungsstrategien bei tumorbedingten pathologischen Frakturen der Extremitäten.

Pathological fractures of the extremities frequently lead to uncertainty with respect to the treatment strategy and timing. The origin of metastases is typically breast, bronchial, renal and prostate cancer and myelomas. Primary bone tumors play a subordinate role. The majority affect the femur, humerus and occasionally the tibia. Surgery is typically the first line treatment as healing under conservative treatment is unlikely. The most important goal is to relieve pain and the preservation or restoration of function. For correct assessment of indications, analysis of the fracture pattern and oncological aspects including dignity, entity, prognosis, metastatic status and the general condition of the patient need to be taken into consideration. Based on all these aspects the surgical approach can be chosen. Treatment options range from osteosynthetic stabilization and augmentation osteosynthesis up to endoprosthesis replacement. The treatment is carried out in an interdisciplinary procedure as additional measures need to be addressed in addition to the surgical treatment.

Preoperative femoral abduction angle correlates with initial postoperative lateral hip pain after transcutaneous osseointegrated prosthetic system (TOPS) in transfemoral amputees.

PURPOSE: To analyse whether a preoperative femoral abduction angle (FAA) correlates with postoperative initial lateral hip pain (LHP) in above-knee amputees (AKA) treated with transcutaneous osseointegrated prosthetic system (TOPS). METHODS: Pre- and postoperative long-leg radiographs of eighteen unilateral AKA (mean age 51.55y ± 12.16) were retrospectively measured. FAA was measured on both sides. Pain intensity of LHP was measured by numeric rating scale (NRS) preoperatively and every week for four weeks from the first day of weight loading. Pearson's r was calculated for correlation. Furthermore, odds ratio for LHP ≥ 5/10 NRS and relative FAA > 13° was calculated. RESULTS: FAA significantly decreased in the postoperative period (pre/post. 15.33° ± 4.22; p < 0.001). Median LHP was 0/10 NRS (min.0, max.3) preoperatively and 4/10 NRS (min.2, max. 7, p < 0.001) postoperatively after first loading. Interestingly, it decreased within four weeks to a median of 0.5/10 NRS (min.0, max. 3) without intervention. A strong correlation was seen on the amputated side between preoperative FAA and LHP after loading (r = 0.835, p < 0.001), as well as the relative FAA to LHP after loading (r = 0.732, p < 0.001) and between the gap of pre- to postoperative FAA and LHP. Odds ratio for LHP ≥ 5/10 and relative FAA > 13° was 6.4 (95%CI = 0.55; 74.89). CONCLUSION: The preoperative FAA strongly correlates with postoperative LHP. Surgeons should be aware of high risk of LHP that can limit prosthetic training. High preoperative FAAs should be realised in the decision meeting of TOPS implantation and pre-rehabilitative reduction of the FAA should be taken into consideration.

Anterior minimally invasive plating osteosynthesis technique (MIPO) for humeral shaft fractures: an anatomical study of neuromuscular structures at risk.

OBJECTIVE: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero-Livani) for humeral shaft fractures. METHODS: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero-Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. RESULTS: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14-13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. CONCLUSION: The modified Belangero-Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. LEVEL OF EVIDENCE: Level IV; Case series with no comparison group; Treatment study.

Risk factors for dislocation after bipolar hemiarthroplasty: a retrospective case-control study of patients with CT data.

PURPOSE: Bipolar hemiarthroplasty has been shown to have a lower rate of dislocation than total hip arthroplasty. However, as the influencing risk factors for bipolar hemiarthroplasty dislocation remain unclear, we aimed to analyse patient and surgeon-specific influencing risk factors for bipolar hemiarthroplasty dislocation. METHODS: We retrospectively analysed patients who were operated between 2012 and 2018 and had dislocated bipolar hemiarthroplasty and matched them to patients without a dislocated bipolar hemiarthroplasty, operated between 2018 and 2019. The study was limited to patients who received either a pre- or postoperative pelvic computed tomography. Besides demographic, morphologic, and physiologic data, we analysed duration of surgery; ASA score; Charlson Comorbidity Index; Almelo Hip Fracture Score; Parker Score; and acetabular morphology angles including acetabular anteversion angle, posterior acetabular sector angle, posterior wall angle, and acetabular roofing. RESULTS: We included nine patients with a dislocated bipolar hemiarthroplasty and 30 with a non-dislocated bipolar hemiarthroplasty. Patient-specific factors prompting a higher risk for dislocated bipolar hemiarthroplasty were longer duration of surgery (min) (115 ± 50 vs. 80 ± 27, p = 0.01); dementia (56% vs. 13%, p < 0.01); smaller posterior acetabular sector angle (°) (96 ± 6 vs. 109 ± 10, p < 0.01); and smaller posterior wall angle (°) (67 ± 6 vs. 77 ± 10, p = 0.02). CONCLUSION: Dementia and insufficient posterior wall angle were associated with higher risk of dislocation in bipolar hemiarthroplasty.

Flexibility of thoracic kyphosis affects postoperative sagittal alignment in adult patients with spinal deformity.

PURPOSE: Proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) surgery patients is a severe complication with potential need for revision surgery. While thoracic kyphosis (TK) is known to influence PJK, the role of TK flexibility is still unknown. We analyzed the influence of TK flexibility to predict postoperative sagittal alignment. METHODS: Patients with ASD, ≥ 2-year follow-up, and upper-most instrumented vertebra (UIV) including and below T10 were included in this retrospective study. TK flexibility, defined as > 10° difference of the TK in standing and supine imaging, was analyzed. Patient characteristics like age, sex, weight, total hip arthroplasty, and sagittal alignment parameters were studied. RESULTS: Sixty-five patients aged 66 ± 8 years were included in the study. Lowest instrumented vertebra was S1 or the ilium in 85% of them; the number of levels being fused averaged 7. Flexible TK was present in 31% (n = 20). These patients had a larger preoperative TK (p < 0.01), but no PJK was found (p = 0.04). In contrast, patients who underwent revision surgery had a decreased TK flexibility (p = 0.04) and increased PJK angle at follow-up (p = 0.01). In the non-flexible patients, the PJK was found in 14% of patients. CONCLUSIONS: Based on our retrospective data, TK flexibility influences the outcome of ASD surgery. In patients demonstrating no TK flexibility, a more cephalad UIV-level should be considered because spontaneous curve correction in the sagittal plane might be low in these patients. This new parameter should be included in future prediction models. These slides can be retrieved under Electronic Supplementary Material.

Orthogeriatric co-management for proximal femoral fractures. Can two additions make a big difference?

BACKGROUND: Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated. METHODS: This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one "elective" operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone. RESULTS: Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573). CONCLUSION: We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.

Correlation between Oxford Elbow Score and Single Assessment Numeric Evaluation: Is one simple question enough?

BACKGROUND: The aim of this study is to evaluate the correlation between the Oxford Elbow Score (OES) and Single Assessment Numeric Evaluation (SANE). To date, there has been no study investigating a correlation between this patient-reported outcome measure and SANE. METHODS: Between December 2018 and February 2019, all patients who underwent consultation for elbow pathology and completed the OES and SANE were retrospectively analyzed. Pearson correlation coefficient between the OES and SANE was calculated. Variables, including age, gender, diagnosis, chief complaint for consultation, and pain level on the visual analog scale (VAS), were also collected, and a mixed effects linear regression model was used to identify predictors for higher correlation. RESULTS: One hundred seven consultations of 86 patients were analyzed. The mean SANE and OES were 62.13% and 60.36%, respectively. Both scores correlated highly (r = 0.903). Across the OES domains, the strongest correlation was found between SANE and the OES psychosocial domain (r = 0.885). High correlations were also found between SANE and the OES function (r = 0.847) and OES pain (r = 0.804) domains. All values were statistically significant (P < .001). A moderate inverse correlation was found between SANE and VAS (r = -0.631). Aside from SANE, the VAS was identified as a significant predictor of the OES. CONCLUSION: SANE correlates highly with the OES. It is an easy tool for assessing the condition of the elbow joint, can be obtained without any license or payment restrictions, and should be considered as a worthwhile adjunct to currently used scores.

[Transcutaneous Osseointegrated Prosthetic Systems (TOPS) for Transfemoral Amputees - A Six-Year Retrospective Analysis of the Latest Prosthetic Design in Germany]. / Transkutane osseointegrierte Prothesensysteme (TOPS) zur Versorgung Oberschenkelamputierter.

PURPOSE: A retrospective analysis of clinical outcomes and complication rates of patients treated with the latest implant design of the so-called Endo-Exo-Femoral Prosthesis (EEFP) was performed. The aim is to gain specific information on long-term complications of this treatment-method. METHODS: In January 2019, data of all transfemoral amputees who were treated with TOPS at an acute clinic in Schleswig-Holstein from 2010 to 2016 were retrospectively analysed. This was done with special consideration of postoperative complications. For this purpose, all examination findings from routine clinical follow-up examinations were used. The complications were divided into stoma problems, orthopaedic-technical (OT) problems, fractures and explantations. All EEFPs had the same implant design (3rd generation). This implant is currently the only TOPS in Germany that is clinically used. Descriptive statistics as well as ratio information about occurred complications were calculated. RESULTS: A total of 68 implantations were performed during this period. Average observation time was 6.32 years (±2.16 years). The mean age of the patients was 51.84 years±12.12 years. Cause of amputation was mainly trauma (82,35%). Stoma-associated problems had the highest incidence (7%) among all observed patient-related complications and posed the greatest challenges during the rehabilitation process. Looking only at surgical complications, 81% had no complications at all. In total, 15% had technical problems, 6% had peri-prosthetic fractures, 7% had stoma problems and 3% had to be explanted due to infection. CONCLUSION: The analysis of collected data shows that TOPS (here the 3rd generation EEFP) can be a successful alternative treatment method to shaft prostheses after transfemoral amputation. The indication should only be given after the failure of a shaft-prosthesis and contraindications must be comprehensively excluded. The greatest challenges in the rehabilitation process are the avoidance of stoma complications, infections and OT-problems. The rehabilitation of amputees treated with TOPS therefore requires an interdisciplinary, specialized rehabilitation team and lifelong rehabilitative care.

[Isolated fracture of the coracoid process in a 14-year-old national water polo player : Case example]. / Isolierte Fraktur des Processus coracoideus bei einem 14-jährigen Wasserballnationalspieler : Fallbeispiel.

BACKGROUND: Isolated fractures of the coracoid process during sporting activities are very rare. There are a few case studies and retrospective studies with low numbers of cases. OBJECTIVE: Presentation of an initially neglected fracture and conservative treatment. METHODS: Case study of a 14-year-old national water polo player with a non-dislocated fracture of the coracoid process and conservative therapy using focused shockwave therapy. RESULT: Return to sports after conservative therapy was after 13 weeks and return to competitive sport after 14 weeks. CONCLUSION: In cases with therapy refractory shoulder pain after trauma and unremarkable native X­ray, extended 3D imaging by magnetic resonance imaging (MRI) or computed tomography (CT) should be done early. Conservative therapy of a non-dislocated fracture in this case showed a good outcome.