Evidence-based and Patient-centered Indication for Knee Arthroplasty - Update of the Guideline. / Evidenzbasierte und patientenorientierte Indikationsstellung zur Knieendoprothese ­ Update der Leitlinie.

Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated.For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications.Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI ≥ 40 kg/m2). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee.The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

[Rehabilitation in rheumatic diseases and osteoporosis-a multidisciplinary task]. / Rehabilitation bei rheumatischen Erkrankungen und Osteoporose ­ eine multidisziplinäre Aufgabe.

Advances in medications and changes in therapeutic options have significantly reduced limitations in functional capacity and quality of life for patients with rheumatic diseases and osteoporosis, but there is still a large number of patients in whom the diseases do not take the desired course. Older rheumatic patients also often have comorbidities that require a multidisciplinary and multimodal approach to therapy. Rehabilitation measures are, therefore, an important part of the treatment concept for these patients in order to maintain their functional health, social participation, and, in the case of those who are still working, in particular their gainful employment. They can help to limit sequelae, preserve existing functions, reduce pain, and maintain the quality of life of those affected. The article aims to provide an overview of the rehabilitative therapy concept and the level of evidence for individual forms of therapy.

[Requirements for trauma rehabilitation centers : Post-acute rehabilitation (phase C) after severe trauma injury]. / Anforderungen an Traumarehabilitationszentren : Postakute Rehabilitation (Phase C) nach schwerer Unfallverletzung.

Severely injured patients need a qualified and seamless rehabilitation after the end of the acute treatment. This post-acute rehabilitation (phase C) places high demands on the rehabilitation facility in terms of personnel, material, organizational and spatial requirements.The working group on trauma rehabilitation of the German Society for Orthopedics and Traumatology e. V. (DGOU) and other experts have agreed on requirements for post-acute phase C rehabilitation for seriously injured people. These concern both the personnel and material requirements for a highly specialized orthopedic trauma surgery trauma rehabilitation as well as the demands on processes, organization and quality assurance.A seamless transition to the follow-up and further treatment of seriously injured people in the TraumaNetzwerk DGU® is ensured through a high level of qualification and the corresponding infrastructure of supraregional trauma rehabilitation centers. This also places new demands on the TraumaZentren DGU®. Only if these are met can the treatment and rehabilitation of seriously injured people be optimized.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment.

BACKGROUND: The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae. METHODS: A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine. RESULTS: The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures. CONCLUSION: It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

[Rehabilitation after Hip Arthroplasty - Between Fast-Track Surgery and Orthogeriatrics]. / Rehabilitation nach Hüftendoprothese.

Surgical procedures as well as length of stay and age limits have changed significantly in recent years in the context of hip arthroplasty. While hospitals are becoming increasingly specialised and patients are sometimes discharged to follow-up rehabilitation after only three to four days, the rehabilitation clinic providing follow-up care has to maintain a well-differentiated treatment pathway in order to meet the different requirements and needs between patients with fast-track surgery and orthogeriatric patients.

The use of exoskeletons in the occupational context for primary, secondary, and tertiary prevention of work-related musculoskeletal complaints.

OCCUPATIONAL APPLICATIONS This guideline includes 20 recommendations and four key statements that achieved consensus or strong consensus regarding the application of exoskeletons in the workplace for the prevention of musculoskeletal complaints and diseases, the general use and implementation of exoskeletons, and recommendations for risk assessment. The guideline is intended for company physicians, occupational physicians, ergonomists, occupational safety specialists, and employers, and serves as information for all other actors in practical occupational safety. Due to the lack of evidence from the scientific literature, the recommendations and key statements are the result of expert discussions that were conducted at a consensus conference in accordance with the Regulations of the Association of the Scientific Medical Societies in Germany, moderated by an external consultant.

TECHNICAL ABSTRACT Background The prevention of work-related musculoskeletal complaints and diseases has high priority, considering the prevalence of musculoskeletal complaints and diseases and the associated high burden on health care systems, the economy, and the people affected. Purpose: This guideline provided recommendations for potential applications of exoskeletons in the workplace for the primary, secondary, and tertiary prevention of musculoskeletal complaints and diseases, general recommendations on the use and implementation of exoskeletons, and recommendations on risk assessment. Methods: A systematic literature search, a survey among exoskeleton manufacturers and companies using exoskeletons, and expert discussions formed the basis of the formulated recommendations and key statements. For reaching consensus on the recommendations and key statements, we applied the Nominal Group and Delphi Techniques under the supervision of an external, independent moderator. Results: We formulated 20 recommendations and four key statements, all of which reached consensus or strong consensus. Conclusion: No answers could be found in the current scientific literature to the central questions in this guideline about primary, secondary, and tertiary prevention. We outline five main directions for future research on exoskeletons in occupational settings. First, using exoskeletons for prevention should be investigated using randomized controlled trials. Second, the effects of exoskeletons on work-related musculoskeletal stress and strain should be investigated both in the body region intended to be supported by the exoskeleton as well as in other non-supported body regions. Third, the effects of exoskeletons should be investigated in samples varying in age, gender, and health status, as well as during different occupational activities. Fourth, a specific risk assessment tool for exoskeletons in occupational settings should be developed and implemented to meet and evaluate the applicable occupational health and safety standards. Fifth, there is a need to expand upon the very limited social science research on the impacts of exoskeletons on employee professional understanding, social role understanding, or diversity.

Evaluation of the Fall Risk of Orthopedic Trauma Surgery Patients by Establishing a Fall Risk Score and a Procedure Instruction in Clinical Routine. / Evaluation des Sturzrisikos orthopädisch-unfallchirurgischer Patienten durch Etablierung eines Sturzrisikoscores und einer Verfahrensanweisung im klinischen Alltag.

This article examines the risk of falls of orthopaedic surgery patients on admission to hospital. For this purpose, an internal clinical fall risk score was developed, which divides the patients into three risk categories. Subsequently, the validity of the score was recorded and possibilities for reducing the individual risk of falling were pointed out. The results show that the score can identify patients at high risk of falling on admission.

[Rehabilitation after Traumatic Fracture of Thoracic and Lumbar Spine]. / Rehabilitation nach traumatischen Frakturen der Brust- und Lendenwirbelsäule.

On the basis of the S2-k guideline "Rehabilitation after traumatic fractures of the thoracic und lumbar spine without neurologic disorder", this article gives an overview of target-oriented rehabilitation of patients with minor fractures or those with column stability and unstable spinal fractures which are stabilised by surgery. To obtain early social and job related reintegration, outpatient or inpatient rehabilitation has to start immediately after treatment in hospital. Rehabilitation must be orientated towards the biopsychosocial model of ICF and has to be adapted for the patient. The overall goal of rehabilitation is functional restoration of patient health to enable participation in society, life and job. Individual goals may change during rehabilitation, because of differential progress in therapy. Pain management must be orientated towards individual requirements and mental health has to be tested early, especially in polytrauma patients. Disorders have to be treated by psychotherapy, because psychic stress supports chronification of pain. Generally early exercise and physiotherapy are recommended in the guideline, with patient education for health-seeking behavior. Otherwise an orthesis device is not really necessary for treatment of a stable fracture. To improve the outcome of rehabilitation aftercare, treatment has to be arranged during rehabilitation, especially for employed patients.

Indication Criteria for Total Knee Arthroplasty in Patients with Osteoarthritis - A Multi-perspective Consensus Study.

Background and Objectives Knee osteoarthritis (OA) is a significant public health burden. Rates of total knee arthroplasty (TKA) in OA vary substantially between geographical regions, most likely due to the lack of standardised indication criteria. We set out to define indication criteria for the German healthcare system for TKA in patients with knee OA, on the basis of best evidence and transparent multi-stakeholder consensus. Methods We undertook a complex mixed methods study, including an iterative process of systematic appraisal of existing evidence, Delphi consensus methods and stakeholder conferences. We established a consensus panel representing key German national societies of healthcare providers (orthopaedic surgeons, rheumatologists, pain physicians, psychologists, physiotherapists), payers, and patient representatives. A priori defined consensus criteria were at least 70% agreement and less than 20% disagreement among the consensus panel. Agreement was sought for (1) core indication criteria defined as criteria that must be met to consider TKA in a normal patient with knee OA, (2) additional (not obligatory) indication criteria, (3) absolute contraindication criteria that generally prohibit TKA, and (4) risk factors that do not prohibit TKA, but usually do not lead to a recommendation for TKA. Results The following 5 core indication criteria were agreed within the panel: 1. intermittent (several times per week) or constant knee pain for at least 3 - 6 months; 2. radiological confirmation of structural knee damage (osteoarthritis, osteonecrosis); 3. inadequate response to conservative treatment, including pharmacological and non-pharmacological treatment for at least 3 - 6 months; 4. adverse impact of knee disease on patient's quality of life for at least 3 - 6 months; 5. patient-reported suffering/impairment due to knee disease. Additional indication criteria, contraindication criteria, and risk factors for adverse outcome were also agreed by a large majority within the multi-perspective stakeholder panel. Conclusion The defined indication criteria constitute a prerequisite for appropriate provision of TKA in patients with knee OA in Germany. In eligible patients, shared-decision making should eventually determine if TKA is performed or not. The next important steps are the implementation of the defined indication criteria, and the prospective investigation of predictors of success or failure of TKA in the context of routine care provision in Germany.

Long-term effects of interprofessional biopsychosocial rehabilitation for adults with chronic non-specific low back pain: a multicentre, quasi-experimental study.

BACKGROUND: Improvement of the long-term effectiveness of multidisciplinary ortho-paedic rehabilitation (MOR) in the management of chronic non-specific low back pain (CLBP) remains a central issue for health care in Germany. We developed an interprofessional and interdisciplinary, biopsychosocial rehabilitation concept named "PASTOR" to promote self-management in adults with CLBP and compared its effectiveness with the current model of MOR. METHODS: A multicentre quasi-experimental study with three measurement time points was implemented. 680 adults aged 18 to 65 with CLBP were assed for eligibil-ity in three inpatient rehabilitation centres in Germany. At first the effects of the MOR, with a total extent of 48 hours (control group), were assessed. Thereafter, PASTOR was implemented and evaluated in the same centres (intervention group). It consisted of six interprofessional modules, which were provided on 12 days in fixed groups, with a total extent of 48 hours. Participants were assessed with self-report measures at baseline, discharge, and 12 months for functional ability (primary outcome) using the Hannover Functional Ability Questionnaire (FFbH-R) and vari-ous secondary outcomes (e.g. pain, health status, physical activity, pain coping, pain-related cognitions). RESULTS: In total 536 participants were consecutively assigned to PASTOR (n=266) or MOR (n=270). At 12 months, complete data of 368 participants was available. The adjusted between-group difference in the FFbH-R at 12 months was 6.58 (95% CI 3.38 to 9.78) using complete data and 3.56 (95% CI 0.45 to 6.67) using available da-ta, corresponding to significant small-to-medium effect sizes of d=0.42 (p<0.001) and d=0.10 (p=0.025) in favour of PASTOR. Further improvements in secondary out-comes were also observed in favour of PASTOR. CONCLUSION: The interprofessional and interdisciplinary, biopsychosocial rehabilita-tion program PASTOR shows some improvements of the long-term effectiveness of inpatient rehabilitation in the management of adults with CLBP. Further insights into mechanisms of action of complex intervention programs are required. TRIAL REGISTRATION: ClinicalTrials.gov NCT02056951.