[Treatment of symptomatic end-stage osteoarthritis of the ankle with anterolateral approach and an anatomical plate]. / Sprunggelenkarthrodese über einen anterolateralen Zugang mit einer anatomischen Platte.

OBJECTIVE: The aim of this paper is to describe the anterolateral approach using an anatomical plate for ankle arthrodesis and to present the first mid-term results with this technique in a high-risk population. INDICATIONS: The indication for arthrodesis of the ankle joint with this described technique is moderate to severe osteoarthritis of the ankle. CONTRAINDICATIONS: In addition to the general contraindications typical of any operation, there is a specific contraindication in cases of active infection of the soft tissues and accompanying osteomyelitis at the ankle. SURGICAL TECHNIQUE: The incision is made along the course of the peroneus tertius muscle. After that, the mobilization of the peroneus superficialis nerve is carried out, followed by the mobilization of the long extensor tendons, especially the extensor digitorum muscle in a medial direction opening the capsule and removal of the residual cartilage on the distal tibia and talus. Subsequently, the subchondral sclerosis is opened, and the implantation of a suitable osteosynthesis material, e.g., an anatomical angle-stable plate, is carried out. Finally, wound closure is performed involving the muscle belly of the extensor digitorum muscle covering the plate. POSTOPERATIVE MANAGEMENT: Immobilization of the ankle for 5-7 days in a dorsal knee-high splint. Retention in a walker after decongestion for another 5 weeks. Increased loading can be done after X­ray/computed tomography (CT) control from the 6th week. RESULTS: In all, 11 patients were observed retrospectively for an average of 14 months. There were no complications. The European Foot and Ankle Society (EFAS) score improved significantly from 3.3 to 17.8 points. All patients were subjectively satisfied with the result and would have the operation again.

The Correction Potential of the Lateral Release of the Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Technique Using a Dorsal Approach.

Background: Lateral release (LR) is an integral part of surgical correction of hallux valgus. A comparison was made between the open and minimally invasive LR techniques using a dorsal approach. The reliability and safety of the two methods were compared. Besides, the release of specific structures was investigated with special emphasis on ascertaining if the release was partial or a total one. Methods: In this study on cadavers, LR was performed on nine pairs of foot and ankle specimens. The group assignments were randomized for each case. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Results: A statistically significant advantage was observed with the open dorsal approach as there was a complete release of the adductor hallucis muscle from the lateral sesamoid and the lateral metatarsosesamoid ligament (p = 0.015 in each case). In terms of releasing the adductor hallucis muscle from the proximal phalanx, the lateral joint capsule, and the lateral collateral ligament, none of the investigated procedures showed better performance. However, open dorsal access tends to show a higher degree of release more frequently. Conclusions: Splitting of the lateral joint capsule, including the lateral collateral ligament and lateral metatarsosesamoid ligament via the dorsal approach can be performed reliably and completely using the open surgical technique. The open dorsal technique shows better rates of detachment when the adductor hallucis muscle is released from the lateral sesamoid. Both techniques resulted in incomplete release of the adductor hallucis muscle from the proximal phalanx. Study Type: Therapeutic-investigating the results of a treatment. Level of Evidence: II (Prospective cohort study). Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00575-3.

Anatomical Study of Sinus Tarsi-Based Lateral Lengthening Calcaneal Osteotomy.

BACKGROUND: Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. METHODS: Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. RESULTS: Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. CONCLUSION: Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. CLINICAL RELEVANCE: Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Iatrogenic Damage to Neurovascular and Soft Tissue Structures During Lateral Release of Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Techniques.

Lateral release is often an integral step in surgical correction of hallux valgus and can be performed using open or minimally invasive techniques. We investigated whether these techniques cause iatrogenic damage to arteries, nerves, tendons, or joint capsules. In this cadaver study, lateral release was performed on 9 pairs of specimens by a specialized foot surgeon. The specimens were randomly assigned to each group. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Iatrogenic damage to arteries, nerves, tendons, or joint capsules was rare, regardless of the surgical technique used. However, with the minimally invasive technique, the tendon of the extensor hallucis longus muscle and the sensitive terminal branches of the fibular nerve were at risk due to their anatomical proximity to the access portal. The deep transverse metatarsal ligament was potentially at risk if the adductor hallucis muscle was completely detached from the lateral sesamoid. When the deep transverse metatarsal ligament was transected there was risk of damaging the underlying plantar neurovascular structures. Both surgical techniques are safe in terms of the risk of injury to neighboring neurovascular and soft tissue structures.

[Description of a technique that uses Lapidus arthrodesis plus osteochondral autotransplantation in the treatment of severe hallux rigidus]. / Lapidusarthrodese in Kombination mit einer osteochondralen Autotransplantation in das Metatarsale-I-Köpfchen zur Behandlung der fortgeschrittenen Arthrose des Großzehengrundgelenkes.

OBJECTIVE: The objective of this technique is the treatment a severe hallux rigidus deformity by reorientation of an elevated first metatarsal using arthrodesis of the first tarsometatarsal joint and performing a one-step transplantation of an osteochondral graft, which is harvested from the first cuneiform, to the head of the first metatarsal bone. INDICATIONS: Severe arthritis of the first metatarsophalangeal joint (MTP) stage 3 and 4 in the Vanore classification. CONTRAINDICATIONS: General contraindications for a foot surgery; ankylosis of MTP joint; severe arthritis of the sesamoid joint; osteonecrosis; short first metatarsal; previous infection in the metatarsophalangeal joint; large cysts at the head of the first metatarsal. SURGICAL TECHNIQUE: The first step is the preparation of the metatarsophalangeal and the first tarsometatarsal joint. After mobilizing the first metatarsal in a medioplantar direction, a cartilage-bone cylinder is removed from the articular surface of the medial cuneiform using special osteochondral autograft transfer system (OATS) instruments (Small Joint OATS, Arthrex medical instruments GmbH, Munich, Germany). This is followed by the arthrodesis of the first tarsometatarsal joint with reorientation of the position of the first metatarsal bone. Then the removed osteochondral cylinder is implanted into the articular surface of the first metatarsal head. After that the capsule is closed and the skin sutured. POSTOPERATIVE MANAGEMENT: Postoperative management is guided mainly by the requirements of the first tarsometatarsal arthrodesis. When a plantar plate is used pain orientated full weightbearing is allowed in a postoperative shoe with a stiffened sole for 6-8 weeks. Physiotherapy is prescribed to exercise the first metatarsophalangeal joint. RESULTS: In the study, 5 patients were treated with the method described in the years 2011-2012 and were followed up for a period of 2 years. All of these patients were subjectively satisfied with the outcome of the operation. There were no relevant surgery-associated complications.

[Cartilage chip transplantation for cartilage defects of the first metatarsophalangeal joint]. / Minced Cartilage bei Knorpeldefekten am Großzehengrundgelenk.

OBJECTIVE: Treatment of circumscribed cartilage defects in the first metatarsophalangeal joint (MTP1) using autologous cartilage fragments. INDICATIONS: Full thickness cartilage defects (ICRS IV) or focal osteoarthritis in combination with hallux rigidus. CONTRAINDICATIONS: Pre-existing ankylosis of the metatarsophalangeal joint; global osteoarthritis of the joint; advanced osteoarthritis of the sesamoidal articulation; osteonecrotic cysts in the head of the first metatarsal bone. SURGICAL TECHNIQUE: Preparation of the metatarsophalangeal joint. Mobilization of the first metatarsal head. Harvesting of the cartilage fragments from the dorsal rim portion as part of the cheilectomy. Mincing the cartilage fragments with a 3.0 mm shaver in sterile conditions. Augmenting the cartilage fragments with autologous conditioned plasma (ACP). Preparing the defect area and creation of a "contained" defect. Replantation of the resulting minced cartilage mass into the defect of the articular surface on the first metatarsal head. POSTOPERATIVE MANAGEMENT: Immobilization of the MTP1 for 48 h. Intensive physiotherapy for 3 months. Full weight bearing after reduced swelling. RESULTS: In 2020, 5 patients were treated with the method described and followed up for a period of 1 year. All patients were subjectively satisfied with the result of the operation. There were no relevant surgery-associated complications.

The role of vitamin D and vitamin D deficiency in orthopaedics and traumatology-a narrative overview of the literature.

Vitamin D is considered to play an important role in musculoskeletal health. It's classical function is the regulation of calcium and phosphate homeostasis, thus ensuring a balanced bone metabolism that is characterised by an equal amount of bone resorption and bone formation. In the past decades, a plethora of pre-clinical and clinical studies reporting on potential health-beneficial properties of vitamin D have emerged. Moreover, there is an abundance of reports highlighting vitamin D deficiency and insufficiency in patients with almost innumerable diseases. Further, it is estimated that more than one billion people globally are affected by insufficient vitamin D levels. As such, research on vitamin D has been particularly popular over the past years. In orthopaedics and traumatology, most studies describe favourable effects of vitamin D in general. However, the relative importance of vitamin D is oftentimes debated. In this narrative review of the literature, we consider first, the properties of vitamin D and how vitamin D, vitamin D deficiency and the vitamin D receptor (VDR) impact on musculoskeletal health. Secondly, we provide an overview of studies reporting the prevalence of vitamin D deficiency in traumatology and diverse orthopaedic diseases including bone oncology. Lastly, we emphasise recent findings and touch on future perspectives in vitamin D research.

Thermal Disinfection Validation: The Relationship Between A0 and Microbial Reduction.

Validating a thermal disinfection process for the processing of medical devices using moist heat via direct temperature monitoring is a conservative approach and has been established as the A0 method. Traditional use of disinfection challenge microorganisms and testing techniques, although widely used and applicable for chemical disinfection studies, do not provide as robust a challenge for testing the efficacy of a thermal disinfection process. Considerable research has been established in the literature to demonstrate the relationship between the thermal resistance of microorganisms to inactivation and the A0 method formula. The A0 method, therefore, should be used as the preferred method for validating a thermal disinfection process using moist heat.

Arthroscopic Minced Cartilage Implantation for Chondral Lesions at the Talus: A Technical Note.

In the past few years, autologous chondrocyte implantation has been shown to be the most suitable cartilage reconstructive technique with the best tissue quality. Although this method is part of the standard surgical repertoire in the knee joint, it has so far not been an established method in the ankle because there are no prospective randomized controlled studies to prove a significant advantage over alternative methods of cartilage repair. The methods most frequently used in this context (e.g., marrow stimulation techniques) can, however, at most generate hyaline-like and thus biomechanically inferior regenerates. Minced cartilage implantation, on the other hand, is a relatively simple and cost-effective 1-step procedure with promising biological potential and-at least in the knee joint-satisfactory clinical results. We present an arthroscopic surgical technique by which the surgeon can apply autologous chondrocytes in a 1-step procedure (AutoCart; Arthrex, Munich, Germany) to treat articular cartilage defects in the ankle joint.

Comparison of Ligament-Repair Techniques for the Syndesmosis: A Simulated Cadaveric Weight-Bearing Computed Tomography Analysis.

Although the literature describes a variety of reconstructive techniques for the syndesmosis, only few studies offer comparative data. Therefore, the authors compared 2 different ligament repair techniques for the syndesmosis. Sixteen paired fresh-frozen human cadaveric lower limbs were embedded in polymethyl methacrylate mid-calf and placed in a custom-made weightbearing simulation frame. Computed tomography scans of each limb were obtained in a simulated foot-flat loading (75N) and single-leg stance (700N) in 5 different foot positions (previously reported data). One of each pair was then reconstructed via 1 of 2 methods: a free medial Achilles tendon autograft or a long peroneal tendon ligament repair. The specimens were rescanned, compared with their respective intact states and directly with each other. Measurements of fibular diastasis, rotation, anteroposterior translation, mediolateral translation, and fibular shortening were performed on the axial cuts of the computed tomography scans, 1 cm proximal to the roof of the plafond. There was no significant difference in fibular positioning with direct comparison of the reconstructions. Comparisons with their respective intact states, however, showed differences in their abilities to control reduction, most notably in the externally rotated and dorsiflexed positions of the foot. Neither reconstruction was clearly superior in restoring physiologic conditions. Only with a comparison of each technique to its respective intact state were differences between the techniques revealed, a benefit of this particular testing method.

Biological responses to individualized small titanium implants for the treatment of focal full-thickness knee cartilage defects in a sheep model.

BACKGROUND: The present study aimed to evaluate the functional, radiological and histological outcome of a customized focal implant for the treatment of focal full-thickness cartilage defects in sheep. METHODS: The study used magnetic resonance imaging data as the basis for construction of the titanium implant using a three-dimensional printing technique. This was then placed on the medial condyle of the knee joint in eight sheep and left in place in vivo over a period of six months. Following euthanasia, the local biological response was analyzed using micro-computed tomography, light microscopy and histological evaluation (International Cartilage Repair Society (ICRS) score). The variables were analyzed using a generalized linear mixed model. Odds ratios were given with 95% confidence intervals. RESULTS: The osseointegration rate was 62.1% (SD 3.9%). All implants were prone to the neighboring cartilage bed (4.4-1096.1 µm). Using the IRCS score, the elements 'surface', 'matrix', 'cell distribution' and 'cell population' all showed pathological changes on the operated side, although these did not correlate with implant elevation. On average, a difference of 0.7 mm (±2 mm) was found between the digitally planned implant and the real implant. CONCLUSIONS: As a result of imprecise segmentation and difficult preparation conditions at the prosthesis bed, as well as changes at the surface of the implant over the operational lifetime of the prosthesis, it must be stated that the approach implemented here of using a customized implant for the treatment of focal full-thickness cartilage defects at the knee did not meet our expectations.

Release of Antibiotics Out of a Moldable Collagen-ß-Tricalciumphosphate-Composite Compared to Two Calcium Phosphate Granules.

Bacterial bone infections after revision surgeries and diseases, like osteomyelitis, are still a challenge with regard to surgical treatments. Local bone infections were treated with antibiotics directly or by controlled drug-releasing scaffolds, like polymethylmethacrylate (PMMA) spheres, which have to be removed at a later stage, but there is a risk of a bacterial contamination during the removement. Therefore, biomaterials loaded with antibiotics for controlled release could be the method of choice: The biomaterials degrade during the drug release, therefore, there is no need for a second surgery to remove the drug eluting agent. Even non-resorbable bone materials are available (e.g., hydroxyapatite (HA)) or resorbable bone graft materials (e.g., beta-tricalcium phosphate (ß-TCP)) that will be replaced by newly formed bone. Composite materials with organic additives (e.g., collagen) supports the handling during surgery and enhances the drug loading capacity, as well as the drug releasing time. The purpose of this study was to investigate the loading capacity and the release rate of Vancomycin and Gentamicin on TCP and HA granules in the shape of a degradable scaffold compared to composite materials from TCP mixed with porcine collagen. Its antibacterial efficacy to a more elementary drug with eluting in aqueous solution was examined. The loading capacity of the biomaterials was measured and compared according to the Minimum Inhibition Concentration (MIC) and the Minimum Biofilm Eradication Concentration (MBEC) of a bacterial biofilm after 24 h aging. Antibiotic elution and concentration of gentamycin and vancomycin, as well as inhibition zones, were measured by using the Quantitative Microparticle Systems (QMS) immunoassays. The antibiotic concentration was determined by the automated Beckman Coulter (BC) chemistry device. For examination of the antibacterial activity, inhibition zone diameters were measured. Generally, the antibiotic release is more pronounced during the first couple of days than later. Both TCP granules and HA granules experienced a significantly decline of antibiotics release during the first three days. After the fourth day and beyond, the antibiotic release was below the detection threshold. The antibiotic release of the composite material TCP and porcine collagen declined less drastically and was still in the frame of the specification during the first nine days. There was no significant evidence of interaction effect between antibiotic and material, i.e., the fitted lines for Gentamycin and Vancomycin are almost parallel. During this first in vitro study, ß-TCP-Collagen composites shows a significantly higher loading capacity and a steadily release of the antibiotics Gentamycin and Vancomycin, compared to the also used TCP and HA Granules.

Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans?

BACKGROUND: Vitamin D deficiency can result in rickets and hypocalcemia during infant and childhood growth. There is an increasing interest in the role of vitamin D with regards to childhood bone health. Osteochondrosis dissecans (OD) is a common disease affecting different joints. To date, the exact etiology of OD still remains unclear. The aim of this study was to evaluate a possible association of vitamin D deficiency and juvenile OD. METHODS: A retrospective chart review of the years 2010 to 2015 of all orthopaedic patients with an initial diagnosis of juvenile OD admitted to undergo operative treatment of the OD was performed. Patient demographics, medical history, information on sports activity (if available) and serum vitamin D (25-OH-D) level on admission date were obtained. For statistical comparison, we measured baseline prevalence of vitamin D insufficiency in age-matched orthopaedic patients presenting at the department of pediatric orthopaedics. RESULTS: A total of 80 patients were included in this study. Overall, 97.5% (n=78) of tested patients in the OD group had serum vitamin D levels below the recommended threshold of 30 ng/mL (mean value of 10.1 ng/mL (±6.7 ng/mL)). Over 60% (n=49) were vitamin D deficient, 29 patients (37%) showed serum levels below 10 ng/mL corresponding to a severe vitamin D deficiency. Of note, only 2 patients (2.5%) reached serum vitamin D levels above the recommended threshold of 30 ng/mL. No statistical difference was found in respect to sports activity level before onset of the symptoms (P=0.09). Statistical analysis found a significant difference in vitamin D levels between patients with OD and patients without an OD (P=0.026). CONCLUSIONS: We found an unexpected high prevalence of vitamin D deficiency in juveniles diagnosed with OD presenting with significant lower mean 25-OH-D level compared with a control group. These results suggest that vitamin D deficiency is potentially associated with the development of OD. Thus, vitamin D deficiency might be an important cofactor in the multifactorial development of juvenile OD. For this reason, supplementation of vitamin D might not only be a potential additional therapy but also be a possible preventative factor in patients with juvenile OD. However, future prospective studies are needed to confirm this preliminary data. LEVEL OF EVIDENCE: Level III-this is a case-control study.

Applications of patient-specific 3D printing in medicine.

Already three decades ago, the potential of medical 3D printing (3DP) or rapid prototyping for improved patient treatment began to be recognized. Since then, more and more medical indications in different surgical disciplines have been improved by using this new technique. Numerous examples have demonstrated the enormous benefit of 3DP in the medical care of patients by, for example, planning complex surgical interventions preoperatively, reducing implantation steps and anesthesia times, and helping with intraoperative orientation. At the beginning of every individual 3D model, patient-specific data on the basis of computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound data is generated, which is then digitalized and processed using computer-aided design/computer-aided manufacturing (CAD/CAM) software. Finally, the resulting data sets are used to generate 3D-printed models or even implants. There are a variety of different application areas in the various medical fields, eg, drill or positioning templates, or surgical guides in maxillofacial surgery, or patient-specific implants in orthopedics. Furthermore, in vascular surgery it is possible to visualize pathologies such as aortic aneurysms so as to improve the planning of surgical treatment. Although rapid prototyping of individual models and implants is already applied very successfully in regenerative medicine, most of the materials used for 3DP are not yet suitable for implantation in the body. Therefore, it will be necessary in future to develop novel therapy approaches and design new materials in order to completely reconstruct natural tissue.

Risk factors for pelvic insufficiency fractures and outcome after conservative therapy.

PURPOSE: The prevalence of osteoporosis has continuously increased over the past decades and it is set to increase substantially as life expectancy rises steadily. Fragility or osteoporotic fractures of the pelvis often occur after low energy falls e.g. from standing, however, some patients present with assumed insufficiency fractures of the pelvis without a previous trauma. Osteoporotic fractures impose a tremendous economic burden and these fractures deserve attention as they lead to a decrease in mobility with an increase in dependency and are associated with a high rate of mortality. To date, little is known about potential risk factors for pelvic insufficiency fractures. Furthermore, information on clinical outcome is scarce. In view of this rather limited knowledge, we aimed to identify potential risk factors for pelvic insufficiency fractures and to collect information on their short- and long-term outcomes. METHODS: Files of all consecutive patients admitted between January 2010 and December 2013 for a pelvic insufficiency fracture were enrolled in this study. Pelvic fractures that occurred on tumorous bone or after high-energy trauma were excluded. Fractures of the pelvis included all pelvic bones except the coccyx. For all patients, we recorded clinical and biological parameters available from their medical history. For comparison, the same biological and clinical parameters were evaluated in an age matched control group of 1083 patients aged over 70 who were admitted to our orthopaedic department to undergo knee or hip arthroplasty. The statistical analyses used or Fisher test for percentages comparison, 2-tailed t-tests and Mann Whitney for mean comparison. To determine what factors are predictors and what factors are confounders of pelvic insufficiency fractures, multivariate linear regression analysis using the fracture as a continuous variable was performed. RESULTS: Ninety-three patients with a pelvic insufficiency fracture were identified. Following the Rommens and Hofmann classification for fragility fractures of the pelvis (FFP), 51 were FFP Type Ia, 26 were FFP Type IIb lesions and 26 were FFP Type IIc. Osteoporosis was found to be significantly associated with pelvic insufficiency fractures (p=0.003), as was hypertension (p=0.036), diabetes (p=0.021), vitamin D deficiency (p=0.004), hypocalcaemia (p=0.002) and nicotine abuse (p=0.0012) after adjustment for possible confounders in the multivariate linear regression analysis. Comparing the autonomous state before and after pelvic fracture, a high loss of autonomy was observed. Patients needing daily assistance nearly doubled their number. Overall mortality was high (20%). CONCLUSIONS: In conclusion, this study showed multiple risk factors for pelvic insufficiency fractures. Some, like vitamin D deficiency, can benefit easy preventive measures. Outcome of conservative therapy is poor, with loss of social and physical independence and autonomy. The mortality rate is high. Efforts should be made in preventing pelvic insufficiency fractures. All patients should be treated for the severe osteoporosis being associated with these fracture type.

Is there an association between low serum 25-OH-D levels and the length of hospital stay in orthopaedic patients after arthroplasty?

BACKGROUND: The purpose of this observational study was to evaluate serum levels of 25-OH-D in patients scheduled to undergo elective hip or knee arthroplasty. We hypothesised that 25-OH-D level is an independent risk factor for length of stay in orthopaedic patients after elective hip or knee arthoplasty. MATERIALS AND METHODS: 25-OH-D levels were measured in 1083 patients admitted to an orthopaedic surgery department to undergo elective hip or knee arthroplasty. Comparisons were performed using Chi square or Student's t test, followed by univariate and multiple linear regression analysis examining the correlation between the length of stay in the orthopaedic department and 25-OH-D level while adjusting for possible confounders. RESULTS: Overall, 86 % of patients had insufficient serum levels of 25-OH-D, and over 60 % were vitamin D deficient. The mean length of stay was 13.2 ± 8.3 days. In patients with hypovitaminosis D, the length of stay was significantly longer compared to patients with normal serum 25-OH-D levels (15.6 ± 7.2 compared to 11.3 ± 7.9 days, P = 0.014). In univariate analyses, serum 25-OH-D level was inversely related to the length of stay in our orthopaedic department compared to patients with normal vitamin D levels (r = -0.16; P = 0.008). In multivariate analyses, the length of stay remained significantly associated with low 25-OH-D levels (P = 0.002), indicating that low vitamin D levels increase the length of stay. CONCLUSIONS: We found a high frequency of hypovitaminosis D among orthopaedic patients scheduled to undergo elective arthroplastic surgery. Low vitamin D levels showed a significant inverse association to the length of stay in our orthopaedic department. Patients with vitamin D levels in the target range were hospitalised 4.3 days less than patients with hypovitaminosis D. Level 3 of evidence according to "The Oxford 2011 levels of evidence".

The Priority position paper: Protecting Europe's food chain from prions.

Bovine spongiform encephalopathy (BSE) created a global European crisis in the 1980s and 90s, with very serious health and economic implications. Classical BSE now appears to be under control, to a great extent as a result of a global research effort that identified the sources of prions in meat and bone meal (MBM) and developed new animal-testing tools that guided policy. Priority ( www.prionpriority.eu ) was a European Union (EU) Framework Program 7 (FP7)-funded project through which 21 European research institutions and small and medium enterprises (SMEs) joined efforts between 2009 and 2014, to conduct coordinated basic and applied research on prions and prion diseases. At the end of the project, the Priority consortium drafted a position paper ( www.prionpriority.eu/Priority position paper) with its main conclusions. In the present opinion paper, we summarize these conclusions. With respect to the issue of re-introducing ruminant protein into the feed-chain, our opinion is that sustaining an absolute ban on feeding ruminant protein to ruminants is essential. In particular, the spread and impact of non-classical forms of scrapie and BSE in ruminants is not fully understood and the risks cannot be estimated. Atypical prion agents will probably continue to represent the dominant form of prion diseases in the near future in Europe. Atypical L-type BSE has clear zoonotic potential, as demonstrated in experimental models. Similarly, there are now data indicating that the atypical scrapie agent can cross various species barriers. More epidemiological data from large cohorts are necessary to reach any conclusion on the impact of its transmissibility on public health. Re-evaluations of safety precautions may become necessary depending on the outcome of these studies. Intensified searching for molecular determinants of the species barrier is recommended, since this barrier is key for important policy areas and risk assessment. Understanding the structural basis for strains and the basis for adaptation of a strain to a new host will require continued fundamental research, also needed to understand mechanisms of prion transmission, replication and how they cause nervous system dysfunction and death. Early detection of prion infection, ideally at a preclinical stage, also remains crucial for development of effective treatment strategies.

Implementation of a software for REmote COMparison of PARticlE and photon treatment plans: ReCompare.

PURPOSE: To guarantee equal access to optimal radiotherapy, a concept of patient assignment to photon or particle radiotherapy using remote treatment plan exchange and comparison - ReCompare - was proposed. We demonstrate the implementation of this concept and present its clinical applicability. MATERIALS AND METHODS: The ReCompare concept was implemented using a client-server based software solution. A clinical workflow for the remote treatment plan exchange and comparison was defined. The steps required by the user and performed by the software for a complete plan transfer were described and an additional module for dose-response modeling was added. RESULTS: The ReCompare software was successfully tested in cooperation with three external partner clinics and worked meeting all required specifications. It was compatible with several standard treatment planning systems, ensured patient data protection, and integrated in the clinical workflow. CONCLUSION: The ReCompare software can be applied to support non-particle radiotherapy institutions with the patient-specific treatment decision on the optimal irradiation modality by remote treatment plan exchange and comparison.

In-vivo analysis of epicutaneous pressure distribution beneath a femoral tourniquet--an observational study.

BACKGROUND: Compression of the tissue beneath tourniquets used in limb surgery is associated with varying degrees of soft tissue damage. The interaction between fluids and applied pressure seems to play an important role in the appearance of skin lesions. The extent of the transfer of force between the tourniquet and the skin, however, has yet to be studied. The aim of the present study was to quantify in-vivo the transfer of pressure between a tourniquet and the skin of the thigh. METHODS: Pressure under the tourniquet was measured using sensors in 25 consecutive patients over the course of elective surgical procedures. Linear mixed modeling was used to assess the homogeneity of the distribution of pressure around the circumference of the limb, variation in pressure values over time, and the influence of limb circumference and the Body-Mass-Index (BMI) on pressure transfer. RESULTS: Mean pressure on the skin was significantly lower than the inner pressure of the cuff (5.95%, 20.5 ± 9.36 mmHg, p < 0.01). There was a discrete, but significant (p < 0.001) increase in pressure within the first twenty minutes after inflation. Sensors located in the area of overlap of the cuff registered significantly higher pressure values (p < 0.01). BMI and leg circumference had no influence on the transfer of pressure to the surface of the skin (p = 0.88 and p = 0.51). CONCLUSIONS: Pressure transfer around the circumference of the limb was distributed inhomogeneously. The measurement series revealed a global pressure drop compared to the initial pressure of the cuff. No relationship could be demonstrated between the pressure transferred to the skin and the BMI or limb circumference.

Vitamin D insufficiency in the elderly orthopaedic patient: an epidemic phenomenon.

PURPOSE: The purpose of this observational study was to evaluate serum levels of 25-OH-D of elderly patients presenting with orthopaedic illness. Furthermore, we enquired about potential confounders and risk factors of hypovitaminosis D in comorbidities and daily medication of the elderly. METHODS: Vitamin D levels in 1,083 patients aged >70 years and admitted to an orthopaedic surgery department were measured. Univariate and multivariate analyses were used to assess risk factors for insufficient vitamin D levels. RESULTS: Overall, 86 % of patients had insufficient serum levels of 25-OH-D and >60 % were vitamin D deficient. Serum vitamin D levels were lower during winter and months with fewer sunshine hours. Patients presenting with obesity, hypertension and osteoporosis were more likely to have low vitamin D levels. CONCLUSIONS: We found a high prevalence of hypovitaminosis D in elderly, nonhospitalized orthopaedic patients. Given the well-known effects of vitamin D on bone metabolism and muscle health, as well as its nonskeletal effects, vitamin D insufficiency may have a negative impact.