[Subtuberosity anterior closing wedge osteotomy to correct the increased posterior slope of the tibial plateau]. / Subtuberositäre anterior schließende Osteotomie zur Korrektur der erhöhten posterioren Reklination des Tibiaplateaus.

OBJECTIVE: Reduction of increased reclination of the tibial plateau (posterior slope) to improve the anterior stability of the knee joint. INDICATIONS: Increased posterior reclination of the tibial plateau greater than 12° in combination with recurrent instability after anterior cruciate ligament (ACL) reconstruction. CONTRAINDICATIONS: Hyperextension of more than 15° (relative). SURGICAL TECHNIQUE: Anterior skin incision approximately 8-10 cm above the tibial tuberosity. Insertion of two converging guidewires directly below the patellar tendon ending obliquely in the area of the posterior cruciate ligament (PCL) insertion. Control of the wire position with the image intensifier core. Oscillating saw osteotomy. Removal of the wedge and closure of the osteotomy. Osteosynthesis with interfragmentary screw and medial angle-stable plate. POSTOPERATIVE MANAGEMENT: Partial load with 10-20 kg for 2 weeks, then step by step increase in load. Mobility: free. RESULTS: To date we have operated on 36 patients with recurrent instability after ACL reconstruction (20 men, 16 women, average age 34.4 years) in the manner described in this article. In 25 cases, enlarged bone tunnels were filled with allogeneic bone at the same time. The posterior slope of the tibial plateau could be reduced from an average of 14.5° to 8.8°. In 28 cases another ACL reconstruction was performed after an interval of 4-12 months. The Lysholm score significantly increased from 76.3 points to 89.2 points.

The Safety and Efficacy of Microporous Polysaccharide Hemospheres in Terms of the Complication Rates in Total Hip Arthroplasty for Femoral Neck Fractures: A Control-Matched Retrospective Cohort.

AIMS: This study aimed to assess the safety and efficacy of microporous polysaccharide hemospheres (MPSHs) in managing blood loss and reducing the risk of postoperative haematoma and early periprosthetic joint infection (PJI) following total hip arthroplasty (THA) for femoral neck fracture (FNF), in the context of the existing treatment challenges. METHODS: A control-matched retrospective analysis of 163 patients undergoing unilateral primary THA for displaced FNF between 2020 and 2023 was performed. The study group consisted of 74 patients who received MPSH administered intraoperatively. The control group consisted of 89 patients who received no topical haemostatics. One-to-one case-control matching between groups was performed. The primary outcome was a perioperative change in the haematologic values (haemoglobin, red blood cell count, haematocrit, platelet concentration) and transfusion rate. The secondary outcomes were the incidence of postoperative local haematoma formation, prolonged wound secretion, surgical site infection (SSI), and PJI within 3 months of surgery. RESULTS: Our analysis found no statistically significant differences in the haematologic parameters between the control and study cohorts. The changes in the haemoglobin concentration were not significant between the control group (3.18 ± 1.0 g/dL) and the treatment group (2.87 ± 1.15 g/dL) (p = 0.3). There were no significant differences (p = 0.24) in the haematocrit and red blood cell concentration (p = 0.15). The platelet levels did not significantly differ (p = 0.12) between the groups. Additionally, we found no significant discrepancy in the incidence of early PJI or blood transfusion rates between the groups. No adverse effects following MPSH use were recorded in the study group. CONCLUSIONS: Routine use of MPSH in THA for FNF management appears to be safe, with no observed adverse events related to Arista® use. Although there was a tendency towards reduced blood loss in the Arista® AH group, MPSH did not significantly impact bleeding complications, local haematoma formation, or subsequent PJI.

Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon.

The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS).

BACKGROUND: The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures. OBJECTIVE: To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw. METHODS: Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits. RESULTS: We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS. CONCLUSIONS: The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

Increased asphericity of the femoral head-neck junction in professional breakers compared to hobby athletes - a retrospective case-control study.

OBJECTIVE: Breaking has gained public attention as a form of sports activity. The associated intense movements of the hip joints are possibly linked to the development of femoroacetabular impingement (FAI). Therefore, this study aimed to assess clinical and radiographic FAI measures in professional breakers compared to hobby athletes. METHODS: The study cohort consisted of professional breakers with persisting hip pain who were 1:1 matched to a cohort of FAI patients without professional sports careers from our outpatient clinic. The primary endpoint assessed on standardized plain radiographs was the alpha angle (AA). Further measures were the acetabular index (AI), lateral center-edge angle (LCEA), crossover sign, ischial spine sign, and femoral head extrusion index (FHEI). The modified Harris Hip Score (mHHS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were used to obtain patient-reported measures. RESULTS: We recruited ten professional breakers and matched them to ten hobby athletes. The median AA was significantly higher in the breakers compared with the hobby athletes (73° [IQR 66.5°, 84.2°]) vs. 61.8° [IQR 59.5°, 64.8°], p = 0.0004). There was a significant reduction in weekly training hours in breakers after diagnosis (13.0 hours [interquartile range [IQR] 9.5, 32.4] to 1.5 hours [IQR 0, 4.8], p = 0.0039). There were no inter-group differences regarding mHHS, WOMAC, and additional radiographic measurements. CONCLUSION: Breakers have higher AA in cam-type FAI compared to nonprofessional athletes. The corresponding hip pain significantly reduced training hours and caused the end of their breaking career. The potentially high prevalence of FAI in breakers and the corresponding consequences need to be considered early when athletes present with hip pain.

Inter-Observer and Intra-Observer Reliability Assessment of the Established Classification Systems for Periprosthetic Shoulder Fractures.

This study evaluated the reliability and comprehensiveness of the Unified classification system (UCPF), Wright & Cofield, Worland and Kirchhoff classifications and related treatment recommendations for periprosthetic shoulder fractures (PPSFx). Two shoulder arthroplasty specialists (experts) and two orthopaedic residents (non-experts) assessed 20 humeral-sided and five scapula-sided cases of PPSFx. We used the unweighted Cohen's Kappa (κ) for measuring the intra-observer reliability and Krippendorff's alpha (α) for measuring the inter-observer reliability. The inter-rater reliabilities for the Wright & Cofield and Worland classifications were substantial for all groups. The expert and non-expert groups for UCPF also showed substantial inter-rater agreement. The all-rater group for the UCPF and the expert and non-expert group for the Kirchhoff classification revealed moderate inter-rater reliability. For the Kirchhoff classification, only fair inter-rater reliability was found for the non-expert group. Almost perfect intra-rater reliability was measured for all groups of the Wright & Cofield classification and the all-rater and expert groups of the UCPF. All groups of the Kirchhoff and Worland classifications and the group of non-experts for the UCPF had substantial intra-rater reliabilities. Regarding treatment recommendations, substantial inter-rater and moderate intra-rater reliabilities were found. Simple classification systems for PPSFx (Wright & Cofield, Worland) show the highest inter- and intra-observer reliability but lack comprehensiveness as they fail to describe scapula-sided fractures. The complex Kirchhoff classification shows limited reliability. The UCPF seems to offer an acceptable combination of comprehensiveness and reliability.

Exertional Rhabdomyolysis in Athletes: Systematic Review and Current Perspectives.

OBJECTIVE: Exertional rhabdomyolysis results from a breakdown of skeletal muscle cells after intense exercise in otherwise healthy patients, causing increased levels of creatine kinase (CK) or myoglobin, as well as urine dipstick positive for blood, and may result in kidney insufficiency. The aim of this study was to outline the current perspectives of exertional rhabdomyolysis in athletes and subsequent treatment based on the current literature. DATA SOURCES: We searched the MEDLINE/PubMed and Google databases for ([exercise] OR [exertional]) AND rhabdomyolysis following the PRISMA guidelines. All abstracts were reviewed by 2 independent examiners. Inclusion criteria consisted of original articles presenting studies on exertional rhabdomyolysis or exercise-induced rhabdomyolysis with 7 or more cases. All case reports, case series, or editorials were excluded. MAIN RESULTS: A total of 1541-abstracts were screened, leaving 25 studies for final inclusion and analysing 772patients. Especially, young male patients were affected at a mean age of 28.7 years (range 15.8-46.6 years). Most of the athletes performed running, including marathons in 54.3% of cases (n = 419/772), followed by weightlifting in 14.8% (n = 114/772). At the time of presentation, the mean creatine kinase was 31 481 IU/L (range 164-106,488 IU/L). Seventeen studies reported the highest level of CK, which was 38 552 IU/L (range 450-88,496 IU/L). For treatment, hydration was the most common method of choice reported by 8 studies. CONCLUSIONS: Exertional rhabdomyolysis seems to be underestimated, and it is essential to screen patients who present with muscle soreness/cramps and/or dark urine after heavy endurance events to avoid any further complications. LEVEL OF EVIDENCE: II; systematic review.

Clinical Outcome after Medial Open-Wedge High Tibial Osteotomy: Comparison of Two Angular Stable Locking Plates-TomoFix™ versus LOQTEQ® HTO Plate.

This study evaluated bony healing and clinical results after medial open-wedge HTO to compare the outcome of the LOQTEQ® HTO plate and the TomoFix™ internal plate fixator. A prospective, non-randomised, comparative study was undertaken. The same surgical technique for the medial open-wedge HTO was used in two treatment groups. In Group 1, the TomoFix™ implant was used for osteosynthesis, and, in Group 2, the LOQTEQ® HTO plate was used. All patients were examined before surgery (T0) and then at 12 months (T1) and at 24 months (T2) postoperatively. The primary outcome measure was the KOOS pain subscore. The secondary outcome criteria were other KOOS subscales, the Tegner score, radiological healing (RUST), and incision length. The KOOS pain subscale and the other KOOS subscores increased significantly in both groups from T0 to T1 and T2 without a significant group difference at each timepoint. The activity measured with the Tegner scale increased significantly from T0 to T2 without a significant group difference. No radiological signs of implant failure were observed in any case at the one-year X-ray, and no patient fulfilled the criteria for non-union. There was no significant difference in the frequency of adverse effects between the two treatment groups. The length of the incision was significantly shorter in the LOQTEQ® HTO group than in the TomoFix™ group. The results of this study show that patient-related outcome scores (KOOS, Tegner) increased after medial open-wedge HTO. There was no difference in clinical outcome or radiological healing between the treatment groups. Both plates are suitable for the osteosynthesis of open-wedge HTO.

[Analysis of rising treatment cost of elevated BMI in patients with proximal femoral fracture]. / Analyse steigender Behandlungskosten bei erhöhtem BMI von Patienten mit proximaler Femurfraktur.

Driven by the aging population, the proximal femoral fracture is a rising fracture entity, challenging trauma surgeons as well as the German healthcare system as a whole. The rising average age of the population is accompanied by a rising BMI in the German population, resulting in longer operation times, longer average length of stay (ALOS) as well as more postoperative complications.The aim of this study was to demonstrate the economic correlation between body mass index and hospital costs. The retrospective analysis of 950 patient cases suffering from a proximal femoral fracture resulted in the finding of rising treatment costs being positively associated with rising BMI due to longer operation times and longer length of hospitalization (10,452 €, 11,505 €, 12,085 € and 13,681 € for patients with BMI < 18.5 kg/m2, BMI = 18.5-24.9 kg/m2, BMI = 25.0-29.9 kg/m2 and BMI ≥ 30.0 kg/m2, respectively).

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis.

INTRODUCTION: Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma. METHOD: A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars. RESULTS: A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion. CONCLUSION: Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome. LEVEL OF EVIDENCE: II, Systematic Review.

A Review of Functional Outcomes after the App-Based Rehabilitation of Patients with TKA and THA.

Following the outbreak of SARS-CoV-2, several elective surgeries were cancelled, and rehabilitation units were closed. This has led to difficulties for patients seeking access to rehabilitation in order to achieve the best possible outcome. New applications with or without sensors were developed to address this need, but the outcome has not been examined in detail yet. The aim of this study was to perform a systematic literature review on smart phone applications for patients suffering from hip and knee osteoarthritis after arthroplasty. The MEDLINE/PubMed and Google databases were queried using the search term "[APP] AND [ORTHOPEDIC]" according to PRISMA guidelines. All prospective studies investigating rehabilitation applications reporting the functional outcome in hip and knee osteoarthritis after arthroplasty were included. The initial search yielded 420 entries, but only 9 publications met the inclusion criteria, accounting for 1067 patients. In total, 518 patients were in the intervention group, and 549 patients were in the control group. The average follow-up was 9.5 ± 8.1 months (range: 3 to 23.4 months). Overall, significantly lower A-VAS values were observed for the interventional group in the short term (p = 0.002). There were no other significant differences observed between the two groups. Smart phone applications provide an alternative to in-person sessions that may improve access for patients after total joint arthroplasty. Our study found there are significant improvements in the short term by using this approach. In combination with a blue-tooth-enabled sensor for isometric exercises, patients can even receive real-time feedback after total knee arthroplasty.

Distal Radius Fracture with Ipsilateral Elbow Dislocation: A Rare but Challenging Injury.

Distal radius fractures are common and account for approximately 14% to 18% of all adult extremity injuries. On rare occasions, ipsilateral elbow dislocation can be observed additionally. However, this can be missed without careful examination, especially in patients experiencing altered mental status. The aim of this study was to analyze the mechanism, level of injury, demographics, and associated injuries in distal radius fracture with ipsilateral elbow dislocation. Between 2012 and 2019, we searched our trauma database for distal radius fracture with ipsilateral elbow dislocation. All patients older than 18 years old were included. Data on demographics, mechanism of injury, level of energy, and subsequent treatment were collected. A total of seven patients were identified. The mean age in this cohort was 68.7 ± 13.3 years old, and the left side was involved in 71.4% of the patients. Females were affected in 85.7% (n = 6/7) of cases, all of whom suffered from low-energy monotrauma at a mean age of 71.5 ± 12.3 years old. One male patient suffered from high-energy trauma (52 years old). Mainly, posterior elbow dislocations were observed (66.7%; n = 4/6). Distal radius fracture patterns, in accordance with the AO classification, included two C2-, two C3-, one C1-, and one B1-type fractures. In the patient suffering from high-energy trauma, the closed distal radius fracture was classified as type C3. Associated injures included open elbow dislocation, ulnar artery rupture, and damage to the flexor digitorum superficialis. Although distal radius fracture with ipsilateral elbow dislocation is thought to be from high-energy trauma, this study shows that most patients were elderly females suffering from low-energy mechanisms. It is important for clinicians to maintain a high level of suspicion for any concomitant injury in this population.

Microbiological Advantages of Open Incisional Biopsies for the Diagnosis of Suspected Periprosthetic Joint Infections.

BACKGROUND: Periprosthetic joint infection (PJI) represents a serious complication following total hip (THA) and knee arthroplasty (TKA). When preoperative synovial fluid cultures remain inconclusive, open incisional joint biopsy (OIB) can support causative microorganism identification. OBJECTIVE: This study investigates the potential benefit of OIB in THA and TKA patients with suspected PJI and ambigious diagnostic results following synovial fluid aspiration. METHODS: We retrospectively assessed all patients treated from 2016 to 2020 with suspected PJI. Comparing the microbiology of OIB and the following revision surgery, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the number needed to treat (NNT). RESULTS: We examined the diagnostic validity of OIB in 38 patients (20 female) with a median age of 66.5 years. In THA patients (n = 10), sensitivity was 75%, specificity was 66.67%, PPV was 60%, NPV was 80%, and NNT was 2.5. In TKA patients (n = 28), sensitivity was 62.5%, specificity was 95.24%, PPV was 83.33%, NPV was 86.96%, and NNT was 1.42. CONCLUSIONS: Our results indicate that OIB represents an adequate diagnostic tool when previously assessed microbiological results remain inconclusive. Particularly in TKA patients, OIB showed an exceptionally high specificity, PPV, and NPV, whereas the predictive validity of the diagnosis of PJI in THA patients remained low.

Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects.

BACKGROUND: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. OBJECTIVE: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament® G or V due to corticomedullary defects in chronic OM. METHODS: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament® for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament® G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. RESULTS: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 ± 17.2 months (95%CI 12.1-28.3). Ten of these patients needed at least one revision (2.0 ± 1.3 revisions per patient (95%CI 1.1-2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. CONCLUSION: The use of Cerament® G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data.

Dysregulation of Wnt signaling in bone of type 2 diabetes mellitus and diabetic Charcot arthropathy.

BACKGROUND: Type 2 diabetes mellitus (T2DM) patients show a markedly higher fracture risk and impaired fracture healing when compared to non-diabetic patients. However in contrast to type 1 diabetes mellitus, bone mineral density in T2DM is known to be normal or even regionally elevated, also known as diabetic bone disease. Charcot arthropathy is a severe and challenging complication leading to bone destruction and mutilating bone deformities. Wnt signaling is involved in increasing bone mineral density, bone homeostasis and apoptotic processes. It has been shown that type 2 diabetes mellitus is strongly associated with gene variants of the Wnt signaling pathway, specifically polymorphisms of TCF7L2 (transcription factor 7 like 2), which is an effector transcription factor of this pathway. METHODS: Bone samples of 19 T2DM patients and 7 T2DM patients with additional Charcot arthropathy were compared to 19 non-diabetic controls. qPCR analysis for selected members of the Wnt-signaling pathway (WNT3A, WNT5A, catenin beta, TCF7L2) and bone gamma-carboxyglutamate (BGLAP, Osteocalcin) was performed and analyzed using the 2-ΔΔCt- Method. Statistical analysis comprised one-way analysis of variance (ANOVA). RESULTS: In T2DM patients who had developed Charcot arthropathy WNT3A and WNT5A gene expression was down-regulated by 89 and 58% compared to healthy controls (p < 0.0001). TCF7L2 gene expression showed a significant reduction by 63% (p < 0.0001) and 18% (p = 0.0136) in diabetic Charcot arthropathy. In all diabetic patients BGLAP (Osteocalcin) was significantly decreased by at least 59% (p = 0.0019). CONCLUSIONS: For the first time with this study downregulation of members of the Wnt-signaling pathway has been shown in the bone of diabetic patients with and without Charcot arthropathy. This may serve as future therapeutic target for this severe disease.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System.

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Therapeutic anticoagulation complications in the elderly: a case report.

BACKGROUND: The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed. CASE PRESENTATION: We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient's renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home. DISCUSSION AND CONCLUSIONS: Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications.

Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure.

INTRODUCTION: Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure. MATERIALS AND METHODS: We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal-pertrochanteric, subtrochanteric-or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected. RESULTS: A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure. CONCLUSION: Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

The role of serum C-reactive protein in the diagnosis of periprosthetic shoulder infection.

INTRODUCTION: There is a paucity of literature regarding serum C-reactive protein (CRP) in the evaluation of a shoulder periprosthetic joint infection (PJI). The purpose of the current study was to establish cutoff values for diagnosing shoulder PJI and evaluate the influence of the type of infecting microorganism and the classification subgroups according to last proposed International Consensus Meeting (ICM) criteria on the CRP level. MATERIALS AND METHODS: A retrospective analysis of all 136 patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between January 2010 and December 2019, was performed. Shoulder PJI was defined according to the last proposed definition criteria of the ICM. Serum CRP levels were compared between infected and non-infected cases, between infection subgroups, as well as between different species of infecting microorganisms. A receiver-operating characteristic (ROC) analysis was performed to display sensitivity and specificity of serum CRP level for shoulder PJI. RESULTS: A total of 52 patients (38%) were classified as infected, 18 meeting the criteria for definitive infection, 26 for probable infection and 8 for possible infection. According to the ROC curve, an optimized serum CRP threshold of 7.2 mg/l had a sensitivity of 69% and specificity of 74% (area under curve = 0.72). Patients with definitive infection group demonstrated significantly higher median serum CRP levels (24.3 mg/l), when compared to probable, possible infection groups and PJI unlikely group (8 mg/l, 8.3 mg/l, 3.6 mg/l, respectively, p < 0.05). The most common isolated microorganism was Cutibacterium acnes in 25 patients (48%) followed by coagulase-negative staphylococci (CNS) in 20 patients (39%). Patients with a PJI caused by high-virulent microorganisms had a significantly higher median serum CRP level compared to patients with PJI caused by low-virulent microorganisms (48 mg/l vs. 11.3 mg/l, p = 0.04). CONCLUSIONS: Serum CRP showed a low sensitivity and specificity for the diagnosis of shoulder PJI, even applying cutoffs optimized by receiver-operating curve analysis. Low-virulent microorganisms and patients with probable and possible infections are associated with lower CRP levels compared to patients with definitive infection and infections caused by high-virulent microorganisms. LEVEL OF EVIDENCE: Diagnostic Level III.

Epidemiology, Injury Severity, and Pattern of Standing E-Scooter Accidents: 6-Month Experience from a German Level I Trauma Center.

BACKGROUND: E-scooter usage was lawfully approved in Germany in June 2019. Since then, a marked increase of e-scooter drivers has been noticed. Evidence concerning factors that may affect the severity of these injuries is limited. The study aimed to retrospectively analyze e-scooter-related injuries in a major German city. METHODS: All patients admitted to the emergency department of a level I trauma center in Berlin, Germany, between June 15, 2019, and December 15, 2019, were retrospectively reviewed. Patients involved in an e-scooter accident were included in this study, and medical reports were analyzed. RESULTS: In the study period, 43 patients were involved in an e-scooter accident and could be included in this study. The median age of the patients was 30 years (interquartile range [IQR], 24.50-39.50 years), with 19 (44.2%) being female patients. The median Injury Severity Score of all patients was 2.0, with the highest Abbreviated Injury Scale (AIS) of 3.00 (IQR, 2.00-3.00) and was recorded as thoracic injuries. Seven patients had extremity fractures, of which 4 had to be stabilized operatively. In 12 patients (27.9%), the accidents occurred under the influence of alcohol. CONCLUSIONS: The majority of injuries reported in this study were associated with a relatively low AIS, possibly due to strict local speed limits. Nonetheless, e-scooter usage bears risks of sustaining severe injuries to the head, face, and extremities, particularly under the influence of alcohol or when illegally ignoring local laws.