Analysis of postoperative complications 5 years after osteosynthesis of patella fractures-a retrospective, multicenter cohort study.

PURPOSE: The study aims to investigate the influence of patient- and fracture-specific factors on the occurrence of complications after osteosynthesis of patella fractures and to compare knee joint function, activity, and subjective pain levels after a regular postoperative course and after complications in the medium term. METHODS: This retrospective, multicenter cohort study examined patients who received surgery for patella fracture at level 1 trauma centers between 2013 and 2018. Patient demographics and fracture-specific variables were evaluated. Final follow-up assessments included patient-reported pain scores (NRS), subjective activity and knee function scores (Tegner Activity Scale, Lysholm score, IKDC score), complications, and revisions. RESULTS: A total of 243 patients with a mean follow-up of 63.4 ± 21.3 months were included. Among them, 66.9% of patients underwent tension band wiring (TBW), 19.0% received locking plate osteosynthesis (LPO), and 14.1% underwent screw osteosynthesis (SO). A total of 38 patients (15.6%) experienced complications (TBW: 16.7%; LPO: 15.2%; SO: 11.8%). Implant-related complications of atraumatic fragment dislocation and material insufficiency/dislocation, accounted for 50% of all complications, were significantly more common after TBW than LPO (p = 0.015). No patient-specific factor was identified as a general cause for increased complications. Overall, particularly following complications such as limited range of motion or traumatic refracture, functional knee scores were significantly lower and pain levels were significantly higher at the final follow-up when a complication occurred. Implant-related complications, however, achieved functional scores comparable to a regular postoperative course without complications after revision surgery. CONCLUSION: The present study demonstrated that implant-related complications occurred significantly more often after TBW compared to LPO. The complication rates were similar in all groups.

Increased ß2-adrenergic signaling promotes fracture healing through callus neovascularization in mice.

Traumatic brain injury (TBI) leads to skeletal changes, including bone loss in the unfractured skeleton, and paradoxically accelerates healing of bone fractures; however, the mechanisms remain unclear. TBI is associated with a hyperadrenergic state characterized by increased norepinephrine release. Here, we identified the ß2-adrenergic receptor (ADRB2) as a mediator of skeletal changes in response to increased norepinephrine. In a murine model of femoral osteotomy combined with cortical impact brain injury, TBI was associated with ADRB2-dependent enhanced fracture healing compared with osteotomy alone. In the unfractured 12-week-old mouse skeleton, ADRB2 was required for TBI-induced decrease in bone formation and increased bone resorption. Adult 30-week-old mice had higher bone concentrations of norepinephrine, and ADRB2 expression was associated with decreased bone volume in the unfractured skeleton and better fracture healing in the injured skeleton. Norepinephrine stimulated expression of vascular endothelial growth factor A and calcitonin gene-related peptide-α (αCGRP) in periosteal cells through ADRB2, promoting formation of osteogenic type-H vessels in the fracture callus. Both ADRB2 and αCGRP were required for the beneficial effect of TBI on bone repair. Adult mice deficient in ADRB2 without TBI developed fracture nonunion despite high bone formation in uninjured bone. Blocking ADRB2 with propranolol impaired fracture healing in mice, whereas the ADRB2 agonist formoterol promoted fracture healing by regulating callus neovascularization. A retrospective cohort analysis of 72 patients with long bone fractures indicated improved callus formation in 36 patients treated with intravenous norepinephrine. These findings suggest that ADRB2 is a potential therapeutic target for promoting bone healing.

Impact of the medial displacement calcaneal osteotomy on foot biomechanics: a systematic literature review.

INTRODUCTION: Progressive collapsing foot deformity (PCFD), formally known as "adult-acquired flatfoot deformity" (AAFFD), is a complex foot deformity consisting of multiple components. If surgery is required, joint-preserving procedures, such as a medial displacement calcaneal osteotomy (MDCO), are frequently performed. The aim of this systematic review is to provide a summary of the evidence on the impact of MDCO on foot biomechanics. MATERIALS AND METHODS: A systematic literature search across two major sources (PubMed and Scopus) without time limitation was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria. Only original research studies reporting on biomechanical changes following a MDCO were included. Exclusion criteria consisted of review articles, case studies, and studies not written in English. 27 studies were included and the methodologic quality graded according to the QUACS scale and the modified Coleman score. RESULTS: The 27 included studies consisted of 18 cadaveric, 7 studies based on biomechanical models, and 2 clinical studies. The impact of MDCO on the following five major parameters were assessed: plantar fascia (n = 6), medial longitudinal arch (n = 9), hind- and midfoot joint pressures (n = 10), Achilles tendon (n = 5), and gait pattern parameters (n = 3). The quality of the studies was moderate to good with a pooled mean QUACS score of 65% (range 46-92%) for in-vitro and a pooled mean Coleman score of 58 (range 56-65) points for clinical studies. CONCLUSION: A thorough knowledge of how MDCO impacts foot function is key in properly understanding the postoperative effects of this commonly performed procedure. According to the evidence, MDCO impacts the function of the plantar fascia and Achilles tendon, the integrity of the medial longitudinal arch, hind- and midfoot joint pressures, and consequently specific gait pattern parameters.

The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients.

BACKGROUND: Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients. METHODS: A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model. RESULTS: Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores. CONCLUSION: With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.

Transcript-dependent effects of the CALCA gene on the progression of post-traumatic osteoarthritis in mice.

Osteoarthritis represents a chronic degenerative joint disease with exceptional clinical relevance. Polymorphisms of the CALCA gene, giving rise to either a procalcitonin/calcitonin (PCT/CT) or a calcitonin gene-related peptide alpha (αCGRP) transcript by alternative splicing, were reported to be associated with the development of osteoarthritis. The objective of this study was to investigate the role of both PCT/CT and αCGRP transcripts in a mouse model of post-traumatic osteoarthritis (ptOA). WT, αCGRP-/- and CALCA-/- mice were subjected to anterior cruciate ligament transection (ACLT) to induce ptOA of the knee. Mice were sacrificed 4 and 8 weeks post-surgery, followed by micro-CT and histological evaluation. Here we show that the expression of both PCT/CT and αCGRP transcripts is induced in ptOA knees. CALCA-/- mice show increased cartilage degeneration and subchondral bone loss with elevated osteoclast numbers compared to αCGRP-/- and WT mice. Osteophyte formation is reduced to the same extent in CALCA-/- and αCGRP-/- mice compared to WT controls, while a reduced synovitis score is noticed exclusively in mice lacking CALCA. Our data show that expression of the PCT/CT transcript protects from the progression of ptOA, while αCGRP promotes osteophyte formation, suggesting that CALCA-encoded peptides may represent novel targets for the treatment of ptOA.

Tranexamic Acid Attenuates the Progression of Posttraumatic Osteoarthritis in Mice.

BACKGROUND: Posttraumatic osteoarthritis (OA) is a common disorder associated with a high socioeconomic burden, particularly in young, physically active, and working patients. Tranexamic acid (TXA) is commonly used in orthopaedic trauma surgery as an antifibrinolytic agent to control excessive bleeding. Previous studies have reported that TXA modulates inflammation and bone cell function, both of which are dysregulated during posttraumatic OA disease progression. PURPOSE: To evaluate the therapeutic effects of systemic and topical TXA treatment on the progression of posttraumatic OA in the knee of mice. STUDY DESIGN: Controlled laboratory study. METHODS: OA was induced via anterior cruciate ligament (ACL) transection on the right knee of female mice. Mice were treated with TXA or vehicle intraperitoneally daily or intra-articularly weekly for 4 weeks, starting on the day of surgery. Articular cartilage degeneration, synovitis, bone erosion, and osteophyte formation were scored histologically. Micro-computed tomography evaluation was conducted to measure the subchondral bone microstructure and osteophyte volume. Cartilage thickness and bone remodeling were assessed histomorphometrically. RESULTS: Both systemic and topical TXA treatment significantly reduced cartilage degeneration, synovitis, and bone erosion scores and increased the ratio of hyaline to calcified cartilage thickness in posttraumatic OA. Systemic TXA reversed ACL transection-induced subchondral bone loss and osteophyte formation, whereas topical treatment had no effect. Systemic TXA decreased the number and surface area of osteoclasts, whereas those of osteoblasts were not affected. No effect of topical TXA on osteoblast or osteoclast parameters was observed. CONCLUSION: Both systemic and topical TXA exerted protective effects on the progression of posttraumatic OA. Drug repurposing of TXA may, therefore, be useful for the prevention or treatment of posttraumatic OA, particularly after ACL surgery. CLINICAL RELEVANCE: TXA might be beneficial in patients with posttraumatic OA of the knee.

Does a prehospital applied pelvic binder improve patient survival?

INTRODUCTION: Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures. METHODS: This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients. RESULTS: 66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes. CONCLUSION: Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

Association of Remaining Anterior Knee Laxity With Inferior Outcomes After Revision ACL Reconstruction.

Background: The relationship between remaining anterior knee laxity and poorer clinical outcomes after anterior cruciate ligament reconstruction (ACLR) may be underrated, and the criteria for failure of revision ACLR have not been defined. Purpose/Hypothesis: To evaluate a possible association between remaining knee laxity and functional scores in patients after revision ACLR. We hypothesized that a postoperative side-to-side-difference (SSD) in knee laxity of ≥6 mm will be an objective parameter for failure. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 200 patients (77 women and 123 men; mean age, 30.8 ± 11 years; range, 18-61 years) who underwent revision ACLR between 2016 and 2019 were evaluated; The mean follow-up period was 30.2 ± 9 months (range, 24-67 months). Patients were divided into 3 groups according to postoperative SSD (<3 mm, 3-5 mm, or ≥6 mm). Preoperative and postoperative outcome measures (Lachman, pivot shift, visual analog scale [VAS] for pain, Tegner, Lysholm, International Knee Documentation Committee, and Knee injury and Osteoarthritis Outcome Score) were compared between the groups. Results: Of the 200 patients, 74% (n = 148) had a postoperative SSD of <3 mm at the latest follow-up, 19.5% (n = 39) had a postoperative SSD of 3 to 5 mm, and 6.5% (n = 13) had a postoperative SSD of ≥6 mm. Patients in all groups saw significant pre- to postoperative reductions in positive Lachman and pivot-shift tests as well as significant improvements in VAS pain, Lysholm, and Tegner scores (P < .001 for all). All postoperative functional scores of the patients with SSDs of <3 mm and 3-5 mm were significantly increased compared with those of patients with an SSD of ≥6 mm (P≤ .01 for all). Conclusion: In patients following revision ACLR, anterior and rotational knee laxity were successfully reduced while increasing postoperative functional outcomes. A remaining postoperative SSD of ≥6 mm was associated with inferior patient outcomes compared with an SSD <6 mm. An SSD of ≥6 mm represents an objective parameter in the definition of failure of revision ACLR.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures.

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Postoperative lymphedema after primary total hip arthroplasty: prospective analysis of bikini incision-type direct anterior approach versus established standard approaches.

BACKGROUND: Minimally invasive approaches to the hip joint for total hip arthroplasty such as the DAA ("Direct Anterior Approach with bikini incision") are increasingly utilized. According to the literature, this approach is more muscle-sparing, results in less postoperative pain, and achieves higher patient satisfaction. The existence of postoperative lymphedema after hip arthroplasty is hardly considered. The aim of this paper is to contribute to the evaluation of the different access methods related to postoperative lymphedema and their functional outcomes. METHODS: This is a prospective non-randomized study at an orthopedic specialist clinic in Northern Europe. The surgeons that performed the arthroplasties are high-volume surgeons in private practice affiliated to the clinic. The study included 188 patients with primary hip arthroplasty in a 1:1 ratio (DAA: standard accesses (posterior, transgluteal, and anterolateral access)). Epidemiologic data, Harris Hip Score, Oxford Hip Score, European Quality of Life 5, and Visual Analog Scale were collected preoperatively on admission day, 3rd and 5th postoperative day, and follow-up after 1 year. Furthermore, the range of motion, gait, and ability to climb stairs, as well as the presence of hypesthesia were assessed. To evaluate the edema situation, both legs were measured on the 3rd and 5th postoperative day. The prescription of manual lymphatic drainage and remaining swelling conditions 1 year postoperatively were recorded. RESULTS: For each group, 94 patients with a mean age of 61.7 years (DAA 60.7 and standard access 62.6) were included. All but one patient in the DAA group showed postoperative lymphedema (n: 93/94; 98.9%). In the standard surgery group, only n: 37/94 (39.4%) showed swelling symptoms requiring treatment. After 1 year, lymphedema persisted in 20 patients in the DAA group and 0 patients in the standard-OR group. Hypesthesia at the ventral thigh persisted in 16/94 (= 17%) patients of the DAA group versus 0/94 patients of the standard group after 12 months. Of these 16 cases, 10 had concomitant edema (62.5%). The DAA showed better results than the standard accesses in terms of Oxford Hip Score (p < 0.05) and ability to climb stairs (p < 0.05). In contrast, the Visual Analog Scale and patient quality of life results showed no significant difference (p > 0.05). CONCLUSION: The present study demonstrated the increased incidence of postoperative lymphedema in patients operated on via DAA access using a Bikini-type skin incision. In the follow-up, significantly more hypesthesia of the ventral thigh occurred in the DAA group. Otherwise, the DAA proved to be superior to the standard approaches from a functional point of view at short-term follow-up. Future research is needed to compare the horizontally oblique to the longitudinal oblique skin incision technique in direct anterior hip surgery regarding the above-mentioned adverse effects found in this study.

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians.

AIM: Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality. METHODS: Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle. RESULTS: 71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p = < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray. CONCLUSION: Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

[Infectious, pathologic humeral fracture in a patient with sickle cell disease-A rare case?] / Infizierte, pathologische Humerusfraktur bei Sichelzellanämie ­ noch ein Einzelfall?

The vaso-occlusive crises of sickle cell disease are accompanied by bone necrosis, which favors endogenous bacterial colonization and thus osteomyelitis. This poses a major challenge for eradication and fracture management.A 22-year-old patient with sickle cell disease sustained a multifragmentary, humeral shaft fracture. During surgical management, pus drained from the fracture site and further diagnostic work-up revealed osteomyelitis with evidence of Klebsiella aerogenes. Septicemia due to Klebsiella aerogenes had been treated 5 months prior to the accident, which occured because of a vaso-occlusive crisis. This is associated with clustered bone necrosis and endogenous germ colonization. Eradication of the germs and fracture care become a challenge. Repeated surgical procedures with segmental transfer can be a successful treatment option.

Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial.

A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment. / S2k-Leitlinie Tibiakopffraktur ­ Klassifikation, Diagnostik und Therapie.

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

The selective norepinephrine reuptake inhibitor reboxetine promotes late-stage fracture healing in mice.

Impaired fracture healing is of high clinical relevance, as up to 15% of patients with long-bone fractures display non-unions. Fracture patients also include individuals treated with selective norepinephrine reuptake inhibitors (SNRI). As SNRI were previously shown to negatively affect bone homeostasis, it remained unclear whether patients with SNRI are at risk of impaired bone healing. Here, we show that daily treatment with the SNRI reboxetine reduces trabecular bone mass in the spine but increases cortical thickness and osteoblast numbers in the femoral midshaft. Most importantly, reboxetine does not impair bone regeneration in a standardized murine fracture model, and even improves callus bridging and biomechanical stability at late healing stages. In sum, reboxetine affects bone remodeling in a site-specific manner. Treatment does not interfere with the early and intermediate stages of bone regeneration and improves healing outcomes of the late-stage fracture callus in mice.

Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study.

INTRODUCTION: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE: Level II.

[Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept]. / Multiligamentäre Instabilitäten des Kniegelenkes bei Sportverletzungen : Ein Update zum "Hamburger Konzept".

BACKGROUND: Knee dislocation (KD) is a rare but severe injury of the knee joint, with a high rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. TREATMENT STRATEGY: Furthermore, a clear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10 days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require a modified approach, due to a limited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows a high success rate.

Operative versus conservative treatment in pelvic ring fractures with sacral involvement.

BACKGROUND: To evaluate the performance in activities of daily living (ADL), level of pain, mortality and rate of complications in patients with a pelvic ring fracture with sacral involvement who were treated conservatively compared to a surgically treated patient collective using percutaneous iliosacral screw fixation. HYPOTHESIS: Conservative treatment does not result in inferior clinical outcome compared to operative treatment. PATIENTS AND METHODS: A retrospective study of 112 conservatively (n=46) or operatively (n=66) treated patients with an isolated posterior or a combined posterior and anterior pelvic ring fracture was performed. The analysis included: age, sex, mechanism of injury, fracture type according to AO/OTA classification, energy of trauma sustained (no-, low-, high-energy trauma), type of treatment (operative or conservative), complications as well as duration of in-hospital stay. To assess clinical and activity outcome, the visual analog scale for pain (VAS), Barthel Scale, American Society of Anaesthesiologists (ASA) scores as well as mortality were assessed. The mean follow-up was 29.3±14.6 months. Furthermore, a geriatric subgroup (n=68, age≥60, low-energy trauma only) was analyzed. RESULTS: The majority of the patients were female (79%) and suffered from low-energy trauma (n=64, 58%). There were no significant differences in the operative and the conservative groups and subgroups concerning VAS, Barthel scores and ASA scores. The survival analyses showed a significantly lower survival rate in the conservative group (41.8±3.6 months) compared to the operative group (55.9±2 months, p=0.002). Similar findings were encountered in the geriatric subgroup analysis. CONCLUSION: This study demonstrates equivalent clinical outcome in conservatively and surgically treated patients using a percutaneous iliosacral screw fixation at a mid-term follow-up. However, operatively treated patients showed decreased mortality. This needs to be carefully considered in clinical decision-making but must be further explored using a prospective randomized study approach. LEVEL OF EVIDENCE: III.

Apps in Clinical Practice: Usage Behaviour of Trauma Surgeons and Radiologists in Northern Germany.

Introduction: Apps, in general, are an integral part of our daily lives. To investigate the current usage behaviour of trauma surgeons and radiologists regarding medical apps in clinical practice and to find out if and how the current range of medical apps can be improved, we surveyed trauma surgeons and radiologists in northern Germany. Material and Methods. An online questionnaire was sent to 100 trauma surgeons and 100 radiologists in northern Germany. Participants were asked about the frequency of their use of medical apps in clinical practice, which apps were used most often, how useful participants thought apps were, and in which area they would like to see improvements. The most frequently mentioned apps were finally analyzed. Results: The survey study showed that 87.4% of the trauma surgeons and 67.4% of the radiologists use medical apps on a regular basis at work. It also revealed that trauma surgeons used medical apps much more often than radiologists and that young doctors were more likely to rely on medical apps than chief physicians. 80.0% of the participants would pay at least 5 euros for a medical app. Trauma surgeons see the greatest need for support in their daily work from medical apps in the area of treatment, while radiologists seek more support in the area of classification. Conclusion: The study underscored the broad acceptance of medical apps in everyday clinical practice. As the physicians are willing to spend money and stated a general interest and need for further developments, there is high potential for the future. This trial is registered with DRKS00026766.