Proximal humeral fractures in children - controversies in decision making.

BACKGROUND: Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality. METHODS: Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined. RESULTS: For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment. CONCLUSIONS: Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies. LEVEL OF EVIDENCE: III.

A Lightweight Browser-Based Tool for Collaborative and Blinded Image Analysis.

Collaborative manual image analysis by multiple experts in different locations is an essential workflow in biomedical science. However, sharing the images and writing down results by hand or merging results from separate spreadsheets can be error-prone. Moreover, blinding and anonymization are essential to address subjectivity and bias. Here, we propose a new workflow for collaborative image analysis using a lightweight online tool named Tyche. The new workflow allows experts to access images via temporarily valid URLs and analyze them blind in a random order inside a web browser with the means to store the results in the same window. The results are then immediately computed and visible to the project master. The new workflow could be used for multi-center studies, inter- and intraobserver studies, and score validations.

Functional outcomes after intramedullary nailing (C-Nail®) of severe calcaneal fractures with mean follow-up of 36 months.

PURPOSE: Calcaneal fractures (CFs) are rare but potentially debilitating injuries. Apart from the open, far lateral or sinus tarsi approach, operative treatment can be performed minimally invasive and percutaneously with intramedullary nailing. In this study, we sought to investigate the functional outcome of severe CFs treated with the C-Nail® implant. METHODS: Twenty-two CFs (9 × Sanders III and 8 × Sanders IV), operated between 2016 and 2019, were followed up with a mean duration of 36 (± 11) months. The AOFAS score, pre- and postoperative Böhler angles, wound healing disorders, and patient-reported outcome measures (PROMs) like pain levels and return to work/sport levels were assessed. RESULTS: The mean AOFAS score was 72.0 (± 9.8). Four patients sustained wound healing disorders, yet no implant-associated surgical revision was required. Fifty percent of patients were pain-free within 1 year. Within 1 year, about 50% of the patients could return to sports, and about 80% of the patients could return to work. PROMs and functional results align with those from other implants reported in the literature. CONCLUSION: Intramedullary nailing of severe CFs with the C-Nail® implant can be considered a safe treatment alternative that yields acceptable results at mid-terms.

Radiographic Evidence of Sufficient Transverse Plane Alignment after Weil Osteotomy without Screw Fixation.

Weil osteotomy is a proven procedure to restore the harmonic distal parabola of the forefoot. In addition to the proximal displacement of the head in the sagittal plane, a displacement in the transverse plane may be necessary, with the refixation of the displaced metatarsal head historically performed by screw fixation. We aimed to determine the radiological differences among 136 feet of 127 patients with 256 Weil osteotomies retrospectively enrolled and divided into groups with (n = 182) and without (n = 74) screw fixation. Demographic data, radiographic union, pre- and postoperative metatarsal angles, and differences in the dorsoplantar view were evaluated. The mean follow-up period was 3.6 months. The mean preoperative metatarsophalangeal angle was 9.24°, and the mean postoperative angle was 12.99°. The restoration of the transversal alignment plane was equally successful in both groups, with a mean extent of angle correction of 10.58°. No nonunions of the osteotomized metatarsals were observed. The radiographic comparisons revealed no significant difference between the groups (p > 0.05). However, visibility of the joint space of the metatarsophalangeal joint was achieved significantly more often in the group without screw fixation (p < 0.05). In the absence of bony malunion and the satisfactory restoration of a harmonious parabola of the forefoot, apparently there does not appear to be a necessity for regular screw fixation after Weil osteotomy based on the available data from the present study.

[Disproportionately increased incidence of proximal femoral fractures in a level one trauma center : Epidemiological analysis from 2016 to 2022]. / Überproportional angestiegene Inzidenz proximaler Femurfrakturen in einem Level-One-Traumazentrum : Epidemiologische Analyse von 2016 bis 2022.

BACKGROUND: Proximal femoral fractures represent the most frequent fracture entity in Germany accounting for more than 20% of all fractures. According to a decision of the Federal Joint Committee from 2019, proximal femoral fractures also have to be surgically treated within 24 h. In order to quantify a subjectively perceived increase in workload in trauma surgery at a supraregional trauma center, a retrospective analysis of the number of surgically treated proximal femoral fractures was performed. Proximal femoral fractures were chosen due to their high incidence and homogeneous treatment. METHODS: Using ICD-10 codes, all surgically treated proximal femoral fractures from 2016 to 2022, including the patient's zip code, were retrieved from the database of the trauma center. RESULTS: The number of surgically treated proximal femoral fractures doubled from 2016 to 2022. The highest increase (60%) was recorded from 2020 to 2022. Heat maps show an increase in the catchment area radius as well. CONCLUSION: When compared (inter)nationally, a disproportionate increase in the amount of surgically treated proximal femoral fractures was recorded at the trauma center studied. The increase of the catchment area radius and the number of patients treated in the urban area show that less and less hospitals participate in emergency treatment. Possible explanations are a lack of resources aggravated by the recent COVID-19 pandemic and a lack of qualified personnel, interface problems between the federal states or the strict requirements of the Federal Joint Committee in the treatment of proximal femoral fractures. It must be assumed that there is a clearly increased workload for all professions involved in the trauma center investigated, although the infrastructure has remained unchanged.

Can we separately measure glenoid vs. humeral lateralization and distalization in reverse shoulder arthroplasty?

BACKGROUND: Lateralization and distalization in reverse shoulder arthroplasty (RSA) can be measured on anteroposterior (AP) radiographs using 2 previously described angles: lateralization shoulder angle (LSA) and distalization shoulder angle (DSA). However, these 2 angles measure global lateralization and distalization but do not allow to differentiate how much lateralization or distalization are attributable to the glenoid and the humerus. We hypothesized that new angles could allow us to separately measure glenoid vs. humeral lateralization and distalization. A more precise understanding of independent glenoid and humeral contributions to lateralization and distalization may be beneficial in subsequent clinical research. METHOD: Retrospective analysis of postoperative AP radiographs of 100 patients who underwent primary RSA for cuff-tear arthropathy, massive cuff tear, or glenohumeral osteoarthritis were analyzed. The new angles that we proposed use well-known bony landmarks (the acromion, glenoid, and humerus) and the most lateral point of the glenosphere, which we termed the "glenoid pivot point" (GPP). For lateralization, we used the GPP to split LSA into 2 new angles: glenoid lateralization angle (GLA) and humeral lateralization angle (HLA). For distalization, we introduced the modified distalization shoulder angle (mDSA) that can also be split into 2 new angles: glenoid distalization angle (GDA) and humeral distalization angle (HDA). Three orthopedic surgeons measured the new angles, using the online tool Tyche. Mean values with overall and individual standard deviations as well as intraclass correlation coefficients (ICCs) were calculated. RESULTS: Because the angles form a triangle, the following equations can be made: LSA = GLA + HLA, and mDSA = GDA + HDA. All angles showed excellent inter- and intraobserver reliability (ICC = 0.92-0.97) with low means of individual standard deviations that indicate a precision of 2° for each angle. CONCLUSION: Use of the most lateral part of the glenosphere (termed glenoid pivot point) allows us to separately measure glenoid vs. humeral lateralization and distalization. The 4 new angles (HLA, GLA, GDA, HDA) described in the present study can be used on true AP radiographs, routinely obtained after shoulder replacement, and the measured angles may be used with all types of reverse prostheses available.

Restoration of preoperative tibial alignment improves functional results after medial unicompartmental knee arthroplasty.

PURPOSE: The alignment obtained after unicompartmental knee arthroplasty (UKA) influences the risk of failure. Kinematic alignment after UKA based on Cartier angle restauration is likely to improve clinical outcomes compared with mechanical alignment. The purpose of this study is to analyze the influence of implant alignment and native knee restoration after UKA using the conventional techniques on clinical outcomes. METHODS: This retrospective study included 144 medial UKA patients from 2015 to 2020. Radiographic measurements were performed pre- and postoperatively. Outliers were defined as follows: Δ Cartier > 3° (difference between the preoperative and postoperative Cartier angle); Δ MPTA (Medial Proximal Tibial angle) and postoperative TCA (Tibial Coronal component Angle) > 3° (difference between the positioning of the tibial implant and the preoperative proximal tibial deformity). The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee score, the Forgotten Joint Score (FJS), and the Subjective Knee Value (SKV) were evaluated. A Student t test or a non-parametric Wilcoxon test was used for non-normal data to compare pre- and postoperative values for functional scores and angular measurements. The correlation of postoperative angles with functional outcomes was assessed by the Spearman's rank correlation coefficient. RESULTS: During the inclusion period, 214 patients underwent medial UKA, 71 patients were excluded, and 19 were lost to follow-up leaving 124 patients with 144 knees (20 bilateral UKA) included for analysis with a mean follow-up of 54.7 months ± 22.1 (24-95). The Δ Cartier was significantly correlated with IKS function (R2 = 0.06, p < 0.001) and FJS (R2 = 0.05, p < 0.01) scores. The Δ preoperative MPTA-TCA was significantly correlated (p < 0.001) with KOOS (R2 = 0.38), IKS Knee (R2 = 0.17), IKS function (R2 = 0.34), SKV (R2 = 0.08), and FJS (R2 = 0.37) scores. In subgroup analysis, non-outliers (< 3°) for Δ preoperative MPTA-TCA had better KOOS score (Δ = 23.5, p < 0.001) and IKS Function (Δ = 17.7, p < 0.001) compared to outliers (> 3°) patients. CONCLUSION: Functional results after medial UKA can be influenced by implant alignment in the coronal plane with slight clinical improvement when positioning the tibial implant close to the preoperative tibial deformity, rather than by restoring the Cartier angle. This series suggests the interest of a more personalized alignment strategy, but these results will have to be confirmed by other controlled studies. LEVEL OF EVIDENCE: IV, retrospective case series.

A Novel Tool for Collaborative and Blinded Orthopedic Image Analysis.

Image analysis plays a central role in orthopedics and research but comes with many challenges, including anonymization, bias, and achieving efficient analyses using multiple independent observers. Appropriate software is still lacking. Tyche is a free online tool that displays images in a random order without showing any metadata. Additionally, when using Tyche, observers can store results in the same window, and the final results are immediately visible to the project manager. In this study, we compared results from Tyche with those from a validated tool. One hundred pelvic radiographs were analyzed separately by five orthopedic surgeons using both Tyche and the validated software. Common orthopedic measurement modalities and scores were determined. The methods were compared using intra-class correlations and Fleiss' kappa coefficients as well as Bland-Altman plots. Significant correlations ranging from r = 0.17 (Kallgren and Lawrence Score) to r = 0.99 (area measurements) were calculated for inter- and intraobserver agreements between the two tools for all measurements. The Bland-Altman plots indicated the non-inferiority of either tool. The images were analyzed significantly faster when Tyche was used. We conclude that Tyche is a valid tool for use in orthopedic image analysis. Tyche could be utilized for determining inter- and intraobserver agreements, in multicenter studies and for score validations.

Normo-or slightly overcorrection show better results after medial closing wedge high tibial osteotomy.

PURPOSE: The objectives of this study were to evaluate functional results, revision-free survival, and the influence of postoperative alignment on outcomes after MCWHTO. METHODS: This retrospective study included 27 MCWHTO operated on from 2009 to 2021. Radiographic measurements were performed pre- and postoperatively. The HKA (Hip-Knee-Ankle angle), MPTA (Medial Proximal Tibial angle), LDFA (Lateral Distal Femoral Angle), JLO (Joint Line Obliquity), and JLCA (Joint Line Convergence Angle) were evaluated. The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee Score, and the Subjective Knee Value (SKV) as well as revision-free survival were evaluated. Postoperative alignment and its influence on clinical outcomes were also analysed. RESULTS: The mean follow-up was 61.9 months ± 31.4 (13-124). The HKA, MPTA, and JLCA angles were decreased post-operatively (respectively, Δ = 5.9° ± 2.6, p < 0.001; Δ = 6.1° ± 3.2, p < 0.001 and Δ = 2.5° ± 1.9, p < 0.001). LDFA and JLO were unchanged, post-operatively (respectively, Δ = 0.1° ± 2.2, p = 0.93 and Δ = 1.2° ± 3.3, p = 0.23). Postoperative HKA correlated with knee IKS (R = - 0.15, p = 0.04) and function IKS (R = - 0.44, p = 0.03). Postoperative LDFA correlated with knee IKS(R = 0.8, p < 0.01). Patients with postoperative HKA ≤ 180° had better KOOS (Δ = 12.3, p = 0.04) and IKS function (Δ = 28.1, p < 0.01) than those with HKA > 180°. CONCLUSION: Functional results and revision-free survival after MCWHTO are satisfactory when the deformity is located in the proximal tibia. The joint line obliquity is not significantly altered with small tibial correction and, obtaining an overall neutral or slightly varus alignment under the conditions of this study allowed an improvement in the postoperative clinical scores. The literature is still inconclusive on the ideal alignment for valgus deformities and larger series are needed to draw definitive conclusions. LEVEL OF EVIDENCE: IV, case series.

The Controversial Definition of Normal Toe Alignment.

"Normal" and "abnormal" are frequently used in surgical planning and to evaluate surgical results of the forefoot. However, there is no objectifiable value of metatarsophalangeal angles (MTPAs) 2-5 in the dorsoplantar (DP) view with which to objectively evaluate lesser toe alignment. We aimed to determine which angles are considered to be "normal" by orthopedic surgeons and radiologists. Thirty anonymized radiographs of feet were submitted twice in randomized order to determine the respective MTPAs 2-5. After six weeks, the anonymized radiographs and photographs of the same feet without apparent affiliation were presented again. The terms "normal," "borderline normal," and "abnormal" were assigned by the observers. Viewers considered MTP-2 alignment from 0° to -20° to be normal, and below -30° abnormal; MTP-3, 0° to -15° to be normal and below -30° abnormal; MTP-4, 0° to -10° normal and below -20° abnormal. Between 5° valgus and 15° varus was the range of MTP-5 recognized as normal. High intra-observer but low interobserver reliability with overall low correlation of clinical and radiographic aspects was observed. The assessment of the terms "normal" or "abnormal" are subject to a high degree of variation. Therefore, these terms should be used cautiously.

Transmembrane BAX Inhibitor-1 Motif Containing Protein 5 (TMBIM5) Sustains Mitochondrial Structure, Shape, and Function by Impacting the Mitochondrial Protein Synthesis Machinery.

The Transmembrane Bax Inhibitor-1 motif (TMBIM)-containing protein family is evolutionarily conserved and has been implicated in cell death susceptibility. The only member with a mitochondrial localization is TMBIM5 (also known as GHITM or MICS1), which affects cristae organization and associates with the Parkinson's disease-associated protein CHCHD2 in the inner mitochondrial membrane. We here used CRISPR-Cas9-mediated knockout HAP1 cells to shed further light on the function of TMBIM5 in physiology and cell death susceptibility. We found that compared to wild type, TMBIM5-knockout cells were smaller and had a slower proliferation rate. In these cells, mitochondria were more fragmented with a vacuolar cristae structure. In addition, the mitochondrial membrane potential was reduced and respiration was attenuated, leading to a reduced mitochondrial ATP generation. TMBIM5 did not associate with Mic10 and Mic60, which are proteins of the mitochondrial contact site and cristae organizing system (MICOS), nor did TMBIM5 knockout affect their expression levels. TMBIM5-knockout cells were more sensitive to apoptosis elicited by staurosporine and BH3 mimetic inhibitors of Bcl-2 and Bcl-XL. An unbiased proteomic comparison identified a dramatic downregulation of proteins involved in the mitochondrial protein synthesis machinery in TMBIM5-knockout cells. We conclude that TMBIM5 is important to maintain the mitochondrial structure and function possibly through the control of mitochondrial biogenesis.