Anterior Column Reconstruction of Destructive Vertebral Osteomyelitis at the Thoracolumbar Spine with an Expandable Vertebral Body Replacement Implant: A Retrospective, Monocentric Radiological Cohort Analysis of 24 Cases.

BACKGROUND: Vertebral osteomyelitis (VO) often necessitates surgical intervention due to bone loss-induced spinal instability. Anterior column reconstruction, utilizing expandable vertebral body replacement (VBR) implants, is a recognized approach to restore stability and prevent neurological compromise. Despite various techniques, clinical evidence regarding the safety and efficacy of these implants in VO remains limited. METHODS: A retrospective cohort analysis, spanning 2000 to 2020, was conducted on 24 destructive VO cases at a Level 1 orthopedic trauma center. Diagnosis relied on clinical, radiological, and microbiological criteria. Patient demographics, clinical presentation, surgical interventions, and radiological outcomes were assessed. RESULTS: The study included 24 patients (62.5% male; mean age 65.6 ± 35.0 years), with 58% having healthcare-associated infections (HAVO). The mean radiological follow-up was 137.2 ± 161.7 weeks. Surgical intervention significantly improved the bi-segmental kyphotic endplate angle (BKA) postoperatively (mean -1.4° ± 13.6°). However, a noticeable loss of correction was observed over time. The study reported a mortality rate of 1/24. CONCLUSIONS: Anterior column reconstruction using expandable VBR effectively improved local spinal alignment in destructive VO. However, the study underscores the necessity for prolonged follow-up and continuous research to refine surgical techniques and postoperative care. Addressing long-term complications and refining surgical approaches will be pivotal as the field progresses.

The PJI-TNM classification for periprosthetic joint infections.

Aims: This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated. Methods: A total of ten orthopaedic surgeons classified 20 cases of PJI based on the PJI-TNM classification. Subsequently, the classification was re-evaluated using the PJI-TNM app. Classification accuracy was calculated separately for each subcategory (reinfection, tissue and implant condition, non-human cells, and morbidity of the patient). Fleiss' kappa and Cohen's kappa were calculated for interobserver and intraobserver reliability, respectively. Results: Overall, interobserver and intraobserver agreements were substantial across the 20 classified cases. Analyses for the variable 'reinfection' revealed an almost perfect interobserver and intraobserver agreement with a classification accuracy of 94.8%. The category 'tissue and implant conditions' showed moderate interobserver and substantial intraobserver reliability, while the classification accuracy was 70.8%. For 'non-human cells,' accuracy was 81.0% and interobserver agreement was moderate with an almost perfect intraobserver reliability. The classification accuracy of the variable 'morbidity of the patient' reached 73.5% with a moderate interobserver agreement, whereas the intraobserver agreement was substantial. The application of the app yielded comparable results across all subgroups. Conclusion: The PJI-TNM classification system captures the heterogeneity of PJI and can be applied with substantial inter- and intraobserver reliability. The PJI-TNM educational app aims to facilitate application in clinical practice. A major limitation was the correct assessment of the implant situation. To eliminate this, a re-evaluation according to intraoperative findings is strongly recommended.

Injury Pattern and Current Early Clinical Care of Pediatric Polytrauma Comparing Different Age Groups in a Level I Trauma Center.

Introduction: Pediatric polytrauma is a complex condition with unique characteristics and requirements for early clinical care. This study aimed to analyze the injury patterns, early clinical care, and outcomes of pediatric polytrauma patients in a Level I trauma center. The focus was on evaluation between different age groups and the recognition of injuries as potential factors influencing outcomes. Methods: A prospective cohort study model of pediatric polytrauma patients (ISS ≥ 16) was conducted over a 13-year period, stratified by age groups (Group A: 0-5 years; Group B: 6-10 years; Group C: 11-15 years; and Group D: 16-18 years). A comparison of the groups was conducted to examine variations in early clinical care, trauma mechanisms, distribution of affected body regions (as per AIS and ISS criteria), and trauma-related mortality. Additionally, factors contributing to mortality were evaluated. Results: The median age of patients was 16 years, with a male predominance (64.7%). The Injury Severity Score (ISS) varied across age groups, with no significant difference. The 30-day mortality rate was 19.0%, with no significant age-related differences. Trauma mechanisms varied across age groups, with motor vehicle accidents being the most common mechanism in all age groups except 0-5 years, where falls were prevalent. Analysis of injury patterns by AIS body regions indicated that head trauma was a significant predictor of mortality (Hazard Ratio 2.894, p < 0.001), while chest, abdominal, and extremity trauma showed no significant association with mortality. Multiple regression analysis identified the ISS and preclinical GCS as valid predictors of mortality (p < 0.001 and p = 0.006, respectively). Conclusions: While age-related differences in injury severity and clinical interventions were limited, head trauma emerged as a critical predictor of mortality. Early recognition and management of head injuries are crucial in improving outcomes. Additionally, the ISS and preclinical GCS were identified as valid predictors of mortality, emphasizing the importance of early assessment and resuscitation. A tailored approach to pediatric polytrauma care, considering both age and injury patterns, might contribute to survival benefits in this vulnerable population.

[Treatment strategies for fracture-related infections with concurrent soft tissue damage]. / Therapiestrategien bei frakturassoziierten Infektionen mit begleitendem Weichteilschaden.

Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.

Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases.

PURPOSE: To investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures. METHODS: Data were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019-2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality. RESULTS: Among 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23-9.58), acute renal failure (OR = 3.20, 95% CI: 2.26-4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64-2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56-0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16-0.71) were identified as potential protective factors (both p < 0.05). CONCLUSION: Comprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors.

[Prehospital treatment of polytrauma : Ongoing challenge in prehospital emergency services]. / Präklinische Polytraumaversorgung : Beständige Herausforderung im präklinischen Rettungswesen.

Tscherne was the first to define the term polytrauma in 1966 as "multiple injuries to different regions of the body sustained simultaneously, with at least one injury or the combination of these injuries being life-threatening". This definition highlights the essential pathophysiological paradigm of polytrauma, with the life-threating characteristics resulting from injuries to multiple organ systems. The treatment of polytrauma patients begins at the scene of the accident. Important life-saving initial interventions can already be carried out on site through targeted measures and expertise of the emergency medical service team, thus improving patient survival. The advanced trauma life support/prehospital trauma life support (ATLS/PHTLS) concept is the worldwide gold standard. As prehospital treatment of severely injured patients is not routine for most emergency teams, concepts and emergency interventions must be regularly trained. This is the prerequisite for safe and effective emergency treatment in this time-critical situation.

Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process.

INTRODUCTION: Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research. METHODS: An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement. RESULTS: The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy. CONCLUSION: This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.

Predictors of Mortality in Head-Preserving Treatment for Dislocated Proximal Humerus Fractures: A Retrospective Analysis of 522 Cases with a Minimum Follow-Up of 5 Years.

PURPOSE: Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, but there is still inadequate knowledge about mortality risk factors after such injuries. In order to provide the best possible therapy, individual risk factors have to be considered and evaluated thoroughly. There is still controversy regarding treatment decisions for proximal humerus fractures, particularly for the elderly. METHODS: In this study, patient data from 522 patients with proximal humerus fractures were obtained from 2004 to 2014 at a Level 1 trauma centre. After a minimum follow-up of 5 years, the mortality rate was assessed, and independent risk factors were evaluated. RESULTS: A total of 383 patients (out of 522) were included in this study. For our patient collective, the mean follow-up was at 10.5 ± 3.2 years. The overall mortality rate was 43.8% in our respondent group and was not significantly impacted by concomitant injuries. The binary logistic regression model showed an increased risk for mortality by 10% per life year, a 3.9 times higher mortality risk for men and a 3.4 times higher risk for conservative treatment. The most powerful predictor was a Charlson Comorbidity Index of more than 2, with a 20 times higher mortality risk. CONCLUSIONS: Outstanding independent predictors of death in our patient collective were serious comorbidities, male patients, and conservative treatment. This patient-related information should influence the process of decision making for the individual treatment of patients with PHFs.

[Elbow joint dislocation : Frequent concomitant injuries and current treatment concepts]. / Ellenbogengelenkluxation : Häufige Begleitverletzungen und aktuelle Therapiekonzepte.

Dislocations of the elbow joint are among the most prevalent dislocation injuries in the human body after shoulder joint dislocations and represent a challenge in the clinical routine because of the concomitant injuries and complications. They predominantly affect young adults who become injured during athletic or daily activities. A distinction is generally made between a simple elbow dislocation and a dislocation fracture of the elbow; however, a uniform classification or treatment algorithm has not yet been established, especially for simple elbow dislocations with associated ligamentous, muscular and capsular concomitant injuries. Due to this and the complexity of this injury, a standardized approach is needed to initiate the optimal treatment at an early stage and to correctly select the narrow treatment pathway between impending chronic instability and elbow stiffness.

Reduced performance after return to competition in ACL injuries: an analysis on return to competition in the 'ACL registry in German Football'.

PURPOSE: ACL injuries are one of the most severe injuries in football, but medical consequences and performance outcomes after return to competition are only rarely investigated. Aim of this study was to analyse the time of return to competition (RTC) in German professional, semi-professional and amateur football. Also, this investigation highlights the rate of career ending and performance outcome after RTC in different playing levels by the measurement of playing level, performed matches and played minutes. METHODS: Database of this investigation is the 'ACL registry in German Football' with prospectively collected injury data. Between 2014 and 2018, four seasons in professional (1st-3rd league), semi-professional (4th-6th league) and amateur leagues (7th league) were analysed regarding the return to competition period and performance parameters. Data were collected for three subsequent seasons after injury and compared with the pre-injury and injury season. Data collection was performed using standardized methods. RESULTS: A total of 607 ACL injuries were registered during the 4-year period with a mean RTC time of 337.1 day (SD: 183). After primary ACL ruptures, the fastest RTC was found in professional football (247.3 days), while in semi-professional (333.5 d; p < 0.0001) and amateur football (376.2 d; p < 0.0001) a prolonged absence was detected. Re-ruptures occurred in 17.8% (n = 108) and showed similar trend with fastest RTC in professionals (289.9 days; p = 0.002). Within the first three seasons after injury, 92 players (36.7%) in semi-professional and 24 (20%) in professionals had to end their career. Keeping the level of play was only possible for 48 (47.5%) of professionals, while only 47 (29.6%) of semi-professionals and 43 (28.1%) of amateurs were able to. Only in professional football, no significant difference could be seen in the played minutes and games after 2 years compared to the pre-injury season. CONCLUSION: Lower playing levels and re-ruptures are the main factors for a prolonged return to competition after ACL rupture in German football. Significant reduction in playing level and a high rate of career endings were found for all levels of play. However, only professional players were able to regain their playing minutes and games 2 years after injury, while lower classed athletes did not reach the same amount within 3 years. LEVEL OF EVIDENCE: Level III.

Practical Relevance of Institutional Guidelines in Translational Large Animal Studies of Cartilage Repair-A Multidisciplinary Survey.

Background and Objective: Translational large animal models are inevitable to transfer cartilage repair methods into clinical practice. Guidelines for these trials have been published by guiding agencies (FDA, ASTM, EMEA) including recommendations for study descriptors and study outcomes. However, practical adherence to these recommendations is not achieved in all aspects. This study includes an assessment of the recommended aspects regarding practical relevance in large animal models for cartilage repair by professionals in the field. Materials and Methods: In an online based survey, 11 aspects regarding study design and 13 aspects regarding study outcome from previously published guidelines were evaluated (0-10 points, with 10 being most important) by study participants. Additionally, the survey contained questions related to professional experience (years), professional focus (preclinical, clinical, veterinarian, industry) and the preferred translational large animal model for cartilage repair. Results: The total number of survey participants was 37. Rated as most important for study design parameters was lesion size (9.54 pts., SD 0.80) followed by study duration (9.43 pts., SD 1.21); and method of scaffold fixation (9.08 pts., SD 1.30) as well as depth of the lesion (9.03 pts., SD 1.77). The most important aspects of study outcome were considered histology (9.41 pts., SD 0.86) and defect filling (8.97 pts., SD 1.21), while gene expression was judged as the least important (6.11 pts., SD 2.46) outcome. A total of 62.2% of all participants were researchers, 18.9% clinicians, 13.5% veterinarians and 5.4% industry employees. Conclusions: In translational research, recommendations published by guiding agencies receive broad theoretical consensus within the community, including both clinically and preclinically orientated scientists. However, implementation into practical research lacks in major aspects. Ongoing re-evaluation of the guidelines under involvement of all stakeholders and approaches to overcome financial and infrastructural limitations could support the acceptance of the guidance documents and contribute to standardization in the field.

Clinical outcomes after refixation of subacute repaired distal biceps tendon ruptures.

Background: The aim of this study was to evaluate the clinical outcome and complication spectrum after delayed repair surgery of distal biceps tendon ruptures, postulating that satisfactory results are possible contrary to previous literature. Methods: Forty-three of 92 patients with a full workup (= OPT in) undergoing primary distal biceps tendon repair were included in this study. The mean age of participants was 49.5 years (range = 22-66 years). This cohort was divided into two groups: patients undergoing acute repair (<21 days = AR group) and a group with delayed intervention (>21 days = SR group). Beside clinical evaluation, functional scores and detection of heterotopic ossification were documented. Strength of flexion and supination were measured using a BIODEX multipoint system. In addition, thirty-one patients were included only in the evaluation of complications in the absence of consent for clinical examination (= OPT out). Results: Concerning the OPT-in group, twenty-eight patients (ø age = 48.9 years; 22-63 years) received acute repair after an average of 9.2 ± 3.7 days. On the contrary, 15 patients (ø age = 50.5 years; 32-66 years) were treated with a delay after an average of 31.4 ± 10.4 days. Regarding patient-reported outcome measures, conflicting results emerge (AR/SR: Subjective Elbow Value = 87/80%, P > .05; Mayo score = 96/93 pts, P > .05; the Disabilities of the Arm, Shoulder and Hand score = 6/13 pts, P < .05; and Oxford Elbow Score = 44/39 pts, P < .05). The main complication is the paresthesia of the lateral antebrachial cutaneous nerve, which occurs more in the group of delayed repair (AR: 21.0%, SR 31.8%). Forty-one percentage of patients in the SR group described pain in the elbow with exertion in contrast to 17.3% in the AR group. In terms of elbow strength, no significant difference in the AR or SR group compared with the contralateral side could be observed. Conclusion: The data suggest that delayed repair of distal biceps ruptures beyond 3 weeks may result in satisfactory clinical outcomes. However, exertional pain and paresthesia of the lateral antebrachial cutaneous nerve may diminish results.

The clinical use of bone graft substitutes in orthopedic surgery in Germany-A 10-years survey from 2008 to 2018 of 1,090,167 surgical interventions.

Aim of the study was to evaluate (1) the overall use of bone graft substitutes, autografts and allografts, (2) of different types of bone graft substitutes (calcium sulfate, calcium phosphate, calcium phosphate ceramics or polymethyl methacrylate) and of different bone grafts (cancellous vs. cortical), and (3) the use of antibiotic-loading of bone graft substitutes in orthopedic surgery in Germany. Gross data were provided from the Federal Statistical Office of Germany and revealed an overall increase in bone defect reconstruction procedures using bone graft substitutes, autografts and allografts from 86,294 in 2008 to 99,863 cases in 2018 (+15.7%). The relative use of bone graft substitutes for these interventions strongly increased from 11.8% in 2008 (10,163 cases) to 23.9% in 2018 (23,838 cases) with an increase of +134.4%. Furthermore, antibiotic-loaded bone graft substitutes were implanted more frequently with an overall increase of +194% (2008: n = 2,657; 2018: n = 7,811). The work shows an increasing use of bone graft substitutes and antibiotic-loaded bone graft substitutes over the last 10 years in Germany.

Decision-making to stop or continue playing after football injuries - a systematic video analysis of 711 injury situations in amateur football.

Scientific injury registration via video analysis is lacking in amateur football. The purpose of this study was to analyse match injury situations with a focus on the decisions made by players and referees after sustaining a football trauma. In a retrospective cohort study, traumatic injuries sustained in any of the 305 matches of the highest amateur level (4th league) in Germany in the 2015-16 season were assessed by means of video analysis and a standardised video protocol. In total, 711 traumatic incidents at 919 different body regions had been recorded. The three most frequently injured body regions were the ankles (34.1%), the head (17.5%) and the knees (17.0%). 90% (n = 156) of head injuries were direct contact injuries, this percentage was significantly higher than that of contact injuries on ankle (68.4%; p < 0.001) or knee (52.6%; p = 0.001). Referees decided on foul play significantly more often in case of knee injuries (57.1%; p = 0.002) or ankle injuries (64.5%; p < 0.001) than in head injuries (39.8%). Only 26.1% of players with a head injury opted for substitution, which was lower than after ankle (27.8%; p = 0.78) and knee injuries (34.0%; p = 0.13). In conclusion, amateur football is associated with a considerable number of injury situations that are followed by match interruptions and the substitution of players. Players and referees decided to continue playing more often after a head injury than after an injury to other body regions. An advanced education programme on the risks and management of head injuries in football is required to prevent long-term health consequences.

Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. / Struktur- und Prozessdaten zur radiologischen Bildgebung bei Behandlung schwerstverletzter Patienten ­ Ergebnisse einer Befragung überregionaler und regionaler TraumaZentren in Deutschland.

PURPOSE: Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. MATERIALS AND METHODS: Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. RESULTS: With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). CONCLUSION: Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. KEY POINTS: · This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed.. CITATION FORMAT: · Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2022; 194: 505 - 514.

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques.

BACKGROUND: Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use. METHODS: A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible. RESULTS: A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant. CONCLUSION: Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted. LEVEL OF EVIDENCE: III.

Revision arthroplasty after unicompartimental knee arthroplasty.

BACKGROUND: Unicompartimental knee arthroplasty (UKA) is a promising and increasing application to treat unicompartimental knee osteoarthritis. However, revision arthroplasty numbers after UKA are unknown. Therefore, aim of this study was to determine the nationwide burden of revision after UKA by answering the following questions: (1) How did numbers of revision UKA procedures developed over the last decade as a function of age and gender? (2) How high is the percentage of revision UKA procedures due to infection? (3) Which therapy strategy was chosen for surgical treatment of aseptic revision UKA? METHODS: Revision arthroplasty rates as a function of age, gender, infection and type of prosthesis were quantified based on Operation and Procedure Classification System codes using revision knee arthroplasty data from 2008 to 2018, provided by the Federal Statistical Office of Germany (Destatis). RESULTS: Over the last decade, revision UKA increased by 46.3% up to 3105 procedures in 2018. A trend towards higher numbers in younger patients was observed. Septic interventions constituted 5.7% of all revisions, whereby total procedures increased by 67.1% from 2008 through 2018. The main treatment strategy was an exchange to a bicondylar surface replacement prosthesis, which was done in 63.70% of all cases, followed by exchange to a femoral and tibial shaft-anchored (16.2% of all revisions). CONCLUSION: The increasing number of revision arthroplasty after UKA in Germany, especially in younger patients and due to infection, underlines the need for future efforts to improve treatment strategies beyond UKA to delay primary arthroplasty and avoid periprosthetic joint infection.

Displacement of the Greater Tuberosity in Humeral Head Fractures Does Not only Depend on Rotator Cuff Status.

It is assumed that dorsocranial displacement of the greater tuberosity in humeral head fractures is caused by rotator cuff traction. The purpose of this study was to investigate the association between rotator cuff status and displacement characteristics of the greater tuberosity in four-part humeral head fractures. Computed tomography scans of 121 patients with Neer type 4 fractures were analyzed. Fatty infiltration of the supra- and infraspinatus muscles was classified according to Goutallier. Position determination of the greater tuberosity fragment was performed in both coronary and axial planes to assess the extent of dorsocranial displacement. Considering non-varus displaced fractures, the extent of the dorsocranial displacement was significantly higher in patients with mostly inconspicuous posterosuperior rotator cuff status compared to advanced fatty degenerated cuffs (cranial displacement: Goutallier 0-1: 6.4 mm ± 4.6 mm vs. Goutallier 2-4: 4.2 mm ± 3.5 mm, p = 0.020; dorsal displacement: Goutallier 0-1: 28.4° ± 32.3° vs. Goutallier 2-4: 13.1° ± 16.1°, p = 0.010). In varus displaced humeral head fractures, no correlation between the displacement of the greater tuberosity and the condition of the posterosuperior rotator cuff could be detected (p ≥ 0.05). The commonly accepted theory of greater tuberosity displacement in humeral head fractures by rotator cuff traction cannot be applied to all fracture types.

Necessity of Immediate MRI Imaging in the Acute Care of Severely Injured Patients.

Background and Objectives: The standard diagnostic procedure for a patient with a suspected polytrauma injury is computed tomography (CT). In individual cases, however, extended acute imaging using magnetic resonance imaging (MRI) can provide valuable and therapy-relevant information. The aim of our cohort study was to find such cases and to describe their characteristics in order to be able to give possible recommendations for MRI application in acute trauma situations. Materials and Methods: In the study period from 2015-2019, an evaluation of the imaging performed on polytrauma patients was carried out. The specific diagnostic and therapeutic criteria of the MRI group were further defined. Results: In total, 580 patients with an ISS ≥16 (injury severity score) were included in the study. Of these 580 patients, 568 patients received a CT scan and 12 patients an MRI scan as part of the initial diagnostic. Altogether, 66.67% of the MRIs took place outside of regular service hours. The main findings for MRI indications were neurological abnormalities with a focus on myelon injuries. Further MRI examinations were performed to rule out vascular injuries. All in all, 58.3% of the MRIs performed resulted in modified therapeutic strategies afterward. Conclusions: MRI in the context of acute diagnostic of a severely injured patient will likely remain reserved for special indications in the future. However, maximum care hospitals with a high flow of severely injured patients should provide 24/7 MR imaging to ensure the best possible care, especially in neurological and blunt vascular injuries.

The Tibial Plateau Map: Fracture Line Morphology of Intra-Articular Proximal Tibial Fractures.

The purpose of this study was to characterize the patterns of a large series of tibial plateau fractures with the use of fracture mapping, with regard to different fracture types using the OTA/AO and Schatzker classification. Patients with intra-articular fractures of the tibial plateau were evaluated, using the OTA/AO and Schatzker classification on CT scans. For fracture mapping, the axial slice that completely displayed the tibial joint plane was first identified, then matched to a template congruently, and the fracture lines were identified and reproduced. In addition to epidemiological data (age and gender), the trauma mechanism (high-energy, low-energy, and pathological fracture) was recorded. In total, 271 patients with 278 intra-articular fractures of the tibial head were analyzed, including seven patients with both sides affected. The mean age was 49.1 years (men 46.3 years, women 53.5 years). The majority of fractures was caused by high-energy trauma. No significant difference could be shown with respect to trauma mechanism and resulting fracture type in terms of OTA/AO (p = 0.352) or Schatzker classification (p = 0.884). A significant difference could be found with respect to gender and resulting fracture type in terms of OTA/AO (p = 0.031). 170 (61.2%) were OTA/AO type B fractures, and 108 (38.8%) were type C fractures. Using the Schatzker classification, we found 53 type I (19.1%), 60 type II (21.6%), 27 type III (9.7%), 32 type IV (11.5%), 16 type V (5.8%), and 90 type VI (32.4%) fractures. The main affection was found in the lateral and intermedial column of the tibial plateaus, concerning both OTA/AO and Schatzker classification. The variability of intra-articular tibial head fractures is very high. In consequence, an individual analysis of fracture patterns and therapy planning by using CT scans is crucial.