The German version of the Nottingham Clavicle Score is a reliable and valid patient-reported outcome measure to evaluate patients with clavicle and acromioclavicular pathologies.

PURPOSE: The Nottingham Clavicle Score (NCS) is a patient-reported outcome measure developed to evaluate treatment results of clavicle, acromioclavicular and sternoclavicular joint pathologies. Valid, reliable and user-friendly translations of outcome measure instruments are needed to allow comparisons of international results. The aim of this cross-sectional study was to translate and adapt the NCS into German and evaluate the psychometric properties of the German version. METHODS: The translation and cross-cultural adaptation of the NCS were completed using a 'translation-back translation" method and the final version was administered to 105 German-speaking patients. The psychometric properties of this version (NCS-G) were evaluated in terms of feasibility, reliability, validity and sensitivity to change. RESULTS: No major differences occurred between the NCS translations into German and back into English, and no content- or linguistic-related difficulties were reported. The Cronbach's alpha for the NCS-G was 0.885, showing optimal internal consistency. The Intraclass Correlation Coefficient for test-retest reliability was 0.907 (95% CI 0.844-0.945), with a standard error of measurement of 5.59 points and a minimal detectable change of 15.50 points. The NCS-G showed moderate to strong correlation with all other investigated scales (Spearman correlation coefficient: qDASH: ρ = - 0.751; OSS: ρ = 0.728; Imatani Score: ρ = 0.646; CMS: ρ = 0.621; VAS: ρ = - 0.709). Good sensitivity to change was confirmed by an effect size of 1.17 (95% CI 0.89-1.47) and a standardized response mean of 1.23 (95% CI 0.98-1.45). CONCLUSIONS: This study demonstrated that NCS-G is reliable, valid, reproducible and well accepted by patients, showing analogous psychometric properties to the original English version. LEVEL OF EVIDENCE: Level III.

Increased rate of enteric bacteria as cause of periprosthetic joint infections in patients with liver cirrhosis.

INTRODUCTION: Periprosthetic joint infections (PJI) are a major complication in joint-arthroplasty. Rifampicin is often used as an additional agent to treat PJI, because it penetrates bacterial biofilms. However, rifaximin, belonging to the same antibiotic class as rifampicin, is frequently used to prevent episodes of hepatic encephalopathy in patients with cirrhosis and may induce resistance to rifampicin. The aim of this study was to examine the microbial pattern of periprosthetic joint infections in cirrhotic patients and to test the hypothesis that intake of rifaximin increases the rate of resistance to rifampicin in periprosthetic joint infections. METHODS: A cohort of cirrhotic patients and PJI (n = 25) was analysed on the characteristics of bacterial isolates from sonication and tissue analysis. In a second step a subgroup analysis on the development of rifampicin resistant bacterial specimens, depending on the intake of rifaximin (8 rifaximin intake patients vs. 13 non rifaximin intake patients) was performed. RESULTS: Intestinal bacteria were found in 50% of the specimens, which was significantly more frequent than in a control cohort. By comparison of the single bacterial isolates, rifampicin resistance was detected in 69.2% (9/13) of the rifaximin-intake samples. In contrast, the non-rifaximin-intake isolates only were resistant to rifampicin in 22.2% (4/18) of the cases (p = 0.01). The odds ratio for developing a rifampicin-resistance through rifaximin intake was calculated as OR = 13.5. CONCLUSION: Periprosthetic joint infections have a high incidence of being caused by enteric bacteria in cirrhotic patients. Due to this change in microbial pattern and the innate resistance to rifampicin of most of gram-negative bacteria, the therapy with rifampicin should be carefully considered. The association between the use of rifaximin and developed resistance to rifampicin has a major impact on the treatment of PJI.

Is Prematurity a Protective Factor Against Developmental Dysplasia of the Hip? A Retrospective Analysis of 660 Newborns.

PURPOSE: In Middle Europe developmental dysplasia of the hip (DDH) has an incidence of up to 5.9 %. The rate of congenital hip dislocation as the worst complication of a growth disorder of the hip is between 1.5 % and 2.5 %. Among known risk factors of DDH are breech position, multiples, foot deformities and family history. The aim of this retrospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). MATERIALS AND METHODS: The hips of 283 infants who were born before the 38th week of gestation or earlier, and those of 377 infants who were born after the 37th week of gestation, none of whom had other risk factors for DDH, were compared using the ultrasound technique according to Graf et al., within the first week after birth. Both hips of all infants were included in the study. RESULTS: Surprisingly, the difference in alpha angles between the two groups was statistically extremely significant, favoring the preterm infants. Moreover, we found a physiological curve of alpha angle development with a peak after the 31st week of gestation. The incidence of pathological dysplasia was not significantly different in the two groups. CONCLUSION: Our results suggest that prematurity is not a predisposing factor for DDH, but rather is protective for hip development.

Anatomic reconstruction of lateral ankle ligaments: is there an optimal graft option?

PURPOSE: Different graft options are available for the reconstruction of lateral ankle ligaments to treat chronic ankle instability (CAI), which fall in two categories: allografts and autografts. This study aims to provide an updated comparison of the clinical outcomes after stabilisation procedures using allografts and autografts, to correctly advise the clinician during the choice of the best material to be used for the reconstruction of the lateral ligamentous complex of the ankle. METHODS: A systematic review was performed to analyse the use of autografts and allografts for anatomic reconstruction of the lateral ligamentous complex of the ankle in CAI patients. The presence of a postoperative assessment through outcome measures with proofs of validation in the CAI population or patient's subjective evaluation on the treatment were necessary for inclusion. The quality of the included studies was assessed through the modified Coleman Methodology Score (mCMS). Relevant clinical outcome data were pooled to provide a synthetic description of the results in different groups or after different procedures. RESULTS: Twenty-nine studies (autograft: 19; allograft: 9; both procedures: 1) accounting for 930 procedures (autograft: 616; allograft: 314) were included. The average mCMS was 55.9 ± 10.5 points. The Karlsson-Peterson scale was the most frequently reported outcome scale, showing a cumulative average post- to preoperative difference of 31.9 points in the autograft group (n = 379, 33.8 months follow-up) and of 35.7 points in the allograft group (n = 227, 25.8 months follow-up). Patient satisfaction was good or excellent in 92.8% of autograft (n = 333, 65.2 months follow-up) and in 92.3% of allograft procedures (n = 153, 25.0 months follow-up). Return to activity after surgery and recurrence of instability were variably reported across the studies with no clear differences between allograft and autograft highlighted by these outcomes. CONCLUSIONS: The systematic analysis of validated CAI outcome measures and the patient's subjective satisfaction does not support a specific choice between autograft and allograft for the reconstruction of the ankle lateral ligamentous complex in CAI patients. Both types of grafts were associated to a postoperative Karlsson-Peterson score superior to 80 points and to a similar rate of patient's subjective satisfaction. LEVEL OF EVIDENCE: Level IV.

The Influence of Iodine-Impregnated Incision Drapes on the Bacterial Contamination of Scalpel Blades in Joint Arthroplasty.

BACKGROUND: Prosthetic joint infections (PJI) are a disastrous and feared complication in arthroplasty. Over the past decades, surgeons have tried to lower infection rates through all sorts of improvements. At present, it is impossible to reduce the risk to zero. As the contamination of surgical instruments and the surgical field has been identified as a remaining gap prone for infection, scalpel blades among others have become a focal point of several studies. This study is the first to compare the effect of adhesive incision drapes on contamination rates of scalpel blades in primary arthroplasty of the hip and knee. METHODS: A total of 344 microbiologic blade culture results from 2 study groups with and without drape usage and 1 group with known PJI were analyzed and compared to histopathologic and microbiologic tissue results. RESULTS: In 78% of all positive cultures, the bacteria were part of the local skin flora. The contamination rate for the skin blades with a drape was 3.81% vs 12.19% without drape usage. A significant difference was determined between positive skin blade culture results incision drape usage (P = .031). The different pathogens likely responsible for the PJI correlated with the deep blade cultures (P ≤ .01). The overall contamination rate of surgical blades (1.37%) is comparatively low to the results obtained from other surgical equipment in literature. None of those blade-positive patients developed a surgical site infection during 12-month follow-up. CONCLUSION: Iodine-impregnated incision drapes are able to reduce surgical skin blade contamination. Further studies may be needed to assess the relationship between blade contamination and surgical site infections.

[Outcome after plate stabilization of symphyseal diastasis]. / Ergebnisse nach Plattenstabilisierung der Symphysensprengung.

BACKGROUND: Separation of the pubic symphysis with corresponding diastasis can be stabilized by symphyseal plating. OBJECTIVE: Which pelvic injuries are stabilized with symphyseal plating and what is their outcome? MATERIAL AND METHODS: A retrospective evaluation of 64 patients who underwent symphyseal plating over a period of 24 months was conducted. RESULTS: Of the patients 56 were male and 8 female with a mean age of 44 years (SD ± 17 years). The main cause of the pelvic injuries were traffic accidents. The distribution according to the AO fracture classification was 14â€¯× B1, 10â€¯× B2, 5â€¯× B3, 23â€¯× C1, 9â€¯× C2 and 3â€¯× C3 injuries. The distribution according to the Young and Burgess classification showed 9â€¯× APC I, 18â€¯× APC II, 13â€¯× APC III, 9â€¯× LC I, 3â€¯× LC II, 2â€¯× LC III and 10â€¯× VS injuries. The mean Injury Severity Score (ISS) was 32 (SD ± 17) and the mean inpatient stay was 29 days (SD ± 16 days; positive correlation p ≤ 0.001). Radiological implant loosening occurred in 52 patients. 14 patients required treatment for severe complications. The leading reason for revision surgery was implant failure (n = 8). CONCLUSION: These observations suggest that radiological signs of implant loosening are commonly observed but rarely the reason for revision surgery. Complete implant failures, however; occur mainly within the first postoperative weeks and require early revision. A timely clarification by additional X-ray imaging should be carried out if this is suspected.

Laser-based Techniques for Microcirculatory Assessment in Orthopedics and Trauma Surgery: Past, Present, and Future.

: Microcirculatory integrity and proper function are the cornerstones to tissue nourishment and viability. In the clinical environment extended immobility, injuries, and inflammatory reactions demand local microcirculatory adaption to provide adequate supply. Assessment of endothelial adjustment capability and microcirculatory perfusion status, as direct or surrogate markers of disease, are therefore of uttermost interest to the treating physician. Given the simple, noninvasive, nonradiating nature of laser-based techniques for bedside or intraoperative microcirculatory perfusion assessment, this article's objective is to present a comprehensive overview of available techniques, their technological aspects, and current application. Advantages of individual methods are pointed out and compared with each other. The areas of medical utilization relevant to orthopedics and trauma surgery are exemplified and their available evidence elaborated. A particular focus is put on laser speckle contrast imaging, with its current and future influence on medical practice.

[Influence of trauma mechanisms on thoracic and lumbar spinal fractures]. / Einfluss des Unfallmechanismus auf die Wirbelkörperfraktur.

BACKGROUND: Vertebral body fractures (VBF) can be caused by various trauma mechanisms. The AOSpine classification system differentiates three main types of fractures according to the grade of instability. How the increasing energy of various accident mechanisms changes the complexity of the individual fracture, its localization and the occurrence of further fractures has not yet been finally investigated. OBJECTIVE: What influence do traumatic events with different kinematics have on the localization, complexity and number of VBF in the thoracic and lumbar spine? MATERIAL AND METHODS: In this retrospective study data from patients with a freshly traumatized VBF were analyzed. The patients were divided into six trauma groups (UFG) depending on the trauma mechanism. The VBF were classified on the basis of computed tomography (CT) imaging according to the AOSpine classification system. Testing was performed bilaterally and a significance level of 5% was used. The statistical calculations were carried out using IBM SPSS Statistics. RESULTS: A significant increase in the severity of fractures (AO classification) was found in the high energy trauma groups (UFG III and V). In addition, the incidence of thoracic (TH) VBF was significantly increased for TH7 (p = 0.011) and TH10 (p = 0.001). In comparison to the other low energy trauma groups, the risk of a TH7 fracture was 7­times higher after a high energy trauma (odds ratio OR = 7.0; 95% confidence interval CI = 1.4; 35.2). The UFG III (falls > 3 m) showed the highest number of fractures with a median of 2.5 (SD 1.84) VBF. CONCLUSION: An exact reproduction of the traumatic event enables a distinction between high and low energy trauma groups to be made. In previous studies traffic accidents were recorded as one group, so an influence of the increasing kinematic energy could not be assessed. The accident kinematics can be taken into account by differentiating between high and low-energy trauma groups. In high-energy accidents the TH7 and TH10 vertebrae were found to be at risk vertebrae. In addition to the force direction, the force strength also has a decisive influence on the distribution pattern of VBF.

Comparison of Minced Cartilage Implantation with Autologous Chondrocyte Transplantation in an In Vitro Inflammation Model.

The current gold standard to treat large cartilage defects is autologous chondrocyte transplantation (ACT). As a new surgical method of cartilage regeneration, minced cartilage implantation (MCI) is increasingly coming into focus. The aim of this study is to investigate the influence of chondrogenesis between isolated and cultured chondrocytes compared to cartilage chips in a standardized inflammation model with the proinflammatory cytokine TNFα. Articular chondrocytes from bovine cartilage were cultured according to the ACT method to passage 3 and transferred to spheroid culture. At the same time, cartilage was fragmented (<1 mm3) to produce cartilage chips. TNFα (20 ng/mL) was supplemented to simulate an inflammatory process. TNFα had a stronger influence on the passaged chondrocytes compared to the non-passaged ones, affecting gene expression profiles differently between isolated chondrocytes and cartilage chips. MCI showed less susceptibility to TNFα, with reduced IL-6 release and less impact on inflammation markers. Biochemical and histological analyses supported these findings, showing a greater negative influence of TNFα on the passaged pellet cultures compared to the unpassaged cells and MCI constructs. This study demonstrated the negative influence of TNFα on chondrogenesis in a chondrocyte spheroid culture and cartilage fragment model. Passaged chondrocytes are more sensitive to cytokine influences compared to non-passaged cells and chondrons. This suggests that MCI may have superior regeneration potential in osteoarthritic conditions compared to ACT. Further investigations are necessary for the translation of these findings into clinical practice.

A Worldwide Analysis of Adipose-Derived Stem Cells and Stromal Vascular Fraction in Orthopedics: Current Evidence and Applications.

The biological enhancement of tissue regeneration and healing is an appealing perspective in orthopedics. We aimed to conduct a systematic review to describe the global distribution of studies investigating the use of adipose tissue derivates in orthopedics and to provide information on their quality and on the products available. The quality of the included studies was assessed using the modified Coleman Methodology Score (mCMS) and the Cochrane risk-of-bias tool for randomized trials. Eighty-two studies were included, with a total of 3594 patients treated. In total, 70% of the studies investigated the treatment of knee disorders, predominantly osteoarthritis; 26% of all studies dealt with expanded adipose-derived stem/stromal cells (ADSCs), 72% of which had stromal vascular fraction (SVF); 70% described the injection of adipose tissue derivates into the affected site; and 24% described arthroscopies with the addition of adipose tissue derivates. The mean mCMS for all studies was 51.7 ± 21.4 points, with a significantly higher score for the studies dealing with expanded ADSCs compared to those dealing with SVF (p = 0.0027). Our analysis shows high heterogeneity in terms of the types of performed procedures as well as the choice and processing of adipose tissue derivates.

Video Based Assessment of Treatment Urgency in Outpatient Orthopaedic and Trauma Patients - a Pilot Trial. / Videobasierte Einschätzung der Behandlungsdringlichkeit - eine Pilotstudie für ambulante Patienten in der Orthopädie und Unfallchirurgie.

INTRODUCTION: When consulting a specialist in orthopaedics and trauma surgery, personal assessment and manual clinical examination by the doctor on site are essential. Nevertheless, implementation of video consultation hours has been made legally easier in Germany. The present pilot study examines the possibility of video-based assessment of the urgency of treatment in outpatient orthopaedic and trauma patients. MATERIALS AND METHODS: Within an ex ante study design, 40 patients with an orthopaedic clinical picture for trauma surgery with elective, urgent or emergency indication were selected from consultation hours. A short questionnaire was filled in based on the information provided and a medical colleague simulated a movement sequence based on the patient information. After modification to the "red flags" and "yellow flags" established in spinal orthopaedics, nine short questions were recorded, which inquire about the urgency of a medical consultation. The video-based movement sequence is based on a 60 s long instruction video in which motor tests and movement sequences are demonstrated: Cervical spine movement in all levels, elevation of the upper extremity, test of the finger-floor distance when "bending forward over-bending", possibility of crouching from standing and getting up again, standing on heels and toes. RESULTS: In 91.1% (n = 328) of the cases, the diagnosis was associated with the same joint or the same pathological entity. In 37.5% (n = 135) of the cases an emergency indication was seen, in 10.8% (n = 39) of the cases an urgent indication and in 51.6% (n = 186) of the cases it was seen to offer an elective indication. 12.5% (n = 45) of the cases were evaluated as "false positives" with regard to an emergency or urgent presentation. This means that the test persons were classified as "emergency" or "urgent", although there was no preventable dangerous course or medical emergency. 18 cases (5%) were evaluated as "false negative". DISCUSSION: The screening questionnaire presented and the short video assessment are technically feasible and practicable method for the initial evaluation in video-based online medical consultation. In addition, the questionnaire presented in combination with the short video assessment was suitable as an instrument for assessing the urgency of the consultation and selecting preventable dangerous processes and acute emergencies. CONCLUSION: The questionnaire, in combination with the short video assessment, is a suitable method for the social distancing requirements during limited accessibility of the medical system. Nevertheless, a false negative rate of 5% is too high to implement the questionnaire presented into daily clinics without further optimisation.

Comparison of Lesser Toe Proximal Interphalangeal Joint Arthrodesis Versus Resection Arthroplasty: A Randomized Controlled Study.

The goal of this study was to compare operative outcomes after lesser toe deformity correction with either proximal interphalangeal (PIP) joint arthrodesis or PIP joint resection arthroplasty. A prospective randomized controlled trial was performed with 37 patients (48 toes) operated on with one of these two procedures. Evaluation of the numeric rating scale score, the American Orthopedic Foot and Ankle Society score, osseous consolidation, and clinical outcome was performed preoperatively and at 6 weeks and 6 months postoperatively. Both study groups showed significant improvement at 6 months postoperatively. Although osseous consolidation was significantly higher for the arthrodesis group (P=.001), this difference did not affect clinical outcomes, and at 6 months postoperatively, pain on the numeric rating scale was 0 (range, 0-7) for the arthroplasty group and 0 (range, 0-5) for the arthrodesis group (P=.669). The American Orthopedic Foot and Ankle Society score was 83 (range, 39-95) and 80 (range, 59-95), respectively (P=.879). No difference was observed for signs of inflammation or axis correction. Even a direct comparison of toes with radiologically osseous fusion (n=16) with those without fusion (n=32) did not show any clinical differences. This randomized controlled study showed no clinical differences in outcome between PIP joint arthrodesis and PIP joint resection arthroplasty for correction of lesser toe deformities, with good to excellent outcomes for both groups. [Orthopedics. 2022;45(2):86-90.].

Economic Effects of the SARS-CoV-2 Pandemic in 2020. / Wirtschaftliche Auswirkungen der SARS-CoV-2-Pandemie im Jahr 2020.

INTRODUCTION: In 2020, the SARS-CoV-2 pandemic necessitated an adjustment to the care structure in all medical facilities in Germany. In this study we analysed the effects of the SARS-CoV-2 pandemic using the data from the annual balance sheet of a university department and maximum care provider for orthopaedics and trauma surgery. METHODS: Data analysis was performed on the clinic's performance parameters from 2019 and 2020. The analysis included 52943 outpatient and 7980 inpatient cases, together with the Case Mix Index (CMI), and the costs and revenues. RESULTS: As a result of the reduction in scheduled surgeries, the mean number of inpatients in March and April 2020 decreased by 10.4% (p = 0.004). Due to the focus on complex cases, the CMI increased by 29.5% (p = 0.007). The number of outpatient surgical procedures increased by 16.9% (n = 84). Rising costs of consumables due to the purchase of protective equipment were offset by a reduced need for orthopaedic implants. CONCLUSION: By reducing the number of elective inpatient surgical treatments, the focus was shifted to treating complex cases; this is reflected in the increased CMI. Due to internal compensation mechanisms, the clinic was able to conserve intensive care capacities while still achieving an increase in revenue.

The Impact of Lead Aprons on Posture of Orthopaedic Surgeons. / Der Einfluss von Röntgenschürzen auf die Körperhaltung von Orthopäden und Unfallchirurgen.

BACKGROUND: Surgeons working in orthopedics and trauma surgery are frequently exposed to repetitive actions and non-ergonomic positions in their operative activities with the regular use of lead aprons. Musculoskeletal complaints of the neck and back among surgeons are reported in the literature as up to 80%. In this study, the effects of lead aprons on the posture of surgeons are examined using videorasterstereography, foot pressure measurement and questionnaires. METHODOLOGY: All subjects (n = 31) were examined before and after exposure to wearing lead aprons during surgery using videorasterstereography and pedography. In addition, a survey with a separately created questionnaire and the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was carried out. RESULTS: An average duration of lead apron use of 102.6 min showed an increase in forefoot load (p = 0.002) especially in the elderly subjects and thoracic kyphosis (p < 0.001) especially in the younger doctors with a significant lateral deviation (p = 0.006). In addition, the lateral deviation was shown to correlate with an increasing body size or a shorter period of employment (p = 0.008; r = 0.51/p = 0.026; r = - 0.44). Significantly fewer surgeons experienced back complaints on working days without lead apron use in the operating room compared to days in the OR (p = 0.011). CONCLUSION: The impact of wearing front covered lead aprons during operations in the field of orthopaedics and trauma surgery leads to more frequent back complaints, even among young and healthy doctors. Under an average duration of surgery of 102 min a temporary postural deviation occurs that can be demonstrated by means of videorasterstereography and foot pressure measurement. The subjects showed a shifted weight distribution on the forefoot, a gain in thoracic kyphosis and an increase in lateral deviation, which also correlated with an increasing height and shorter length of employment.

A Feasibility Pilot Study on the Use of Telemedicine for the Examination of the Knee Joint. / Eine Pilotuntersuchung zur Machbarkeit der Videosprechstunde bei muskuloskelettalen Beschwerden des Kniegelenks.

BACKGROUND: In times of a pandemic threat, such as COVID-19, and the need for reduced direct doctor-patient contact, internet-based telemedicine has attracted more and more attention as a surrogate service. Suspending the diagnosis and treatment of non-virus related diseases for longer periods of time is not a viable option since this would only exacerbate problems on the patient and national level. The need for alternative treatment modalities increased rather quickly. So far, telemedical applications have mainly focused on teleradiological diagnosis, follow-up and monitoring of psychiatric and internal diseases, as well as geriatric patient care. As far as these authors are aware, orthopaedic physical examination of the knee joint, including trauma work-up, has not been the subject of any studies to date. This feasibility study explores how video consultation can be designed and implemented in the context of history taking and physical examination in knee joint complaints. MATERIAL AND METHOD: 21 patient actors (PA) with simulated complaints of the knee joint were examined individually for each diagnosis, first via video consultation and then directly by a specialist (SP). One PA group has a medical background, the other was made up of laypersons. The time was measured for both types of consultation. The physician documented the detected symptoms, the quality of implementation of the self-examination steps, and the derived diagnosis on an assessment form. After completion of both consultation sessions, the PAs were handed a questionnaire on the respective examination modality. RESULTS: With the video consultation the examination lasted 8.63 (± 2.5) minutes on average and with the regular consultation in person 5.63 (± 1.7) minutes (p < 0.001). For the group with medical background the examination lasted 7.67 (± 1.4) minutes on average, while for the lay group the video consultation took 9.7 (± 3.1) minutes (p = 0.049). With increased age, the video consultation was prolonged (p = 0.032; r = 0.47). The mean value for self-examination of leg axis, gait pattern and degrees of freedom was 9.32 (± 0.4) of 10 points. The following functional tests resulted in lower mean values (points): Payr 7.2 (± 2.3), Merke 5.9 (± 2.8), no-touch Lachmann 6.4 (± 2.7), gravity sign-recurvatum 6.7 (± 2.4). The mean grade by the PAs for the feasibility of self-examination was 2.43 (± 0.98) out of 5 points. CONCLUSION: The video consultation for musculoskeletal complaints of the knee joint allows exploratory remote examination and helps to minimise the number of patients in hospitals and practices. It takes longer for the physician to perform and does not permit functional testing for ligament injuries of the knee joint. In its present form, telemedical examination is not able to fully replace personal consultation.

The Value of Video Rasterstereography in the Detection of Alterations in Posture as a Marker of Pain Relief after Targeted Infiltrations of the Lumbar Spine.

BACKGROUND: Targeted infiltrations to the lumbar spine are used to identify the correct scope for surgery in patients with chronic lumbar back pain (CLBP) and multi-segmental pathologies, where radiologic imaging and clinical presentation do not match. Conclusions from that method have so far been based on individual statements of pain relief. The main principle for the infiltrations is the assumption that by locally administering an analgesic agent to possible surgical target areas, the effect of surgery can be temporarily simulated. The aim was to investigate the use of rasterstereographic posture measurements to substantiate reported pain reduction after infiltrations. METHODS: In this case-control study (Level II), rasterstereography was performed on 57 patients and 28 reference subjects to evaluate changes in posture during 1 week of injections under fluoroscopic guidance and correlated with changes in the Numeric Pain Rating Scale (NRS). Statistical analysis was performed with SPSS (α = .05, two-sided) and presented in the form of box, scatter, and Bland-Altman plots. RESULTS AND CONCLUSION: The CLBP patients' trunk inclination (median 6°) and absolute lateral tilt were significantly increased (p < .01 each) compared to the reference group. No significant difference was observed for trunk length, kyphotic/lordotic angle, or lateral deviation. During infiltration, no significant difference in posture could be observed. A subgroup analysis of patients reporting the highest pain improvement indicated no significant difference. No correlation was observed with pain improvement reported by the patients during injections. Subsequent rasterstereography does not seem to be able to verify results of injections in the diagnostics of lumbar spine pathologies, as patients' reported pain relief does not correlate with a relevant alteration in posture. The short-term effect of the targeted infiltrations may not suffice to change false posture being developed over years.

In-Depth Characterization of Stromal Cells within the Tumor Microenvironment Yields Novel Therapeutic Targets.

Cells within the tumor stroma are essential for tumor progression. In particular, cancer-associated fibroblasts (CAF) and CAF precursor cells (resident fibroblasts and mesenchymal stromal cells) are responsible for the formation of the extracellular matrix in tumor tissue. Consequently, CAFs directly and indirectly mediate inflammation, metastasis, immunomodulation, angiogenesis, and the development of tumor chemoresistance, which is orchestrated by complex intercellular cytokine-mediated crosstalk. CAFs represent a strategic target in antitumor therapy but their heterogeneity hinders effective treatment regimes. In-depth understanding of CAF subpopulations and knowledge of specific functions in tumor progression will ultimately result in more specific and effective cancer treatments. This review provides a detailed description of CAFs and CAF precursor cells and summarizes possible treatment strategies as well as molecular targets of these cells in antitumor therapies.

Trans-obturator cable fixation of open book pelvic injuries.

Operative treatment of ruptured pubic symphysis by plating is often accompanied by complications. Trans-obturator cable fixation might be a more reliable technique; however, have not yet been tested for stabilization of ruptured pubic symphysis. This study compares symphyseal trans-obturator cable fixation versus plating through biomechanical testing and evaluates safety in a cadaver experiment. APC type II injuries were generated in synthetic pelvic models and subsequently separated into three different groups. The anterior pelvic ring was fixed using a four-hole steel plate in Group A, a stainless steel cable in Group B, and a titan band in Group C. Biomechanical testing was conducted by a single-leg-stance model using a material testing machine under physiological load levels. A cadaver study was carried out to analyze the trans-obturator surgical approach. Peak-to-peak displacement, total displacement, plastic deformation and stiffness revealed a tendency for higher stability for trans-obturator cable/band fixation but no statistical difference to plating was detected. The cadaver study revealed a safe zone for cable passage with sufficient distance to the obturator canal. Trans-obturator cable fixation has the potential to become an alternative for symphyseal fixation with less complications.

The Performance of a Dithiothreitol-Based Diagnostic System in Diagnosing Periprosthetic Joint Infection Compared to Sonication Fluid Cultures and Tissue Biopsies.

PURPOSE: The aim of this study was to evaluate the performance of a commercially available dithiothreitol (DTT) kit for routine use in diagnosing periprosthetic joint infections (PJIs) in comparison to conventional microbiological tissue specimens and sonication procedures in a maximal care hospital. METHODS: We applied the DTT system in 40 consecutive cases of revision arthroplasty (23 PJIs and 17 aseptic revisions), with an exchange or a removal of components. The hardware components were split between the DTT system and the conventional sonication procedure. At least three tissue biopsies and a joint fluid specimen were sent for microbiological and histopathological analysis. Data was analysed retrospectively to compare between the different methods. RESULTS: Cultures of the DTT fluid showed a sensitivity of 65% and specificity of 100%, as referenced to conventional microbiological cultures. Sonication had better sensitivity (75%) but lower specificity (85%). The categorical agreement of DTT cultures compared to sonication fluid cultures was 78% (31/40). Neither pathogen type, infection duration nor antibiotic pretreatment influenced the accuracy of the DTT, but a low pH in the DTT seemed to be associated with false-negative results. CONCLUSION: DTT was inferior in sensitivity when diagnosing PJIs compared to sonication fluid cultures and tissue biopsies. A low pH in the DTT fluid correlated with false-negative results. Nevertheless, the closed system of the DTT kit avoids contamination and false-positive results, and DTT can be an alternative where sonication is not available.

sCD28, sCD80, sCTLA-4, and sBTLA Are Promising Markers in Diagnostic and Therapeutic Approaches for Aseptic Loosening and Periprosthetic Joint Infection.

Aseptic prosthetic loosening and periprosthetic joint infections (PJI) are among the most frequent complications after total knee/hip joint arthroplasty (TJA). Current research efforts focus on understanding the involvement of the immune system in these frequent complications. Different immune cell types have already been implicated in aseptic prosthetic loosening and PJI. The aim of this study was to systematically analyze aspirates from knee and hip joints, evaluating the qualitative and quantitative composition of soluble immunoregulatory markers, with a focus on co-inhibitory and co-stimulatory markers. It has been shown that these molecules play important roles in immune regulation in cancer and chronic infectious diseases, but they have not been investigated in the context of joint replacement. For this purpose, aspirates from control joints (i.e., native joints without implanted prostheses), joints with TJA (no signs of infection or aseptic loosening), joints with aseptic implant failure (AIF; i.e., aseptic loosening), and joints with PJI were collected. Fourteen soluble immunoregulatory markers were assessed using bead-based multiplex assays. In this study, it could be shown that the concentrations of the analyzed immunoregulatory molecules vary between control, TJA, AIF, and PJI joints. Comparing TJA patients to CO patients, sCD80 was significantly elevated. The marker sBTLA was significantly elevated in AIF joints compared to TJA joints. In addition, a significant difference for eight markers could be shown when comparing the AIF and CO groups (sCD27, sCTLA-4, sCD137, sCD80, sCD28, sTIM-3, sPD-1, sBTLA). A significant difference was also reached for nine soluble markers when the PJI and CO groups were compared (sLAG-3, sCTLA-4, sCD27, sCD80, sCD28, sTIM-3, sPD-1, IDO, sBTLA). In summary, the analyzed immunoregulatory markers could be useful for diagnostic purposes as well as to develop new therapeutic approaches for AIF and PJI.