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.

Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures.

PURPOSE: Epileptic seizures can cause multiple shoulder injuries, the most common of which are dislocations, recurrent instability, fractures, and isolated lesions of the rotator cuff. Currently, only limited literature exists which describes the frequency and types of lesions in cohorts of epileptic patients and the corresponding treatment outcome. This study aims to document the occurrence of shoulder lesions in patients affected by seizures and to provide detailed information on trauma dynamics, specific lesion characteristics and treatment complications. METHODS: All patients referring to a tertiary epilepsy center were screened for shoulder injuries and the clinical records of those sustaining them during a seizure were reviewed. Demographic information, lesions' characteristics and trauma dynamics were analysed, as wells as-when carried out-the type of surgical intervention and any postoperative complications. RESULTS: The average age at the time of injury of 106 included patients was 39.7 ± 17.5 years and a male predominance was recorded (65%). Bilateral injuries occurred in 29 patients, simultaneously in 17 cases. A younger age, bilateral shoulder injuries and shoulder dislocations were significantly associated with the occurrence of a shoulder injury solely by muscular activation (p = 0.0054, p = 0.011, p < 0.0001). The complication rate in 57 surgically treated patients with follow-up data was 38.7%, with recurring instability being the most frequently reported complication (62.5%). CONCLUSIONS: Uncontrolled muscle activation during a seizure is a distinctive but not exclusive dynamic of injury in epileptic patients, accounting for more than the half of all shoulder lesions, especially in the younger. This can lead both to anterior and posterior dislocations or fracture-dislocations and is frequently cause of bilateral lesions and of instability recurrence after surgery. The high complication rates after surgical treatment in this selected subgroup of patients require that appropriate preventative measures are taken to increase the probability of treatment success. LEVEL OF EVIDENCE: Cohort study, level III.

The base of coracoid process as a reference for glenoid reconstruction in primary or revision reverse shoulder arthroplasty: CT-based anatomical study.

INTRODUCTION: Joint replacement surgery as a treatment for glenohumeral arthritis with glenoid bone loss is challenging. The aim of this study is to offer an anatomical orientation for glenoid reconstruction. METHODS: In this study, we measured size, inclination and version of the glenoid surface, as well as the distance between the articular line of the glenoid, base of the coracoid process, and acromion using computer tomographic (CT) imaging of 131 study participants aged 19-88 years in the period of 2010-2013. RESULTS: We measured a mean distance of 6.5 ± 0.2 mm from the glenoid articular line to the base of the coracoid process in the transverse CT plane. Body height has shown no significant impact on the glenoid morphology. We observed significant differences between males and females: The glenoid appeared to be located 5.2 ± 0.9 mm higher and the humeral head was 4.5 ± 0.7 mm larger in male subjects compared with females (r = .699; p < .01). CONCLUSION: In our study, the base of the coracoid offers an anatomical reference during reconstruction of the glenoid in primary and revision shoulder arthroplasty. As only 2D-CT imaging allows for accurate assessment of glenoid bone defects, we consider conventional X-ray imaging insufficient for proper preoperative planning before shoulder arthroplasty. LEVEL OF EVIDENCE: III.

[Reliability of the FFP classification in pelvic fractures]. / Anwendungsverlässlichkeit der FFP-Klassifikation bei Beckenfrakturen.

BACKGROUND: Pelvic fractures are typical for frail geriatric patients. They are characterized by increasing pain and loss of mobility. As geriatric pelvic fractures differ from the typical high velocity injuries, Rommens and Hofmann recommended a new classification for fragility fractures of the pelvis (FFP) in 2013. In addition to the location of the fracture they also assessed the degree of dislocation. OBJECTIVE: Compared to known fracture classifications of the pelvis, the FFP classification appears complex. Therefore, this study was designed to investigate the interobserver reliability of the FFP classification. MATERIAL AND METHODS: The members of the Section of Geriatric Traumatology (DGOU) were presented with 10 DICOM data sets with fractures of the pelvis for classification. As a reference the classification of P.M. Rommens, the author of the FFP, was established. RESULTS: In this study 24 consultants (47%) and 27 (53%) residents took part. Also, six radiologists were invited to participate. A total of 493 assessments were made. In 184 (37%) cases there was agreement with the reference, in 183 (37%) computed tomography images the fractures were classified lower, in 26 (26%) higher than the reference. This initially resulted in a Cohens κ coefficient of 0.36. This corresponds to a sufficient agreement (fair) according to Garbuz. With the reduction of the classification to four main groups, the Cohens κ coefficient increased to a satisfactory value. CONCLUSION: The reasons for the partly low agreement could be the participants' lack of experience and an inaccurate description of the classification levels. In the end, however, the FFP classification is the only one that meaningfully represents pelvic fractures of geriatric and frail patients. By simplifying to the four main groups, a better interobserver reliability is achieved. For a successful treatment, however, attention to the individual patient and the "fracture personality" is essential.

Investigation of Cytotoxicity, Oxidative Stress, and Inflammatory Responses of Tantalum Nanoparticles in THP-1-Derived Macrophages.

Tantalum (Ta) is gaining attention as a biomaterial in bone tissue engineering. Although the clinical advantage of Ta-based implants for primary and revision total joint replacement (TJA) has been well documented, few studies investigated the effect of wear products of Ta implants on peri-implant cells, and their potential contribution to aseptic implant loosening. This study is aimed at examining the cytotoxicity, oxidative stress, and proinflammatory potential of Ta and TiO2 nanoparticles (NPs) on macrophages in vitro. NPs were characterized using scanning electron microscopy, dynamic light scattering, and energy-dispersive X-ray. To test the NP-mediated cellular response in macrophages, THP-1-derived macrophages were challenged with both NPs, and cytotoxicity was analyzed using CCK-8 and LDH assays. Flow cytometry was used to investigate particle uptake and their internalization routes. NP-mediated oxidative stress was investigated by measuring the production of reactive oxygen species, and their proinflammatory potential was determined by quantifying the production of TNFα and IL-1ß in cell culture supernatants using ELISA. We found that both Ta and TiO2 NPs were taken up through actin-dependent phagocytosis, although TiO2 NPs did also show some involvement of macropinocytosis and clathrin-mediated endocytosis. Ta NPs caused no apparent toxicity, while TiO2 NPs demonstrated significant cytotoxicity at a concentration of over 100µg/mL at 24 h. Ta NPs induced negligible ROS generation and proinflammatory cytokines (TNFα, IL-1ß) in macrophages. In contrast, TiO2 NPs markedly induced these effects in a dose-dependent manner. Our findings indicate that Ta NPs are inert, nontoxic, and noninflammatory. Therefore, Ta could be considered an excellent biomaterial in primary and revision joint arthroplasty implants.

Vertebral Bone Marrow-Derived Mesenchymal Stromal Cells from Osteoporotic and Healthy Patients Possess Similar Differentiation Properties In Vitro.

Osteoporosis is a disease characterized by low bone mass and an increased risk of fractures. Although several cellular players leading to osteoporosis have been identified, the role of mesenchymal stromal cells (MSC) is still not fully elaborated. The aim of this study was, therefore, to isolate and characterize MSCs from vertebral body of healthy non-osteoporotic and osteoporotic patients, with a particular focus on their osteogenic differentiation potential. Isolated MSCs were characterized by their osteogenic, adipogenic, and chondrogenic differentiation, as well as surface marker expression, proliferation behavior, and immunomodulatory capacity. The mineralization process was confirmed using Alizarin Red S and alkaline phosphatase (ALP) stains and further evaluated by determining ALP activity, mineral deposition, and free phosphate ion release. MSCs from both healthy and osteoporotic patients showed common fibroblast-like morphology and similar proliferation behavior. They expressed the typical MSC surface markers and possessed immunomodulatory capacity. Both groups demonstrated solid trilineage differentiation potential; osteogenic differentiation was further confirmed by increased ALP activity, deposition of inorganic crystals, phosphate ion release, and expression of osteoblast marker genes. Overall, MSCs from osteoporotic and non-osteoporotic patients showed neither a difference in general MSC features nor in the detailed analysis regarding osteogenic differentiation. These data suggest that vertebral body MSCs from osteoporotic patients were not impaired; rather, they possessed full osteogenic potential compared to MSCs from non-osteoporotic patients.

Characterization and Comparison of Human and Ovine Mesenchymal Stromal Cells from Three Corresponding Sources.

Currently, there is an increasing focus on mesenchymal stromal cells (MSC) as therapeutic option in bone pathologies as well as in general regenerative medicine. Although human MSCs have been extensively characterized and standardized, ovine MSCs are poorly understood. This limitation hampers clinical progress, as sheep are an excellent large animal model for orthopedic studies. Our report describes a direct comparison of human and ovine MSCs from three corresponding sources under the same conditions. All MSCs presented solid growth behavior and potent immunomodulatory capacities. Additionally, we were able to identify common positive (CD29, CD44, CD73, CD90, CD105, CD166) and negative (CD14, CD34, CD45, HLA-DR) surface markers. Although both human and ovine MSCs showed strong osteogenic potential, direct comparison revealed a slower mineralization process in ovine MSCs. Regarding gene expression level, both human and ovine MSCs presented a comparable up-regulation of Runx2 and a trend toward down-regulation of Col1A during osteogenic differentiation. In summary, this side by side comparison defined phenotypic similarities and differences of human and ovine MSCs from three different sources, thereby contributing to a better characterization and standardization of ovine MSCs. The key findings shown in this report demonstrate the utility of ovine MSCs in preclinical studies for MSC-based therapies.

Molecular and Functional Phenotypes of Human Bone Marrow-Derived Mesenchymal Stromal Cells Depend on Harvesting Techniques.

Mesenchymal stromal cells (MSC) harvested in different tissues from the same donor exhibit different phenotypes. Each phenotype is not only characterized by a certain pattern of cell surface markers, but also different cellular functionalities. Only recently were different harvesting and processing techniques found to contribute to this phenomenon as well. This study was therefore set up to investigate proteomic and functional properties of human bone marrow-derived MSCs (hBM-MSC). These were taken from the same tissue and donor site but harvested either as aspirate or bone chip cultures. Both MSC populations were profiled for MSC markers defined by the International Society for Cellular Therapy (ISCT), MSC markers currently under discussion and markers of particular interest. While classic ISCT MSC markers did not show any significant difference between aspirate and outgrowth hBM-MSCs, our additional characterization panel revealed distinct patterns of differentially expressed markers. Furthermore, hBM-MSCs from aspirate cultures demonstrated a significantly higher osteogenic differentiation potential than outgrowth MSCs, which could be confirmed using a transcriptional approach. Our comparison of MSC phenotypes obtained by different harvesting techniques suggests the need of future standardized harvesting, processing and phenotyping procedures in order to gain better comparability in the MSC field.

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.

Modified anteromedial and anterolateral elbow arthroscopy portals show superiority to standard portals in guiding arthroscopic radial head screw fixation.

PURPOSE: Arthroscopic fixation of radial head radial head fractures is an appealing alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. The aim of this study was to evaluate if modifications to the standard anteromedial (AM) and anterolateral (AL) portals could allow screw placement for radial head fracture osteosynthesis closer to the plane of the radial head articular surface. METHODS: Eight fresh-frozen specimens were prepared to mimic arthroscopic setting. Standard AL (ALst) and AM (AMst) and distal AL (ALdi) and AM (AMdi) portals were established. Eleven independent examiners were asked to indicate the optimal trajectory, when aiming to place a cannulated screw parallel to the radial head surface for radial head osteosynthesis. A three-dimensional digital protractor was used to measure the angle between the indicated position and a Kirschner wire placed parallel to the radial head articular surface (α). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the samples. Means, standard deviations, and 95% confidence intervals (95% CI) were calculated for each portal. A coefficient of variation (CoV) was calculated to determine agreement among observers and intra-observer variability. RESULTS: Mean α angles were 25.1 ± 11.5° for AMst, 13.8 ± 4.8° for AMdi, 17.1 ± 13.4° for ALst, -2.6 ± 9.2° for ALdi. No overlapping in the 95% CI of ipsilateral standard and distal portals was observed, indicating that the difference between these means was statistically significant. The distal portals showed smaller inter-observer CoV as compared to the standard ones (AMst: 10.0%; AMdi: 4.6%; ALst: 12.5%; ALdi: 10.6%). Intra-observer CoV was similar for all portals (AMst: 5.5%; AMdi: 6.1%; ALst: 7.7%; ALdi: 7.1%). CONCLUSIONS: The use of distal AM and AL portals permits to obtain α angles closer to the radial head articular surface than standard AM and AL portals. This is expected to allow screw placement in a flatter trajectory, which should correlate with a superior biomechanical performance of fixation. Good reproducibility of Kirschner wire placement from distal portals was observer among different examiners. Modifications to the standard AM and AL elbow arthroscopy portals allow to place screws for radial head fracture osteosynthesis in a position which should guarantee superior biomechanical performance of fixation.

[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.

Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis.

BACKGROUND: There are many injection therapies for lateral epicondylalgia but there has been no previous comprehensive comparison, based on the Bayesian method. METHODS: The MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for appropriate literature. The outcome measurement was the pain score. Direct comparisons were performed using the pairwise meta-analysis, and network meta-analysis, based on a Bayesian model, was used to calculate the results of all of the potentially possible comparisons and rank probabilities. A sensitivity analysis was performed by excluding low-quality studies. The inconsistency of the model was assessed by means of the node-splitting method. Metaregression was used to assess the relationship between the sample size and the treatment effect. RESULTS: All of the injection treatments showed a trend towards better effects than placebo. Additionally, the peppering technique did not add additional benefits when combined with other treatments. No significant changes were observed by excluding low-quality studies in the sensitivity analysis. No significant inconsistencies were found according to the inconsistency analysis, and metaregression revealed that the sample size was not associated with the treatment effects. CONCLUSIONS: Some commonly used injection therapies can be considered treatment candidates for lateral epicondylalgia, such as botulinum toxin, platelet-rich plasma and autologous blood injection, but corticosteroid is not recommended. Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research. The peppering technique is not helpful in injection therapies.

An Updated Overview of Risk Factors for Shoulder Stiffness. / Risikofaktoren für die Entstehung der primären Schultersteife: ein aktueller Überblick.

A painful reduction in shoulder mobility, known as "shoulder stiffness", can occur both as a primary idiopathic condition and as a secondary condition, for example, following surgical procedures. Various factors can contribute to the development of primary shoulder stiffness. In this review we summarize the pathophysiological mechanisms, genetic influences, endocrine disorders, metabolic conditions, as well as other diseases and medical-therapeutic approaches that might have an impact on the development of primary shoulder stiffness.

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.

Osteomyelitis is associated with increased anti-inflammatory response and immune exhaustion.

Introduction: Osteomyelitis (OMS) is a bone infection causing bone pain and severe complications. A balanced immune response is critical to eradicate infection without harming the host, yet pathogens manipulate immunity to establish a chronic infection. Understanding OMS-driven inflammation is essential for disease management, but comprehensive data on immune profiles and immune cell activation during OMS are lacking. Methods: Using high-dimensional flow cytometry, we investigated the detailed innate and adaptive systemic immune cell populations in OMS and age- and sex-matched controls. Results: Our study revealed that OMS is associated with increased levels of immune regulatory cells, namely T regulatory cells, B regulatory cells, and T follicular regulatory cells. In addition, the expression of immune activation markers HLA-DR and CD86 was decreased in OMS, while the expression of immune exhaustion markers TIM-3, PD-1, PD-L1, and VISTA was increased. Members of the T follicular helper (Tfh) cell family as well as classical and typical memory B cells were significantly increased in OMS individuals. We also found a strong correlation between memory B cells and Tfh cells. Discussion: We conclude that OMS skews the host immune system towards the immunomodulatory arm and that the Tfh memory B cell axis is evident in OMS. Therefore, immune-directed therapies may be a promising alternative for eradication and recurrence of infection in OMS, particularly in individuals and areas where antibiotic resistance is a major concern.

Extracellular micronutrient levels and pro-/antioxidant status in trauma patients with wound healing disorders: results of a cross-sectional study.

BACKGROUND: Disorders in wound healing (DWH) are common in trauma patients, the reasons being not completely understood. Inadequate nutritional status may favor DWH, partly by means of oxidative stress. Reliable data, however, are lacking. This study should investigate the status of extracellular micronutrients in patients with DWH within routine setting. METHODS: Within a cross-sectional study, the plasma/serum status of several micronutrients (retinol, ascorbic acid, 25-hydroxycholecalciferol, α-tocopherol, ß-carotene, selenium, and zinc) were determined in 44 trauma patients with DWH in addition to selected proteins (albumin, prealbumin, and C-reactive protein; CRP) and markers of pro-/antioxidant balance (antioxidant capacity, peroxides, and malondialdehyde). Values were compared to reference values to calculate the prevalence for biochemical deficiency. Correlations between CRP, albumin and prealbumin, and selected micronutrients were analyzed by Pearson's test. Statistical significance was set at P < 0.05. RESULTS: Mean concentrations of ascorbic acid (23.1 ± 15.9 µmol/L), 25-hydroxycholecalciferol (46.2±30.6 nmol/L), ß-carotene (0.6 ± 0.4 µmol/L), selenium (0.79±0.19 µmol/L), and prealbumin (24.8 ± 8.2 mg/dL) were relatively low. Most patients showed levels of ascorbic acid (<28 µmol/L; 64%), 25-hydroxycholecalciferol (<50 µmol/L; 59%), selenium (≤ 94 µmol/L; 71%) and ß-carotene (<0.9 µmol/L; 86%) below the reference range. Albumin and prealbumin were in the lower normal range and CRP was mostly above the reference range. Plasma antioxidant capacity was decreased, whereas peroxides and malondialdehyde were increased compared to normal values. Inverse correlations were found between CRP and albumin (P < 0.05) and between CRP and prealbumin (P < 0.01). Retinol (P < 0.001), ascorbic acid (P < 0.01), zinc (P < 0.001), and selenium (P < 0.001) were negatively correlated with CRP. CONCLUSIONS: Trauma patients with DWH frequently suffer from protein malnutrition and reduced plasma concentrations of several micronutrients probably due to inflammation, increased requirement, and oxidative burden. Thus, adequate nutritional measures are strongly recommended to trauma patients.

The Influence of Sagittal Pin Angulation on the Stiffness and Pull-Out Strength of a Monolateral Fixator Construct.

Monolateral pin-to-bar-clamp fixators are commonly used to stabilize acute extremity injuries. Certain rules regarding frame geometry have been established that affect construct stability. The influence of sagittal pin angulation on construct stiffness and strength has not been investigated. The purpose of this biomechanical study was to demonstrate the effect of a pin angulation in the monolateral fixator using a composite cylinder model. Three groups of composite cylinder models with a fracture gap were loaded with different mounting variants of monolateral pin-to-bar-clamp fixators. In the first group, the pins were set parallel to each other and perpendicular to the specimen. In the second group, both pins were set convergent each in an angle of 15° to the specimen. In the third group, the pins were set each 15° divergent. The strength of the constructions was tested using a mechanical testing machine. This was followed by a cyclic loading test to produce pin loosening. A pull-out test was then performed to evaluate the strength of each construct at the pin-bone interface. Initial stiffness analyses showed that the converging configuration was the stiffest, while the diverging configuration was the least stiff. The parallel mounting showed an intermediate stiffness. There was a significantly higher resistance to pull-out force in the diverging pin configuration compared to the converging pin configuration. There was no significant difference in the pull-out strength of the parallel pins compared to the angled pin pairs. Convergent mounting of pin pairs increases the stiffness of a monolateral fixator, whereas a divergent mounting weakens it. Regarding the strength of the pin-bone interface, the divergent pin configuration appears to provide greater resistance to pull-out force than the convergent one. The results of this pilot study should be important for the doctrine of fixator mounting as well as for fixator component design.

Practicability of a Virtual Consultation to Evaluate the Shoulder Joint. / Durchführbarkeit einer digitalen Sprechstunde zur Untersuchung des Schultergelenkes.

OBJECTIVE: In the course of the corona pandemic, resource conservation and the protection of further infections have made it necessary to break new ground in the organisation of orthopaedic and trauma surgery consultations. One solution is consistent digitisation and the offer of video consultation hours. In this study, non-contact examination of patients with shoulder disorders is described and critically examined. METHODS: Thirty patients who presented with pathologies of the shoulder joint in a university outpatient clinic were subjected to a physical examination in a conventional and contactless manner. The data obtained on mobility, function and provocation test of both examinations were compared to draw conclusions about the virtual feasibility. RESULTS: 46% of the patients suffered from a traumatic shoulder lesion, and 54% showed degenerative lesions. The assessment of mobility showed a high correlation of 70 - 90% between the two examinations. Common tests to evaluate the supraspinatus, infraspinatus, subscapularis and the long head of the biceps could be adequately performed in a contactless version by more than three quarters of the patients, but with low-to-moderate performance values. CONCLUSION: Contact-less examination is particularly disadvantageous when evaluating stability criteria. For the medical history and functional test, there were no significant differences between the classic consultation and contactless consultation. Although virtual consultation is a widespread and valuable addition in pandemic times, it cannot replace a safe assessment and indication by personal examination.

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.

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.