Sonography-Based Determination of Hip Joint Anterior Alpha-Angle: A Reliable and Reproducible Method.

PURPOSE: Femoroacetabular impingement (FAI) is a known risk factor for hip osteoarthritis. The gold standard for diagnostics is X-ray and MRI. The accuracy of hip joint alpha angle measurements obtained using sonography is equal to measurements in MRI for patients with cam impingement of the hip joint. MATERIALS AND METHODS: Patients with hip pain and MRI and sonography were evaluated between January 2015 and December 2019 in a single center. Musculoskeletal sonography was performed according to the DEGUM guidelines by ultrasound-certified specialists. Measurements were repeated three times by two independent investigators. RESULTS: 285 patients were screened, and 110 patients (49 females, 61 males) met the inclusion criteria. The mean age at time of investigation of 54 left and 56 right hip joints was 54.2 years. 1320 measurements were performed. The mean alpha angle was 50.7° in MRI and 50.4° in sonography with a mean difference of 0.28° (p>0.05). CONCLUSION: Determining hip alpha angle using sonography is a safe and reproducible method. No statistically significant differences between results in MRI and sonography could be seen. Although this is a retrospective, single-center study including only Caucasian mid-Europeans and with the known limitations of ultrasound imaging, it nevertheless shows that sonography can be used as a simple, cheap, and fast technique to assess the hip alpha angle without losing diagnostic quality.

Traumatic pancreas, kidney, liver, spleen, gastric and diaphragma rupture with enterothorax after blunt trauma caused by falling in an adolescent: a case report.

Injury of almost all intra-abdominal organs in blunt trauma without bone and brain injury is very rare. This is the case report of a 16-year-old adolescent with severe abdominal trauma who was hit on his abdomen by a falling maytree. After admission to a Level I trauma center, emergency room treatment according to ATLS and after this emergency surgery was performed. Blood coagulation diagnostics was done using thrombo-elastography and factors and blood products have been applied according to its results keeping guidelines in mind. Damage-control surgery stopped the bleeding, and he was admitted to ICU. After second and third look surgery, the abdomen was closed. Structured diagnostics and treatment were crucial in this case. The education of trauma surgeons should include general surgery skills. These skills and knowledge of blood coagulation diagnostics and therapy saved the patient's life in this case.

Implementation of Copy Number Variations-Based Diagnostics in Morphologically Challenging EWSR1/FUS::NFATC2 Neoplasms of the Bone and Soft Tissue.

In the last decade, new tumor entities have been described, including EWSR1/FUS::NFATC2-rearranged neoplasms of different biologic behavior. To gain further insights into the behavior of these tumors, we analyzed a spectrum of EWSR1/FUS::NFATC2-rearranged neoplasms and discuss their key diagnostic and molecular features in relation to their prognosis. We report five patients with EWSR1/FUS::NFATC2-rearranged neoplasms, including one simple bone cyst (SBC), two complex cystic bone lesions lacking morphological characteristics of SBC, and two sarcomas. In three cases, fluorescence in situ hybridization (FISH) and in all cases copy number variation (CNV) profiling and fusion analyses were performed. All patients were male, three cystic lesions occurred in children (aged 10, 14, and 17 years), and two sarcomas in adults (69 and 39 years). Fusion analysis revealed two FUS::NFATC2 rearrangements in two cystic lesions and three EWSR1::NFATC2 rearrangements in one complex cystic lesion and two sarcomas. EWSR1 FISH revealed tumor cells with break-apart signal without amplification in one complex cystic lesion and EWSR1 amplification in both sarcomas was documented. CNV analysis showed simple karyotypes in all cystic lesions, while more complex karyotypes were found in NFATC2-rearranged sarcomas. Our study supports and expands previously reported molecular findings of EWSR1/FUS::NFATC2-rearranged neoplasms. The study highlights the importance of combining radiology and morphologic features with molecular aberrations. The use of additional molecular methods, such as CNV and FISH in the routine diagnostic workup, can be crucial in providing a correct diagnosis and avoiding overtreatment.

Pelvic antropometric measurement in 3D CT for placement of two unilateral iliosacral S1 - 7.3 mm screws.

PURPOSE: Stability of the dorsal pelvic ring is important for patient mobilisation and can be restored using several surgical procedures after fracture. Placement of percutaneous iliosacral screws is a reliable and minimal-invasive technique to achieve stabilisation of the dorsal pelvic ring by placement of two screws in the first sacral vertebra. Aim of this study was to evaluate 3D CT scans regarding the anatomical possibility to place two 7.3 mm iliosacral screws for fixation of the dorsal pelvic ring. METHODS: 3D CT datasets of 500 consecutive trauma patients with 1000 hemipelves of a mid-european level I trauma centre with or without pelvic injury were evaluated and measured bilaterally in this retrospective study. RESULTS: One thousand hemipelvic datasets of 500 patients (157 females, 343 males) with a mean age of 49.7 years (18 to 95) were included in this study. Only 16 hemipelves (1.6%, 11 in females, 5 in males) in 14 patients (2.8%, 9 females = 5.73%, 5 males = 1.5%) showed too narrow corridors so that 7.3 mm screw placement would not be possible (p = 0.001). In women, too narrow corridors occurred 3.9 times as often as in men. Only two females showed this bilaterally. CONCLUSION: The evaluation of 3D CT scans of the pelvis showed the importance of planning iliosacral screw placement, especially if two 7.3 mm screws are intended to be placed in the first sacral vertebra.

Low complication rate and better results for intramedullary nail - arthrodesis for infected knee joints compared to external fixator-a series of one hundred fifty two patients.

PURPOSE: Arthrodesis of the knee joint is still a salvage procedure after recurrent prosthetic joint infections (PJI) of total knee arthroplasties (TKA) with substantial bone loss and seems to be a good solution to avoid amputation. Until now, intramedullary arthrodesis has increasingly been performed; no study has yet been published to compare these techniques after septic removal of TKA in terms of functional assessment and quality of daily life. METHODS: In a single-centre retrospective setting, clinical and radiographic evaluation of consecutive patients after knee arthrodesis using intramedullary and external fixation for infected knee joints was performed. All patients were evaluated clinically, with x-ray and questionnaire including analysis regarding any complications at latest follow-up of a minimum 12 months postoperatively. RESULTS: We included 152 patients (75 females, 77 males) in this study. The mean age of the patients at surgery was 63.6 years (range 12 to 90 years). The minimum follow-up was 12 months (mean 3.1 years, range 12 to 49 months). Arthrodesis with external fixator (83 patients, 52.2%) showed less blood loss and less peri-operative complications (1.6%) but a high rate of post-operative, pin-track infections (35.5%); loose pins (12.7%); and pin fractures (4.8%), and therefore risk factors for instability and nonunion (30.9%). Revision rate was 22.6% for arthrodesis with external fixator, and the primary union rate was 65.6%. Intramedullary arthrodesis (69 patients, 43.4%) showed a similar re-infection rate to external fixation (16.1% and 15.9%, respectively) but a significantly lower revision rate (5.4%, p < 0.001). Eighty percent of patients with intramedullary arthrodesis showed very good patient-related outcomes regarding pain, function and daily life activities in the questionnaire. CONCLUSION: Despite similar results regarding patient satisfaction and everyday competences in questionnaires, intramedullary arthrodesis of the knee is superior to the external fixator, as it results in fewer complications, lower revision rate, and union rates/loosening.

[Safety culture in orthopedics and trauma surgery : A qualitative study of the physicians' perspective]. / Sicherheitskultur in der Orthopädie und Unfallchirurgie : Eine qualitative Untersuchung der ärztlichen Perspektive.

BACKGROUND: Hospitals in Germany operate risk management, which can support the prevention of adverse events and to systematically process them. Safety culture is one aspect of this. In German-speaking countries, however, surveying the safety culture is still limited and almost exclusively carried out using quantitative instruments. In Germany, the discipline of orthopedics and trauma surgery is characterized by a high number of confirmed treatment errors and lack of risk clarification, Therefore, this study investigated the safety culture in this discipline. OBJECTIVE: (I) How do orthopedic and trauma surgeons perceive the handling of adverse events in trauma centers and (II) what are relevant components of the safety culture from a medical perspective? MATERIAL AND METHODS: A qualitative study using 14 semi-structured one-to-one interviews was carried out with physicians in orthopedics and trauma surgery. The interviews were audiotaped, transcribed, and analyzed using the thematic analysis by Braun and Clarke and the Yorkshire contribution factors framework. The MAXQDA software was used to organize data. RESULTS: A strong influence of senior staff on the handling of adverse events in the medical team could be determined. It was expected that senior staff members have a strong model role function. They were expected to exemplify a high safety culture, because their behavior influences the team's behavior in patient safety-related situations. CONCLUSION: The involvement of senior staff in the development of interventions to improve the safety culture in orthopedics and trauma surgery should be considered due to the importance of hierarchical structures.

[Bone segment transport for defects of the tibia : Technique with unilateral fixator and plate]. / Knochensegmenttransport bei Defekten der Tibia : Technik mit unilateralem Fixateur und Platte.

BACKGROUND: Various options are available for treatment of bone defects of the tibia. Bone segment transport is carried out relatively rarely because the surgical technique is not easy and there is a learning curve. OBJECTIVE: This article gives an overview of the history, indications, planning and surgical technique of bone segment transport of the tibia. MATERIAL AND METHODS: A technique using unilateral external fixation in combination with a locking plate osteosynthesis is described. RESULTS: The technique and results are explained exemplified by a case report and in particular pitfalls during surgery and the aftercare concept are outlined. CONCLUSION: Bone segment transport of the tibia using an external fixator and a locking plate is a reliable and practicable technique for treatment of bone defects of the tibia.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]. / "Terror awareness" bei Humanmedizinstudierenden im 5. Jahr des Mannheimer Reformierten Curriculums Medizin plus.

BACKGROUND: The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar. METHODS: All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students. RESULTS: A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism. CONCLUSION: With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.

Donor site complications following anterior iliac crest bone graft for treatment of distal radius fractures.

INTRODUCTION: In distal radius fractures with metaphyseal comminution, bone grafting or the use of a bone substitute may be necessary. Harvesting autologous iliac crest bone graft for other orthopedic procedures has complications. The aim of this study was to evaluate the complication rate after harvesting a small amount of bone as used for the treatment of radius fractures. PATIENTS AND METHODS: Patients treated in a single level I trauma center with surgical treatment for distal radius fracture with iliac crest bone graft between January 2008 and December 2012 were included in this retrospective study. Patients' records were evaluated and clinical evaluation was performed at follow-up. RESULTS: 42 patients (20 females, 22 males, mean age 56.3 ± 15.9 years) were included in this study. Follow-up was mean 6.3 ± 1.2 years. Only minor complications such as hematoma could be identified; in one patient, revision surgery for bleeding was performed. No nerve injuries, long-term pain, fractures, infections or wound healing disturbances could be seen. The use of a drain of hemostyptics, the type of wound closure or pattern of harvested bone did not influence complication rate. CONCLUSION: This study shows that harvesting a small amount of iliac crest bone graft for the treatment of distal radius fractures is a safe procedure with a very low complication rate.

[Isolated fracture of the lesser trochanter-What age-related differences are important?] / Die isolierte Trochanter-minor-Fraktur ­ Worauf muss man in Abhängigkeit vom Patientenalter achten?

Isolated fractures of the lesser trochanter are very rare injuries. This case report describes the age-related differences based on two cases. A 13-year-old girl suffered an avulsion fracture of the lesser trochanter while sprinting. The patient received conservative treatment with pain-adapted partial weight bearing as tolerated using crutches with the goal of full weight bearing after 6 weeks. After 3 months she could return to the preinjury functional level without impairments. A 55-year-old woman also suffered an isolated fracture of the lesser trochanter, which was a pathological fracture due to a breast cancer metastasis. The cause of an isolated fracture of the lesser trochanter in adults is assumed to be the sign of an underlying malignant disease, until this has been disproven.

Minimally invasive reduction and percutaneous posterior fixation of one-level traumatic thoraco-lumbar and lumbar spine fractures.

INTRODUCTION: Although open procedures are the gold standard, the alternative approach of minimal invasive reduction using percutaneous screws for thoracic and lumbar spine fractures is under discussion. Aim of this study was to investigate the results of reduction and the accuracy of screw placement in minimally invasive percutaneous posterior instrumentation for these fractures. MATERIALS AND METHODS: One hundred and twenty-seven patients with thoraco-lumbar and lumbar burst fractures and minimal invasive dorsal instrumentation were analyzed retrospectively in terms of the accuracy of pedicle screw placement and results of fracture reduction. RESULTS: In total, 542 screws were placed. Thirty-four (6.3%) screws of 22 patients (17.3%) were misplaced, but misplacement was minimal, replacement of any screw position due to instability was not necessary, and no new neurological deficit occurred. In thoraco-lumbar fractures (82/64.5%), reduction succeeded from 2.5 ± 6° kyphosis to 5.6 ± 5.7° lordosis (p < 0.001) and in lumbar spine fractures from 6.9° ± 10.3° lordosis to 14.5° ± 8.8° lordosis (p < 0.001). CONCLUSION: Minimal invasive percutaneous dorsal instrumentation of burst fractures of the thoraco-lumbar and lumbar spine provides adequate reduction and reliable regular screw placement. LEVEL OF EVIDENCE: Level IV (retrospective series).

Antibacterial Bioactive Glass, S53P4, for Chronic Bone Infections - A Multinational Study.

Osteomyelitis is an infectious process in bone that occasionally leads to bone destruction. Traditionally, the surgical treatment procedure is performed in combination with systemic and local antibiotics as a two-stage procedure that uses autograft or allograft bone for filling of the cavitary defect. Bioactive glass (BAG-S53P4) is a bone substitute with proven antibacterial and bone bonding properties.One hundred and sixteen patients who had verified chronic osteomyelitis was treated using BAG-S53P4 as part of the treatment. Most of the patients had previously undergone numerous procedures, sometimes for decades. A register of patient data obtained from 11 centers from Finland, Italy, the Netherlands, Germany, Azerbaijan and Poland was set-up and continuously maintained at Helsinki University Central Hospital.The location of the osteomyelitis was mainly in the tibia followed by the femur and then the calcaneus. The median age of the patients was 48 years (15-87). The patients were either treated according to a one-stage procedure without local antibiotics (85 %) or by a two-stage procedure using antibiotic beads in the first procedure (15 %). The minimum follow-up was 1 year (12-95 months, median 31).The cure rate was 104/116, the total success rate 90 % and most of the patients showed a rapid recovery.The study shows that (BAG-S53P4) can be used in a one-stage procedure in treatment of osteomyelitis with excellent results.

Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: ideal diagnostic test still not found.

PURPOSE: Diagnosing periprosthetic infection remains a challenge. Multiplex-PCR and biomarkers such as alpha-defensin are potentially useful and fast methods for detecting periprosthetic infection. This study compared these new methods with clinical assessment, conventional microbiological methods and histo-pathological examination. METHODS: Twenty-eight consecutive patients with 30 joints and a mean age of 67.7 years (range 39 to 88) with removal of total hip arthroplasty (THA) or total knee replacement (TKR) were included in this study. Patients were classified according to the modified Musculoskeletal Infection Society score (MSIS) for infected joints. Punction fluid and tissue specimens were taken for conventional microbiological examination, alphadefensin test was performed, a synovial membrane specimen was used for multiplex-PCR and histopathological examination was carried out. RESULTS: The alpha-defensin test and multiplex-PCR showed a sensitivity of 76.9 vs. 30.8% and a specificity of 82.4 vs. 100%, respectively. We found a significant difference between the positive and negative results (p = 0.0023). The conventional microbiological methods were not significantly different from the alpha-defensin test (p = 0.244) with a sensitivity of 84.6% and a specificity of 100% but did differ significantly from the multiplex PCR (p = 0.0030). There was a significant difference between modified MSIS classification and multiplex PCR (p = 0.0007). CONCLUSIONS: Neither alpha-defensin test nor multiplex-PCR could detect periprosthetic infection immediately and reliably. Multiplex-PCR was suitable for detecting the non-infected but not the truly infected. Alpha-defensin test was helpful but showed no satisfactory results. Conventional microbiological methods remain the most reliable for periprosthetic infection diagnosis.

Good isometric and isokinetic power restoration after distal biceps tendon repair with anchors.

INTRODUCTION: Distal biceps brachii tendon rupture can lead to 30-40% power loss of elbow flexion and up to 50% of forearm supination. Re-fixation of the distal biceps brachii tendon is recommended to warrant an adequate quality of the patient's life. This study reports the isometric and isokinetic results after anchor re-fixation 2.5 years after surgery. PATIENTS AND METHODS: Between 2007 and 2010, 69 patients with distal biceps brachii tendon tear underwent a suture anchor reattachment. During the follow-up examination, a questionnaire and DASH score were filled in, the circumferences of the arm were measured, range of motion was collected, and different trials were conducted at the BTE Primus RS™ (Baltimore Therapeutic Equipment) on both arms. RESULTS: 49 patients (71%) were reinvestigated with a follow-up of 32 months (11-58 months). A significant difference was found in the ability of elbow flexion between the affected arm and the opposite side as well as in pronation and supination. In elbow flexion and extension as well as in pronation and supination of the forearm, the strength was significantly diminished. CONCLUSIONS: 32 months after surgical re-fixation of the distal biceps brachii tendon rupture, strength in all exercises is marginally reduced in comparison to the opposite arm. Re-fixation of the distal biceps brachii tendon is an adequate method to return the range of motion and the strength in the elbow joint to an almost normal level and that gives rise to a high level of patient satisfaction. LEVEL OF EVIDENCE: Level III, case-control study.

Flaps for closure of soft tissue defects in infected revision knee arthroplasty.

PURPOSE: Total knee arthroplasty revision has wound healing deficits of up to 20 %. Defects in the knee region of multimorbid patients are hard to treat as complete explantation and revision arthroplasty is often too burdensome for them. In this study, we present our results with flaps for the treatment of defects after knee replacement, arthrodesis or osteosynthesis. METHODS: Twenty-five patients (26 knees) with defects in the knee region were treated with flaps. Mean follow-up was 37 months (13-61) and the patients had a mean age of 72 years (49-85). A total of 39 flaps were performed (27 muscle flaps, seven fascio-cutaneous flaps and five free flaps). RESULTS: Patients with more than three comorbidities showed higher risk of complications after surgery. Fifteen patients showed no infection at last follow up. Five patients received an arthrodesis of the knee, two showed persistent infection of the implant with fistula, and three were amputated above the knee. CONCLUSIONS: Amputation could be avoided in 22 cases (85 %). The gastrocnemius muscle flap showed good results in the treatment of defects after arthroplasty or arthrodesis of the knee in multimorbid patients. This procedure can be used if further revision surgery is not indicated.

Establishment of a new methicillin resistant Staphylococcus aureus animal model of osteomyelitis.

PURPOSE: The increase in methicillin-resistant Staphylococcus aureus (MRSA) infections is currently a major health care problem. Vancomycin is still often the first-line anti-microbiological agent for treating such infections; however, a recent decline in efficacy of vancomycin in MRSA infections has raised concerns and accelerated the search for new antibiotics. The aim of this study was to establish a MRSA peri-implant osteomyelitis animal model for future testing of new anti-microbiological agents under typical MRSA infection conditions. METHODS: Eighteen randomised NZW-rabbits underwent a standardised surgical procedure with the insertion of a femoral bone implant. Animals were then divided into group 1 (MRSA inoculation, no antibiotics; M/N), group 2 (MRSA inoculation, Vancomyin; M/V), and group 3 (no MRSA inoculation, no antibiotics; N/N). The primary study outcome parameters were animal leucocyte count, animal weight, and animal body temperature at one, seven, and 42 days after surgery. Additionally, a histo-morphometrical score was established and adjusted to a modified histological Smeltzer score. RESULTS: Macroscopic and histo-morphometrical findings showed a peri-implant osteomyelitis in group 1 with both increased acute and chronic infection parameters in M/N, as compared to M/V and N/N, indicating that vancomycin treatment prevented typical morphological changes of MRSA peri-implant osteomyelitis. Similarly, there was a reduction in animal weight and increase in leucocyte count and body temperature in group 1 (each p < 0.005). Vancomycin treatment again resulted in significantly reduced leucocyte count and body temperature, and increased animal body weight. CONCLUSIONS: Here we have established a peri-implant MRSA osteomyelitis model that successfully combined clinical and laboratory outcome parameters of infection with histo-morphometrical results; this model appears to be valuable for future experimental use and therapeutic monitoring of new anti-microbiological MRSA drugs.