Orthopaedics and Trauma Surgery in Germany in 2023 - Will We Have Sufficient Doctors in the Future? / Orthopädie und Unfallchirurgie 2023 ­ haben wir genug Nachwuchs?

There has been a growing shortage of physicians in Germany in recent years. In this study, we analyse the situation facing orthopaedic hospitals and trauma centres.Between 22 November and 5 December 2022, a web-based questionnaire was sent out by the Academy of the German Trauma Society (AUC) and by the Society of Leading Orthopaedic and Trauma Surgeons (VLOU).The questionnaire was answered by 185 heads of department. Of the responses, 20% came from university hospitals or major trauma centres, and a third from regional or local clinics. More than half of the hospital departments (55%) had a median of 2.7 vacant doctor positions. Among those hospitals, 47% had a vacant position for a consultant, 33% for a board-certified specialist, and 89% for a junior doctor. Within the university hospitals, only one third had vacant doctor positions. The responding heads of department gave negative feedback regarding the number of applications, the qualifications of young doctors, and their motivation for scientific work (in university hospitals).More than half of the responding hospitals had vacant doctor positions. If we are to counteract the growing shortage of doctors in orthopaedics and trauma surgery, the number of clinical doctors in general and the working conditions in hospitals have to be improved. Teaching hospitals should try to improve the training of medical students with a view to inspiring greater motivation to work in orthopaedics and trauma surgery.

Research in orthopaedic trauma surgery: approaches of basic scientists and clinicians and the relevance of interprofessional research teams.

BACKGROUND: An increasing clinical workload and growing financial, administrative and legal burdens as well as changing demands regarding work-life balance have resulted in an increased emphasis on clinical practice at the expense of research activities by orthopaedic trauma surgeons. This has led to an overall decrease in the number of scientifically active clinicians in orthopaedic trauma surgery, which represents a serious burden on research in this field. In order to guarantee that the clinical relevance of this discipline is also mirrored in the scientific field, new concepts are needed to keep clinicians involved in research. METHODS: Literature review and discussion of the results of a survey. RESULTS/CONCLUSION: An interdisciplinary and -professional team approach involving clinicians and basic scientists with different fields of expertise appears to be a promising method. Although differences regarding motivation, research focuses, funding rates and sources as well as inhibitory factors for research activities between basic scientists and clinicians exist, successful and long-lasting collaborations have already proven fruitful. For further implementation of the team approach, diverse prerequisites are necessary. Among those measures, institutions (e.g. societies, universities etc.) must shift the focus of their support mechanisms from independent scientist models to research team performances.

Evaluation of Quality of Life (BREAST-Q) and Scar Quality (POSAS) after Breast Augmentation.

This study examines the effects of breast augmentation on women who underwent surgery in Germany regarding their quality of life (QOL) and scar quality using patient-reported surveys. The purpose of this study was to determine if there is an increase in women's QOL after surgery compared with preoperative, and to evaluate their postoperative scar quality. Methods: A prospective monocentric study was conducted on 50 women who underwent breast augmentation with nanotextured silicone-filled implants between October 2018 and December 2020. Of these women, 21 (42%) participated in the preoperative survey (BREAST-Q), and 50 (100%) participated in the postoperative survey (BREAST-Q and POSAS). We used the BREAST-Q questionnaire to measure patients' QOL and the Patient and Observer Scar Assessment Scale to determine the scar quality. Results: Psychosocial well-being increased by 34.3 points according to the Q-score, sexual well-being increased by 35.7, and satisfaction with breasts increased by 48.8. Physical well-being decreased by 12 points. The Patient and Observer Scar Assessment Scale mean scores, according to the patient/observer, are 3.8/2.5 for inframammary scars and 4.4/3.1 for periareolar scars. Conclusions: In this study, we discovered that aesthetic breast augmentation with nanotextured silicone-filled breast implants is associated with significantly higher scores for patient satisfaction, which indicates an improvement in women's QOL.

[Evaluation of the current research structures in trauma surgery : A survey of the scientific committee of the German Society for Trauma Surgery]. / Erhebung der Forschungsstrukturen in der Unfallchirurgie : Eine Umfrage des Wissenschaftsausschusses der DGU.

BACKGROUND: To improve research in orthopedics and traumatology (O&T) in Germany, the implementation of comprehensive research collaborations and enhanced communication pathways among different institutions are necessary. This survey was initiated to collect data regarding the current research structures in O&T. MATERIAL AND METHODS: A subject-specific questionnaire was sent via email to collect data regarding demographics, on-going and past research activities and the funding. Naming of current and future research topics and problems regarding realization of projects were determined. All results were submitted electronically, anonymously and voluntarily. RESULTS: Of 229 participants, 83% worked as clinicians and 59.6% of the participants were working in departments with joint structures (O&T). Industry and universities were found to be the essential funding sources. Future research topics tend to concentrate on digital health issues (artificial intelligence, big data, 3D-printing). Resource scarcity in time and staff as well as administrative barriers but also insufficient funding were identified as major impediments of research activity. CONCLUSION: Future research development in O&T will cause an expansion of techniques and methods. At the same time aggravated personnel, financial, administrative and legal framework conditions can only be managed with an intensively increased effort. Cooperation projects and collaborative research structures might be a solution to these challenges.

[Photodynamic intramedullary bone stabilization of pathological fractures]. / Fotodynamische intramedulläre Knochenstabilisierung bei pathologischen Frakturen.

Pathological fractures of long tubular bones are stabilized with conventional implants. Essentially, plates and intramedullary nails are used for stabilization and are two different techniques, which compete with each other with respect to the surgical treatment. A large number of such means of osteosynthesis are commercially available but are primarily focused on acute fractures in otherwise biologically healthy bones. The pathological fracture or the treatment of impending pathological fractures due to metastatic osteolysis differs from the treatment of healthy bones in some fundamental aspects. The characteristics of pathological fractures make the development of new technologies that meet the specific needs of both the patient and the surgeon desirable. A new approach in treatment is stabilization of internal long bone fractures by the use of a cylindrical balloon implant, which is introduced into the bone via a small proximal or distal hole and then filled and expanded to a much larger diameter with a liquid monomer. The curing process is initiated with the application of blue light forming a rigid implant by polymerization (IlluminOss™). Many of the well-known disadvantages of conventional implants can be eliminated with this technology. Specifically, with respect to the irregular shape of the natural medullary canal it is possible to completely fill the medullary canal of the tubular bone. The filling of the canal provides torsional stability without the use of interlocking screws. Similarly, the use of the balloon technique enables minimally invasive surgery and furthermore permits the additive use of conventional metallic plates whenever necessary. The new balloon techniques show high primary stability in the treatment of pathological shaft fractures. In particular cases, the addition of a supplemental plate osteosynthesis is recommended.

[Osteoporotic bone fractures: intramedullary augmentation and hybrid osteosynthesis]. / Frakturen des osteoporotischen Knochens: intramedulläre Augmentation und Hybridosteosynthese.

The increasing number of people who are living longer and have a far more active lifestyle is inevitably associated with greater numbers of fractures. Stabilization of these fractures in older patients with plates and screws is complicated by fragile bone substance, especially in osteoporotic bone, since osteosynthesis with a conventional plate depends exclusively on the holding power of the screws. Therefore, treatment requires new stabilization technologies designed for these specific tasks. A small diameter polyethylene terephthalate (PET, Dacron®) balloon is delivered in a minimally invasive fashion and placed within the canal, transversing the fracture. Once positioned, the balloon is expanded with a liquid monomer to fill the medullary canal. The liquid monomer is then rapidly cured using visible blue light, forming a patient-customized intramedullary implant that stabilizes the entire length of the bone in contact with the implant. The described intramedullary implant can be easily drilled in any position or location, providing a substantial increase in screw holding power. Thus, a major advantage of the technique is the possibility to augment the newly formed balloon "nail" with a conventional plate and screws at the primary stabilization or at any later time.

The Photodynamic Bone Stabilization System in the Treatment of Humerus Fractures: A Prospective Clinical Trial.

Background Fractures of the proximal humerus are among the most common long-bone fractures and present unique challenges to surgeons. Traditional internal fixation methods, such as intramedullary nails, are associated with drawbacks such as an inability to fully fill the trabecular space and a limited ability to utilize supplemental hardware in many cases. We evaluated the safety and effectiveness of a novel fracture fixation device that utilizes a light-cured monomer to stabilize the fracture in a cohort of patients suffering from humerus fractures. Methods We prospectively collected data from patients being treated surgically for humerus fractures. Fractures were treated using the photodynamic bone stabilization system (PBSS) consisting of a balloon and light-cured monomer. Patients were evaluated at 7-14, 30, 60, 90, 180, and 360 days post-procedure. Primary outcomes included normal and complete radiographic fracture healing. Secondary outcomes included pain (via visual analog scale), function (via the disability of the arm, shoulder, and hand (DASH) and constant shoulder scales), and the rate of complications. Results A total of 33 patients were included in the intent-to-treat analysis (mean age: 76.6 yrs). Of these patients, 88% demonstrated normal radiographic healing at their 90-, 180-, and 360-day visits. Complete radiographic healing was observed in 81%, 88%, and 96% of patients at 90, 180, and 360 days, respectively. Pain scores decreased significantly at day seven when compared with baseline (28.2+20.9 vs.53.6+32.2, p<0.001) and continued to decrease at the 90-day (24.7+15.5, p<0.001), 180-day (17.8+12.5, p<0.001) and 360-day (6.6+6.7, p<0.001) evaluations. DASH scores demonstrated statistically significant improvements over baseline (65.5+31.5) at 90 (37.0+14.9, p<0.001), 180 (30.6+15.7, p<0.001), and 360 days (23.9+15.0, p<0.001) post-procedure. The procedure-related event rate was 36.4%, with 5 (11.4%) device-related adverse events reported at the one-year follow-up. Conclusions Our study demonstrates the ability of a novel internal fixation device to safely and effectively treat fractures of the humerus in the elderly population.

Effective Management of Bone Fractures with the Illuminoss® Photodynamic Bone Stabilization System: Initial Clinical Experience from the European Union Registry.

The IlluminOss® system (IS) uses a light-curable polymer contained within an inflatable balloon catheter, forming a patient customized intramedullary implant. A registry was established in Germany and The Netherlands to prospectively collect technical and clinical outcomes in patients treated with IS for fractures of the phalange, metacarpal, radius, ulna, distal radius, fibula, clavicle and/or olecranon. Humeral, femoral, tibial and pelvic fractures were included under compassionate use. Procedural success included successful placement of the device at the target fracture site and achievement of fracture stabilization. Clinical and radiographic assessments were made postoperatively through 12 months. One hundred thirty two patients (149 fractures) were enrolled with most fractures (85%) resulting from low-energy trauma. Simple fractures predominated (47%) followed by complex (23%) and wedge (16%) fractures. Procedural success was achieved in all patients and no implants required removal or revision. Normal range of motion was realized in 87% of fractures. Radiographically, there was substantial cortical bridging, total dissolution of the fracture line, and complete fracture healing. Across a variety of fracture types, the IS provides a safe and effective approach for rapid healing and functional recovery.

Mallet finger: a simulation and analysis of hyperflexion versus hyperextension injuries.

The goal of this study was to simulate the mechanisms of hyperflexion and hyperextension injuries of the distal interphalangeal (DIP) joint of the hand and to analyze the resulting extensor tendon injury patterns. The hypotheses were raised that hyperflexion trauma leads to a plastic deformation of the extensor tendon aponeurosis, with or without a small bony avulsion fragment but without joint surface involvement, and that hyperextension injuries can create a shear fracture of the dorsal lip of the distal phalanx, without injury to the extensor tendon aponeurosis. Loading was applied with a swinging pendulum impacting the distal phalanx in 103 human specimens in either an extended or flexion position. After loading, injury patterns were analyzed radiologically and histologically. There was evidence that hyperflexion trauma leads to a plastic deformation or rupture of the extensor tendon. Bony tendon avulsion was evident in 12.2 % of cases. With hyperextension, the extensor tendon remained intact in all cases, but there were large fracture fragments involving the articular surface in 4.1 % of cases. The results of the study show that force on the flexed joint leads to overstretching of the extensor tendon, and to an associated dorsal bony avulsion with intact joint line. Force applied to the joint in extension can lead to a bony dorsal edge fracture with articular involvement and with it, a palmar DIP joint capsule rupture. The results illuminate a direct correlation between the mechanism of injury and the pattern of injury in the clinical picture of mallet finger.

Complex forearm deformities: operative strategy in posttraumatic pathology.

Complex posttraumatic forearm deformities have a significant impact on the integrity of the upper extremity leading to pain, instability in both the proximal and/or distal radioulnar articulation, and reduced range of forearm motion. Corrective osteotomy or more advanced procedures for malunited fractures or other posttraumatic deformities of the upper extremity, especially in the forearm are challenging procedures. In this review we will discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the pathway from preoperative planning to the actual deformity correction surgery, either with one-stage correction or using gradual lengthening with external fixation ("callotasis techniques") and finally the functional outcome we can expect for our patients. In addition we will analyze the modern computer-assisted techniques available to date.

Percutaneous lateral ulnar collateral ligament reconstruction.

PURPOSE: Open surgical reconstruction of the lateral ulnar collateral ligament is the standard treatment for symptomatic posterolateral rotatory instability of the elbow. It involves dissection and retraction of the lateral elbow muscles, which have been shown to be secondary stabilizers of the lateral elbow. We introduce a new muscle-protecting technique for single-strand lateral ulnar collateral ligament reconstruction and report on the isometry and primary stability when compared with a conventional muscle-splitting procedure. It was hypothesized that percutaneous lateral ulnar collateral ligament reconstruction provided isometry over the range of motion and that stability was comparable with a conventional open procedure. METHODS: In sixteen human cadaver arms, the intact and the lateral collateral ligament complex-deficient situation was tested. Open lateral ulnar collateral ligament reconstruction was performed using a single-strand palmaris graft with humeral and ulnar tenodesis screw fixation. Posterolateral rotational stability was compared with a new reconstruction method, which percutaneously places a single-strand palmaris graft with humeral and ulnar tenodesis screw fixation. RESULTS: Both open and percutaneous lateral ulnar collateral ligament reconstruction provided isometry over the range of motion and restored posterolateral stability to that of the intact situation. No significant differences between open and percutaneous reconstruction were found. CONCLUSIONS: Percutaneous lateral ulnar collateral ligament reconstruction aims to preserve the lateral elbow muscles and to minimize soft tissue dissection. It has been shown that in an in vitro setup, this new procedure provides isometry over the range of motion and sufficiently restores posterolateral rotatory stability.

Reconstruction of radial capitellar fractures using fine-threaded implants (FFS).

Fractures of the capitulum humeri are rare and challenging injuries to the elbow and outcome results are limited to case series, often with different fixation devices. This article aims to present 15 patients with a fracture of the capitulum humeri treated with the same implant, fine-threaded Kirschner wires (FFS). Besides range of motion and grip strength, outcome measurements include the following scores: the Mayo Elbow Performance index (MEPI); the American Shoulder and Elbow Surgeons' Elbow Assessment (ASES) Form; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and the Broberg-Morrey score. Using the modified Bryan and Morrey classification, there were seven type-I injuries, three type-II, two type-III and three type-IV fractures. In addition to fractures of the capitellum, five patients were diagnosed with a complex ligamentous injury and three had suffered radial head fractures. After a minimum follow-up of 12 months, we obtained a range of motion in flexion and extension of 124° and a pro- and supination of 173°. The mean DASH showed 10.84 and the Broberg-Morrey score reached 90.8. ASES and MEPI scores were 91.5 and 90, respectively. The mean grip strength of the injured side was 217.9N versus 236.4N on the healthy side. The use of FFS for capitellar fractures of the humerus achieved good clinical results and these implants can be considered as a treatment option for this fracture entity.

Morphometric and biomechanical comparison of tendons used for interposition arthroplasty in carpometacarpal arthritis of the thumb.

PURPOSE: To identify the wrist tendon most effectively maintaining the trapezial space in interpositional arthroplasty in osteoarthritis of the carpometacarpal joint of the thumb. METHODS: The morphometrics of the os trapezium and the tendons of the flexor carpi radialis, extensor carpi radialis longus, and abductor pollicis longus were determined. The stiffness and compressive loading characteristics of the rolled-up tendons were compared to the os trapezium. RESULTS: No significant morphometric differences between the three tendons were found. The mass and volume of the trapezium was significantly larger when compared to the tendon balls. No significant differences in the compressive loading resistance were found between the tendons, but the mean stiffness was 85% lower when compared to the os trapezium. CONCLUSIONS: Neither tendon material approached the volume nor the stiffness provided by the os trapezium. Any tendon is considered to insufficiently maintain the trapezial space following trapeziectomy.

Treatment of displaced proximal fifth metatarsal fractures using a new one-step fixation technique.

BACKGROUND: Fractures of the tuberosity of the fifth metatarsal are common after foot twisting injuries, and operative treatment is recommended in cases of displacement. The purpose of this study was to report the radiologic outcome and clinical results of displaced fractures of the tuberosity of the fifth metatarsal treated using fine-threaded K-wires (FFS). METHODS: In 3 years' time, in a total of 35 cases, patients had an initial fracture displacement of more than 2 mm for isolated extraarticular fractures and an involvement of the cuboidal joint surface of more than 30%. After 15 months to 60 months (mean, 30.6), 32 of these patients participated in a clinical follow-up examination and questionnaire according to a clinical rating system for midfoot fractures. Radiologic outcome measurements were the remaining postoperative intraarticular step off and the healing time. RESULTS: The mean midfoot scale score was 96.5 points. All the patients returned to prior activities after operative treatment. Seven patients reported minor pain during longer periods of walking. One patient with secondary wound healing experienced frequent pain. Radiologically, in 32 of 35 patients, there was a remaining step off of less than 1 mm and in three patients less than 3 mm. All fractures except one healed within the first 3 months to 6 months. CONCLUSION: Operative treatment of displaced proximal fifth metatarsal fractures using the FFS system leads to a good clinical and radiologic outcome. The FFS system provides a new treatment option for this fracture type.

Tension degradation of anterior cruciate ligament grafts with dynamic flexion-extension loading: a biomechanical model in porcine knees.

PURPOSE: This study investigates the influence of various femoral anterior cruciate ligament graft fixation methods on the amount of tension degradation and the initial fixation strength after cyclic flexion-extension loading in a porcine knee model. METHODS: One hundred twenty porcine digital extensor tendons, used as 4-stranded free tendon grafts, were fixated within porcine femoral bone tunnels by use of extracortical button, cross-pin, or interference screw fixation. One hundred twenty porcine patellar tendon-bone grafts were fixated by use of cross-pin, interference screw, or press-fit fixation. Each femur-graft complex was submitted to cyclic flexion-extension loading for 1,000 cycles throughout different loading ranges, and the total loss of tension was determined. After cyclic testing, the grafts were loaded to failure, and the data were compared with a pullout series without cyclic loading. RESULTS: Tension degradation after 1,000 cycles of flexion-extension loading averaged 62.6% +/- 10.0% in free tendon grafts and 48.9% +/- 13.35% in patellar tendon-bone grafts. There was no influence of the loading range on the total amount of tension degradation. The total amount of tension degradation was the highest with interference screw fixation of free tendon and patellar tendon-bone grafts. Despite excessive loss of tension, the initial fixation strength of the femur-graft complex was not reduced. CONCLUSIONS: The method of femoral graft fixation significantly influenced tension degradation during dynamic flexion-extension loading. Femoral graft fixation methods that secure the graft close to the tunnel entrance and that displace the graft substance from the center of the bone tunnel show the largest amount of tension degradation during cyclic flexion-extension loading. The graft substance, not the fixation site, was the weakest link of the graft complex within this investigation. CLINICAL RELEVANCE: We believe that the graft fixation method should be considered when aiming to improve the precision of femoral graft placement in anterior cruciate ligament reconstruction.

Treatment of chronically unreduced complex dislocations of the elbow.

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107 degrees (range, from 100 degrees to 110 degrees ). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.

Side differences in the anatomy of human knee joints.

Side-to-side comparison of anatomical or functional parameters in the evaluation of unilateral pathologies of the human knee joint is common practice, although the amount of symmetry is unknown. The aim of this study was to test the hypothesis that there are no significant differences in the morphometric knee joint dimensions between the right and the left knee of a human subject and that side differences within subjects are smaller than intersubject variability. In 20 pairs of human cadaver knees, the morphometry of the articulating osseous structures of the femorotibial joint, the cruciate ligaments, and the menisci were measured using established measurement methods. Data were analyzed for overall side differences and the ratio between within-subject side differences and intersubject variability was calculated. In three out of 71 morphometric dimensions there was a significant side difference, including the posterior tibial slope, the anatomical valgus alignment of the distal femur, and the position of the femoral insertion area of the ACL. In two additional parameters, including the cross-sectional area of the ACL and PCL, within-subject side differences were larger than intersubject variability. In general, there was a positive correlation in morphometric dimensions between right and left knees in one subject. It is concluded that a good correlation in the morphometric dimensions of a human knee joint exists between the right and the left side. This study supports the concepts of obtaining morphometric reference data from the contralateral uninjured side in the evaluation of unilateral pathologies of the knee joint.