[Periprosthetic fractures of the acetabulum and femur : Causes-classification-treatment algorithms]. / Periprothetische Frakturen des Acetabulums und des Femurs : Ursache ­ Klassifikation ­ Therapiealgorithmen.

BACKGROUND: Both increasing implantation numbers of total hip replacements and demographic change with higher populations of older people, indicate that there will be an increase in periprosthetic fractures in the future. CAUSES: Falls in the home environment are the most common cause. Significant co-factors include reduced patient coordination, reduced bone quality, or implant-associated factors such as local osteolysis or pre-existing implant loosening. CLASSIFICATION: In the classification of periprosthetic fractures of the femur, the Vancouver classification has prevailed in recent years, which in addition to a description of the localization of the fracture also considers the stability of the prosthesis and bone quality. Based on this, therapeutic algorithms have been developed that can vary from the conservative approach via osteosynthetic options to a replacement of the prosthesis. In order to allow the description of periprosthetic fractures on all joints, the Vancouver classification has been extended to the UCS classification by including the AO/OTA bone and joint coding system. In the selection of the treatment method, the consideration of individual patient factors such as activity level and secondary diagnoses is essential. Based on the established classifications, the importance of the different therapeutic methods is presented.

[Acute acromioclavicular joint injuries. Changes in diagnosis and therapy over the last 10 years]. / Die akute Schultereckgelenkverletzung. Diagnostik, Therapie und Entwicklungen der letzten 10 Jahre.

BACKGROUND: The goal of the present study was to summarize current treatment for acute acromioclavicular (AC) joint dislocations. METHOD: In all, 796 orthopedics and/or trauma departments in Germany were identified in the national hospital directory (www.dka.de). Using the respective hospital web sites, the email addresses of the responsible shoulder/sports surgeon or, if not available, the head of department (successful in 746 cases) were identified. Emails with a link to an online survey with 36 questions and two reminders were sent; 60 were undeliverable. Thus, 686 emails probably reached the addressee. A total of 203 colleagues (30%) participated in the survey. Findings were compared to results of the survey published by Bäthis et al. in 2001. RESULTS: More than 90% treat Rockwood I or II injuries conservatively and Rockwood IV to VI injuries surgically. However, 34% answered having never seen a Rockwood VI injury. Of those replying, 73% prefer surgical treatment for Rockwood III injuries. Favored surgical techniques were the hook plate in 44% and the arthoscopic TightRope® in 27%, while 11% prefer coracoclavicular cerclage, 6% AC joint transfixation, 3% minimally invasive AC joint reconstruction (MINAR), 1% coracoclavicular screw fixation, and 8% a completely different procedure. Concerning acute Rockwood III injuries, orthopedics and/or trauma surgeons still prefer surgical treatment but less often than 10 years ago (84%). CONCLUSIONS: Favored techniques have completely changed since 2001 when the majority of physicians preferred AC joint transfixation or coracoclavicular cerclages, both techniques that are hardly used today. The hook plate appears to have become "standard therapy". The arthroscopic TightRope® is the second most common despite being the newest technique.

A five to seven year follow-up comparing computer-assisted vs freehand TKR with regard to clinical parameters.

PURPOSE: Computer-assisted knee surgery has become established in routine clinical practice. Still, there is no study investigating midterm clinical outcome after five to seven years postoperatively. We aimed to test the hypothesis that there is no difference either for subjective [Western Ontario and McMaster Universities (WOMAC) scores] or for objective (Knee Society Score, degree of flexion) criteria between computer-assisted total knee replacement (TKR) and freehand TKR after 5.6-7.3 years. METHODS: We performed a matched-pair analysis; 100 patients who received a primary TKR were investigated after a median follow-up of 6.25 years. Group A was operated on with the support of a computer system, while surgery on patients in group B was performed with the freehand technique. We determined WOMAC Score, Knee Society Score and degree of flexion. RESULTS: Overall we found similar results for WOMAC Score [group A: 42.98 (SD 13.80); group B: 41.54 (SD 15.01; p = 0.62)], Knee Society Score [group A: 168.20 (SD 21.94); group B: 166.60 (SD 21.44; p = 0.71)] and range of motion [group A: 106° (SD 9.19); group B 107° (SD 7.44; p = 0.62)]. CONCLUSIONS: No significant differences in midterm clinical outcome were found after TKR performed in the freehand vs computer-assisted technique.

[Prevention of infection in the current treatment of open fractures: an evidence-based systematic analysis]. / Prävention von Infektionen bei offenen Frakturen heute: Ein evidenzbasierter systematischer Review.

BACKGROUND: Treatment of open fractures remains an interdisciplinary challenge. Even success and evidence of infection prevention especially of new treatment options is not clear. METHOD: A systematic search in available electronic databases over the years 1974 until 2011 was conducted. Only clinical analyses with more than 5 adult patients in the German, English or French languages were included. All studies were rated according to Centre for Evidence-Based Medicine (CEBM) criteria. RESULTS: Over 855 articles were found due to the search and after applying the exclusion and inclusion criteria 49 studies were finally assessed to contribute to the evidence-based recommendations. Grade A recommendation: early application of antibiotics against gram-positive organisms for all open fracture types, additional coverage of gram-negative organisms for type III open fractures. Early surgical debridement should be performed. Grade B recommendation: type III open fractures should be treated with antibiotics for a minimum of 72 h but not longer than 24 h after wound closure. Vacuum treatment is justified and beneficial if wound closure is not achieved. Grade C recommendation: additional local antibiotic treatment in combination with systematic antibiotics may be of benefit. Definitive wound closure should be achieved within 1 week. DISCUSSION: This evidence-based analysis shows that there is good evidence for the treatment of open fractures with antibiotics and surgical debridement. Vacuum treatment can be recommended if wound closure is not possible.

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?]. / Schockraummanagement von Schwerverletzten. Eignet sich ATLS als SOP?

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Two year follow-up comparing computer assisted versus freehand TKR on joint stability, muscular function and patients satisfaction.

Computer assisted (CAS) knee surgery has been established in clinical routine. There is still no study that investigates clinical outcome. Fifty patients who received a primary total knee replacement 2 years before were investigated. These patients were divided into two groups of matched-pairs; group A was operated in the freehand technique and group B with support of a computer system. We compared Womac score, Knee Society score, range of motion, leg alignment, knee stability and isokinetic muscle strength. We found similar results for WOMAC, Knee Society score and isokinetic muscle force. Stability and range of motion revealed slightly better values for the CAS group. A statistically significant difference could only be demonstrated for postoperative leg alignment. Two years after freehand versus computer assisted TKR we found slightly better values for range of motion and ligamentous stability. Only postoperative leg alignment was statistically better in the CAS group.

The Impact of Pinless Navigation in Conventionally Aligned Total Knee Arthroplasty.

BACKGROUND: Restoration of the mechanical axis is a main objective in total knee replacement (TKR). Aim of this study was to analyse the verification tool of a pinless navigation system in conventional TKR (cTKR). METHODS: In a prospective study, 147 TKR were performed by conventional technique. Using the "pinless verification" mode of a smartphone based navigation system, the cutting block position and final resection plane for distal femur and proximal tibial resection were measured. If necessary, the block position or resection level were optimized, corrections were protocolled. Postoperatively, standardized radiographs were performed. RESULTS: In 65.3%, intraoperative measurements changed the surgical procedure (corrections: 20.4% femoral, 25.9% tibial, 19% both). The additional time for surgery compared to cTKR averaged 6 minutes (79 ± 15 versus 73 ± 17 minutes). Using navigation data, the final femoral and tibial axes were in 93% within a range of ±2°. A mean difference of 1.4° and 1.6° could be shown between the final measurement of the navigation system and the postoperative mLDFA and mMPTA. CONCLUSION: Intraoperative pinless navigation has impact on the surgical procedure in the majority of cTKR. It represents a less time-consuming tool to improve implant position while maintaining the routine of conventional technique.

Imageless navigation for insertion of the acetabular component in total hip arthroplasty: is it as accurate as CT-based navigation?

In a prospective randomised clinical study acetabular components were implanted either freehand (n = 30) or using CT-based (n = 30) or imageless navigation (n = 30). The position of the component was determined post-operatively on CT scans of the pelvis. Following conventional freehand placement of the acetabular component, only 14 of the 30 were within the safe zone as defined by Lewinnek et al (40 degrees inclination sd 10 degrees ; 15 degrees anteversion sd 10 degrees ). After computer-assisted navigation 25 of 30 acetabular components (CT-based) and 28 of 30 components (imageless) were positioned within this limit (overall p < 0.001). No significant differences were observed between CT-based and imageless navigation (p = 0.23); both showed a significant reduction in variation of the position of the acetabular component compared with conventional freehand arthroplasty (p < 0.001). The duration of the operation was increased by eight minutes with imageless and by 17 minutes with CT-based navigation. Imageless navigation proved as reliable as that using CT in positioning the acetabular component.

Precision of computer-assisted core decompression drilling of the knee.

INTRODUCTION: Core decompression by exact drilling into the ischemic areas is the treatment of choice in early stages of osteonecrosis of the femoral condyle. Computer-aided surgery might enhance the precision of the drilling and lower the radiation exposure time of both staff and patients. The aim of this study was to evaluate the precision of the fluoroscopically based VectorVision-navigation system in an in vitro model. MATERIALS AND METHODS: Thirty sawbones were prepared with a defect filled up with a radiopaque gypsum sphere mimicking the osteonecrosis. 20 sawbones were drilled by guidance of an intraoperative navigation system VectorVision (BrainLAB, Munich, Germany). Ten sawbones were drilled by fluoroscopic control only. RESULTS: A statistically significant difference with a mean distance of 0.58 mm in the navigated group and 0.98 mm in the control group regarding the distance to the desired mid-point of the lesion could be stated. Significant difference was further found in the number of drilling corrections as well as radiation time needed. CONCLUSION: The fluoroscopic-based VectorVision-navigation system shows a high feasibility and precision of computer-guided drilling with simultaneously reduction of radiation time and therefore could be integrated into clinical routine.

Eversion or subluxation of patella in soft tissue balancing of total knee arthroplasty? Results of a cadaver experiment.

Correct postoperative leg alignment and stability of total knee prosthesis over the full range of movement are critical factors for successful TKA. This is achieved by correct implantation of prosthesis and soft tissue handling. However, the surgical approach and how to displace the patella are still controversial. We have carried out a cadaver study looking at the effect of patella eversion or subluxation on limb axis alignment during balancing of the knee in three different standard surgical approaches; subvastus, midvastus, or medial parapatellar. For each approach, five knees were studied. Leg alignment was visualised by the Ci CT-free DePuy/BrainLAB navigation system. Using a navigation system alignment was determined in the AP axis in both extension and 90 flexion, with the patella everted as well as subluxated. Eversion of the patella gave a more valgus axis reading than subluxation in both extension 0.58 (SD: 0.03, range 0.54 -0.60 ) and 90 flexion 0.48 (SD: 0.11, range 0.38 -0.60 ). The effect was greatest using the medial paraptellar approach. Surgeons should be aware that everting the patella influences the AP alignment when soft tissue balancing in total knee replacement.

Computer assistance in total knee replacement - a critical assessment of current health care technology.

The last five years have seen the rapid development of computer assisted surgery (CAS) in total knee replacement (TKR). Many surgeons perform TKR using navigation systems, which offer user-friendly workflows and reproducible results. A number of level 1 and 2 studies, according to evidence-based medicine criteria, have demonstrated that navigation in TKR allows a more precise implantation of the prosthesis, though CAS still requires an experienced surgeon and is time consuming. Nevertheless, 30% of surgeons in Germany who perform TKR have used navigation. It is still not known whether this new technique improves the longevity of TKR, however, and we therefore performed a meta-analysis to assess the results of this new health care technology.

[Prevention of deep vein thrombosis in total knee replacement--current status of therapy in orthopedie and trauma departments in Germany]. / Thromboseprophylaxe in der Knieendoprothetik. Stand der Therapie an deutschen orthopädisch-traumatologischen Kliniken.

INTRODUCTION: Symptomatic deep vein thrombosis is a serious complication after total knee arthroplasty, with a risk of about 4-5% despite prevention with herparin. Aim of the current study was to find out about the actual status of thrombosis prophylaxis in Germany after total knee replacement. MATERIAL AND METHODS: In a countrywide survey 470 German trauma and orthopaedic surgery departments were asked about their prophylactic procedures addressing deep vein thrombosis after total knee replacement. RESULTS: 98% perform prevention of thrombosis with low-molecular-weight heparin, 2% use unfractioned heparin. Low-molecular-weight heparin is applicated in standard doses in 48% and in 44% according to patient's weight. In 82% the prophylaxis is begun the night before surgery. The therapy is carried out for 4.7 weeks in mean. 96% use graduated compressions stocking as additional therapeutic option. CONCLUSION: Our survey shows that most of the surgeons perform prevention of deep vein thrombosis according to the official guidelines.

Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique.

Restoration of neutral alignment of the leg is an important factor affecting the long-term results of total knee arthroplasty (TKA). Recent developments in computer-assisted surgery have focused on systems for improving TKA. In a prospective study two groups of 80 patients undergoing TKA had operations using either a computer-assisted navigation system or a conventional technique. Alignment of the leg and the orientation of components were determined on post-operative long-leg coronal and lateral films. The mechanical axis of the leg was significantly better in the computer-assisted group (96%, within +/- 3 degrees varus/valgus) compared with the conventional group (78%, within +/- 3 degrees varus/valgus). The coronal alignment of the femoral component was also more accurate in the computer-assisted group. Computer-assisted TKA gives a better correction of alignment of the leg and orientation of the components compared with the conventional technique. Potential benefits in the long-term outcome and functional improvement require further investigation.

[Therapy of traumatic anterior shoulder dislocation: current status of therapy in Germany. Are there scientifically verified therapy concepts?]. / Die Therapie der traumatischen vorderen Schulterluxation: Aktueller Stand der Therapie in Deutschland. Gibt es wissenschaftlich gesicherte Therapiekonzepte?

There are no generally accepted concepts for the treatment of traumatic anterior shoulder dislocation. The objective of this study was to ascertain the current treatment for traumatic shoulder dislocations in German hospitals and to compare this with the data reported in the literature. A total of 210 orthopedic surgery departments were asked for their treatment strategy in an anonymous country-wide survey; 103 questionnaires (49%) were returned for evaluation. Additional imaging (ultrasound, CT, MRI) beyond the routine X-rays is performed in 82% of clinics for primary shoulder dislocation (94% in recurrent dislocation). A young, athletic patient (< 30 years old) would be operated on for a primary traumatic shoulder dislocation in 73% of hospitals (98% in recurrent dislocation). In contrast, a patient of the same age, with a moderate level of sporting activity would be treated conservatively in 67% of cases (14% in recurrent dislocation). Similarly, for an active, middle-aged patient with a demanding job, 74% of responses favored conservative treatment after a primary dislocation and 6% after a recurrent dislocation. Older patients (> 65 years old) are usually treated conservatively after a primary or recurrent shoulder dislocation (99%, 69%). For a primary shoulder dislocation the most popular surgical reconstruction is a Bankart repair (75%). For recurrent shoulder dislocation several different operative techniques are seen (Bankart 29%, T-shift 26%, Putti-Platt 8%, Eden-Lange-Hybbinette 22%, Weber osteotomy 13%). Based on our literature review, we found: (1) The clinical examination of both shoulders is important to diagnose hyperlaxity; (2) Routine CT or MRI is not necessary for primary traumatic shoulder dislocations; (3) A young, athletic patient should undergo surgical reconstruction after a primary shoulder dislocation; (4) The operation of choice for primary and recurrent dislocation is the Bankart repair; (5) There is no sufficient evidence that an arthroscopic Bankart repair is as good as an open procedure; (6) There are limited indications for other operative techniques, as they are associated with a higher recurrence and arthrosis rate.

[The displaced proximal humeral fracture: is there evidence for therapeutic concepts?]. / Die dislozierte proximale Humerusfraktur: Gibt es gesicherte Therapiekonzepte?

INTRODUCTION: There is no general agreement on the operative treatment of displaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have been favoured during the past decade. The indication for primary shoulder prosthesis is controversial. The purpose of this report was to evaluate the scientific evidence of current treatment recommendations. METHODS: Relevant articles were retrieved from "Medline" and "Knowledge-Finder" using the combined search strategy for the keywords "proximal humerus" and "fracture". Retrieved articles were evaluated according to the criteria of evidence-based medicine. RESULTS: The analysis retrieved 3 randomized, 4 prospective, and 26 retrospective studies and a number of review articles relevant to the subject. Limitations of most publications were due to small study populations, differences in patient selection and fracture classification as well as measurements of outcome. According to these studies good functional results can be achieved in dislocated two-part fractures treated with minimal osteosynthesis in the elderly and T-plate fixation in younger patients. For three- and four-part fractures minimally invasive techniques seem to be more favourable in the elderly. However, there is some evidence that alternative therapies such as conservative treatment and plating can be successful in defined populations. A general indication for primary implantation of a prosthesis in four-part fractures in the elderly is not supported by the literature. CONCLUSION: We conclude from our analysis that the scientific evidence for treatment recommendations of displaced proximal humeral fractures is still limited.

[Conservative or surgical therapy of acromioclavicular joint injury--what is reliable? A systematic analysis of the literature using "evidence-based medicine" criteria]. / Konservative oder operative Therapie der Schultereckgelenkverletzung--was ist gesichert? Eine systematische Literaturanalyse nach Kriterien der "evidence based medicine".

There is controversy about the therapy for third-degree acromioclavicular dislocation according to Tossy and Rockwood's classification. Both operative and non-operative treatment is reported to have satisfactory results in the literature. The purpose of this study was to analyze the literature in a systematic manner based on the criteria of evidence-based medicine. It was our hypothesis that there is no scientific evidence for the superiority of one treatment over the other. A total of 370 papers were retrieved and classified into three groups: (1) randomized controlled trials; (2) comparative retrospective studies; and (3) retrospective studies. In three studies that were graded with high evidence, the major outcome for both operative and non-operative treatment was similar. The advantages of non-operative treatment include a shorter period of rehabilitation and a significantly lower complication rate while the advantages of operative treatment include a low rate of persisting subluxation of the AC joint. Similar results were found for retrospective comparative and long-term studies. For retrospective studies without controls, both operative and conservative therapy are described with good and excellent results, ranging between 80 and 97%. In conclusion, there is good evidence on the therapy of third-degree acromioclaviculary dislocation studies. The functional result according to the literature is similar, and complications associated with therapy occur more often with operative treatment. Conservative treatment appears to be the method of choice for third-degree acromioclavicular dislocations unless the patient's preference is operative therapy.

[Useability of an image based nagivation system in reconstruction of leg alignment in total knee arthroplasty - results of a propsective study]. / Einfluss eines bildgestützten Navigationssystems auf die Implantationsgenauigkeit in der Knieendoprothetik--Ergebnisse einer prospektiven Studie.

Accurate leg alignment is one important factor for long term survival in total knee arthroplasty (TKA). The aim of this study was to determine the accuracy of a CT-based navigation system in restoration of the leg axis. 80 TKA (P.F.C.-Sigma--DePuy) were implanted either using a CT-based navigation-system or the conventional technique. There were no significant differences between the groups according to the preoperative leg deformity. Accuracy of implantation was determined on postoperative long-leg coronal and lateral x-rays. A postoperative leg axis between 3 degrees varus and 3 degrees valgus was obtained in 35/40 patients (88%) in the computer assisted and 28/40 patients (70%) in the conventional operated group. A higher precision in the sagittal plane was seen for the tibial (computer assisted: 3.9 +/- 2.2 vs. conventional TKA 1.3 +/- 5.8) and the femoral component (computer assisted: 3.5 +/- 2.3 vs. conventional TKA 6.9 +/- 3.6). The use of the CT-based VectorVision-System allows a significant improvement in the accuracy of implantation in TKA. The CT-based module has the advantage of a precise preoperative planning and a useful documentation and control tool for each important step. On the other hand there are additional costs and time consuming logistics.

[Accuracy of an image-free cup navigation system--an anatomical study]. / Genauigkeit eines bildfreien Navigationssystemes für die Hüftpfannenimplantation--eine anatomische Studie.

The position of the acetabular cup is of decisive importance for the function of a total hip replacement (THR). Using the conventional surgical technique, correct placement of the cup often fails due to a lack of information about pelvic tilt. With CT-based and fluoroscopically-assisted navigation procedures the accuracy of implantation has been significantly improved. However, additional radiation exposure, high cost and the increased time requirement have hampered the acceptance of these techniques. The present anatomical study evaluates the accuracy of an alternative procedure--image-free navigation. This method requires little extra effort, does not substantially delay surgery, and needs no additional imaging. Press-fit cups were implanted in 10 human cadaveric hips with the help of the image-free navigation system, and the position of the cups was checked intraoperatively with a CT-based navigation system and postoperatively by computed tomography. All cups were implanted within the targeted safe zone with an average inclination of 44 degrees (range 40 degrees-48 degrees, SABW 2.7 degrees) and an average anteversion of 18 degrees (range 12-24 degrees, SABW 4.1 degrees). Analysis of accuracy of the image-free navigation software revealed only a small, clinically tolerable deviation in cup anteversion and cup inclination in comparison with the CT-based navigation system and the post operative CT scans. The evaluated image-free navigation system appears to be a practicable and reliable alternative to the computer-assisted implantation of acetabular cups in total hip arthroplasty.

[Reconstruction of insufficient anterior cruciate ligament]. / Therapie der vorderen Kreuzbandruptur des Kniegelenks. Ergebnisse einer Umfrage an unfallchirurgischen und orthopädischen Kliniken in Deutschland.

AIM: Reconstruction of insufficient anterior cruciate ligament (ACL) has become a standard operative procedure. Still, graft choice and fixation technique are discussed controversially. The objective of this study was to ascertain the current treatment of ACL reconstruction in german orthopedic surgery and trauma centers. METHODS: A total of 250 trauma and 220 orthopedic surgery centers were asked for their treatment strategy and postoperative procedure of ACL reconstruction in an anonymous German-wide survey. RESULTS: 230 questionnaires (48.9 %) were returned for evaluation. 90.4 % of the surgeons reconstruct the anterior cruciate ligament. Patellar tendon is used by 73 % of orthopedists and 80.7 % of trauma surgeons. Reconstruction with semitendinosus tendon transplant is performed by 71.6 % of the orthopedists and 41.6 % of trauma surgeons. For tibial fixation the interference screw is as well of the semitendinosus tendon as of the patellar tendon the most common technique. In about 30 % each the femoral fixation results from interference screw and endo-button. CONCLUSION: There is still no generally accepted intra- and postoperative strategy for reconstruction of ACL. Reconstruction with semitendinosus tendon becomes more common.

[Surgical training in orthopaedic and trauma departments in Germany]. / Die operative Weiterbildung an deutschen orthopädischen und traumatologischen Kliniken.

AIM: Training in surgical skills is not at its best in German hospitals in comparison to other countries. There is no detailed curriculum describing which operations a resident has to learn at which stage of his training as in Switzerland or Denmark. We aimed to find out how many typical operations are performed by trainees/residents in orthopaedic surgery. METHOD: We performed a survey at Orthopeadic and Trauma Departments in Germany to measure the percentage of operations (knee arthroscopies, shoulder arthroscopies and knee arthroplasties) which are performed by trainees and residents. RESULTS: Retrospective data were evaluated. Out of 35 654 knee arthroscopies, 49.4% were performed by the head of department or senior consultants, 27.6% by junior consultants and 26.9% by trainees. A total of 30,642 shoulder arthroscopies was analysed. 78.4% were operated on by the head of department or senior consultants, 18.3% by junior consultants and 6.9% by trainees. We evaluated 31,138 knee arthroplasties, 80% were operated by the the head of department or senior consultants, 14% by junior consultants and 7% by trainees. CONCLUSION: Surgical training is still not at its best for trainees. Further improvement is necessary to create a transparent training environment for younger surgeons.