Retrospective Comparative Study of the Influence on Quality of Primary Total Hip Arthroplasty by the EndoCert-Certification System in a Communal Hospital. / Retrospektive vergleichende Untersuchung zum Einfluss auf die Qualität bei primärer Hüftendoprothetik durch EndoCert-Zertifizierung an einem kommunalen Krankenhaus.

The EndoCert®-Initiative system sets specific requirements for the structural, process and result quality in certified Arthroplasty Centers in Germany. However, it remains unclear to what extent the certification process can increase the quality in total hip and knee arthroplasty. Aim of the comparative retrospective study is to analyse the change in quality of total hip arthroplasty in a communal hospital before and after the certification process. All primary total hip arthroplasties (n = 366) between 2013 and 2016 were included in the study retrospectively and grouped by treatment period. Treatment was performed in group 1 without clinical pathways, in group 2 pathway-controlled without a valid certificate and in group 3 pathway-controlled after final completion of the certification process. Outcome quality was analysed using quality indicators defined by the EndoCert-Initiative and further predefined indicators. Results show quality improvement under certified pathway-controlled treatment, e.g. time of surgery, cup and stem positioning, blood transfusion rate, periprosthetic fractures. However, improvements were not significantly in all cases and limitations must be recognized. Positive effects of the certification process legitimate capital investment and efforts. Further quality indicators may be implemented in the certification process to improve quality of treatment in arthroplasty.

[Simultaneous fracture of the acromion and coracoid process : Rare variant of double disruption of the superior shoulder suspensory complex]. / Gleichzeitige Frakturen von Acromion und Korakoid : Seltene Variante der doppelten Unterbrechung des "superior shoulder suspensory complex".

INTRODUCTION: Simultaneous fracture of the acromion and coracoid process represents a double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide a review of the relevant literature. MATERIAL AND METHODS: In this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend a follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study. RESULTS: A total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered a high-impact trauma with other associated injuries. The coracoid fracture was classified as type I according to Ogawa in all cases, and the acromion fracture was type III according to Kuhn in 5 out of 6 cases. At least one of the fracture sites was stabilized. Of the patients one showed a concurrent lateral clavicle fracture, representing a third disruption of the SSSC, and another had a fracture of the medial third of the clavicle, representing a strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47 months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22 points and the average Constant score was 74 points. CONCLUSION: This rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.

Periprosthetic Tibial Fracture with Nonunion and Ascending Prosthetic Joint Infection: A Case Report of an Individual Treatment Strategy.

INTRODUCTION: Periprosthetic fractures are severe injuries that demand the surgeon's full expertise and special diagnostic and therapeutic strategies. A major complication is the occurrence of an infectious nonunion, including an ascending infection from the fracture site to the arthroplasty. CASE REPORT: This case report presents on a patient with a well-functioning revision total knee arthroplasty (TKA) who suffered a periprosthetic tibia fracture. Initial treatment with plating failed and the fracture had to be revised due to an infectious non-union with a multidrug-resistant Staphylococcus epidermidis, and its eradication was complicated by septic loosening of the patient's knee arthroplasty. After multiple revisions of the nonunion, a two-stage exchange arthroplasty with a partial replacement of the distal femur due to a bone defect was necessary to obtain an acceptable result. CONCLUSION: The objective of this case report is to present an individual surgical strategy in a complex case of periprosthetic fracture and TKA with major complications. It is shown that the infection of the bone and implants is a challenging situation for surgical treatment. There is still no optimal management strategy due to missing standards as well as controversies in treatment.

Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings.

BACKGROUND: Axillary nerve injuries after shoulder surgery are rare. In most studies, the frequency of injury is usually determined using clinical examinations, but results from intraoperative neuromonitoring studies have revealed higher than expected rates. Few studies have investigated this topic. Our aim was to determine the frequency of axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures by using electrophysiological assessments and to provide a review of the relevant literature. METHODS: This was a retrospective cohort study of 76 consecutive patients who received open reduction and internal fixation of a proximal humeral fracture using a locking plate through a deltoid-splitting approach. We performed a clinical and electrophysiological examination at a minimum follow-up time of 12 months. Functional results were assessed according to the Constant-Murley and Disabilities of the Arm, Shoulder and Hand scores. Electrophysiological examinations comprised electromyography, electroneurography, and motor and somatosensory evoked potentials. The main outcome was the frequency of axillary nerve lesions. RESULTS: Forty patients were monitored for an average of 28 months. The mean raw Constant-Murley score was 61 points, the age- and gender-adjusted score was 71%, and the mean Disabilities of the Arm, Shoulder and Hand score was 33 points. Neurapraxia occurred in 1 patient, axonotmesis with incomplete reinnervation occurred in 3, and complete reinnervation occurred in 3. The latter group was classified as having a temporary axillary nerve lesion. CONCLUSIONS: The 10% rate of permanent axillary nerve lesions in our cohort is higher than expected based on the clinical examination. Electrophysiological assessment is therefore more appropriate to detect axillary nerve injuries.

Population-based prospective study on the incidence of osteoporosis-associated fractures in a German population of 200,413 inhabitants.

BACKGROUND: A limited body of data is available with regard to the incidence of osteoporotic fractures in Germany. Most of the data published thus far have been derived from hospital records or health insurance settlements. The aim of the present study was to prospectively register four types of fractures in an urban population. The data we obtained were compared with the results of retrospective analysis procedures in order to determine the differences and underlying errors. METHODS: An urban population of 200 413 residents was investigated prospectively with regard to osteoporosis-associated fractures over a period of 12 months. All fractures were recorded and confirmed on radiographs. The results of this analysis were compared with the data from the Statistical Bureau and the International Classification of Disease (ICD) registers of the hospitals. RESULTS: A total of 979 fractures occurred during the period of investigation. The most common type was the distal radius fracture (395; 197.1 per 100 000). The retrospective detected data of the Statistical Bureau were 31, 56% lower than the actual number of fractures. A retrospective analysis of fractures based on the ICD registers of the hospitals revealed an over-registration rate of 26.67%. CONCLUSIONS: Retrospective methods of fracture registration do not provide sufficiently reliable data.

Retrograde cement removal in periprosthetic fractures following hip arthroplasty.

INTRODUCTION: Revision of cemented hip arthroplasty after periprosthetic fractures of the femur is a demanding procedure. Many different technical devices have been developed for this purpose. This paper presents a new surgical technique of cement removal avoiding excessive exposure of the fracture site. MATERIALS AND METHODS: In six patients with periprosthetic fractures of the femur following hip arthroplasty (Johansson Type II and III) cement removal was performed by means of advancing a retrograde nail through the intercondylar notch of the knee. RESULTS: In all cases the cement was removed completely. Intraoperative complications or significant knee problems were not observed. CONCLUSION: The intracondylar approach provides a simple, rapid and less invasive technique for cement removal in revision hip arthroplasty.

Outcome after surgery of distal radius fractures: no differences between external fixation and ORIF.

The purpose of this study was to determine the most appropriate surgical treatment from three procedures used for fractures of the distal radius. In a retrospective comparative study, 166 out of 237 patients who underwent surgery for AO/ASIF A3 or C2 distal radius fractures were evaluated. Surgical procedures were external fixation or open reduction and internal fixation with either palmar or dorsal plates. Radiological outcomes were palmar tilt, radial angle, radial length and ulnar variance. Functional outcomes were range of motion and grip strength. In addition, outcomes according to Gartland and Werley and the Disabilities of the Arm, Shoulder and Hand questionnaire were compared. Further outcome criteria were the treatment time and the number of complications. Data were analysed using an analysis of variance statistical procedure respective of the chi2-test. Open reduction and internal fixation, in particular palmar plate fixation, demonstrated the best radiological and functional results. Subjective assessment of ORIF proved better than that of external fixation as treatment time was shorter and complications were more rarely seen. However, most of the differences between groups were not significant. Although there were no significant differences between groups, our data indicates that most dorsally displaced distal radius fractures can be treated successfully by open reduction and internal fixation. Palmar plate fixation seems to have slight advantages compared to both the external fixation and dorsal plate fixation surgical procedure.

Outcome of surgically treated intraarticular calcaneus fractures--SF-36 compared with AOFAS and MFS.

BACKGROUND: There is no consensus as to which is the best treatment for intraarticular fractures of the calcaneus. Furthermore, few studies have assessed general health after calcaneus fractures. We therefore measured the state of general health after operation of calcaneal fractures and compared these data with usual foot-scores. PATIENTS AND METHODS: We compared the general health of 71 patients with surgically treated calcaneal fractures 2.5 years after injury, with the general health of 71 people from the standard German population (German National Health Survey, 1998) using the SF-36 form. We compared the results of the examination with results of AOFAS Ankle Hindfoot Scale and Maryland Foot Score in the treated patients. RESULTS: In patients with calcaneal fractures, there were significant limitations regarding general health in all 9 elements of the SF-36 form. Correlations between SF-36 and foot-scores were strong regarding function and pain scales, but moderate for all other scales. INTERPRETATION: Patients face significant limitations regarding general health after calcaneal fractures. The usual foot-scores measure only 2 dimensions of outcome: function and pain. To measure all dimensions of outcome, SF-36 is a better alternative.

Recombinogenic effects of suppressors of position-effect variegation in Drosophila.

Compact chromatin structure, induction of gene silencing in position-effect variegation (PEV), and crossing-over suppression are typical features of heterochromatin. To identify genes affecting crossing-over suppression by heterochromatin we tested PEV suppressor mutations for their effects on crossing over in pericentromeric regions of Drosophila autosomes. From the 46 mutations (28 loci) studied, 16 Su(var) mutations of the nine genes Su(var)2-1, Su(var)2-2, Su(var)2-5, Su(var)2-10, Su(var)2-14, Su(var)2-15, Su(var)3-3, Su(var)3-7, and Su(var)3-9 significantly increase in heterozygotes or by additive effects in double and triple heterozygotes crossing over in the ri-p(p) region of chromosome 3. Su(var)2-2(01) and Su(var)2-14(01) display the strongest recombinogenic effects and were also shown to enhance recombination within the light-rolled heterochromatic region of chromosome 2. The dominant recombinogenic effects of Su(var) mutations are most pronounced in proximal euchromatin and are accompanied with significant reduction of meiotic nondisjunction. Our data suggest that crossing-over suppression by heterochromatin is controlled at chromatin structure as well as illustrate the possible effects of heterochromatin on total crossing-over frequencies in the genome.