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Interpretation of the evidence from randomised controlled trials (RCTs) of remdesivir in patients treated in hospital for COVID-19 is conflicting. We aimed to assess the benefits and harms of remdesivir compared with placebo or usual care in these patients, and whether treatment effects differed between prespecified patient subgroups.

ObjectiveTo systematically assess the robustness of reported postacute SARS-CoV-2 infection health outcomes in children.MethodsA search on PubMed and Web of Science was conducted to identify studies published up to 22 January 2022 that reported on postacute SARS-CoV-2 infection health outcomes in children (<18 years) with follow-up of ≥2 months since detection of infection or ≥1 month since recovery from acute illness. We assessed the consideration of confounding bias and causality, as well as the risk of bias.Results21 studies including 81 896 children reported up to 97 symptoms with follow-up periods of 2.0–11.5 months. Fifteen studies had no control group. The reported proportion of children with post-COVID syndrome was between 0% and 66.5% in children with SARS-CoV-2 infection (n=16 986) and between 2.0% and 53.3% in children without SARS-CoV-2 infection (n=64 910). Only two studies made a clear causal interpretation of an association between SARS-CoV-2 infection and the main outcome of ‘post-COVID syndrome’ and provided recommendations regarding prevention measures. The robustness of all 21 studies was seriously limited due to an overall critical risk of bias.ConclusionsThe robustness of reported postacute SARS-CoV-2 infection health outcomes in children is seriously limited, at least in all the published articles we could identify. None of the studies provided evidence with reasonable certainty on whether SARS-CoV-2 infection has an impact on postacute health outcomes, let alone to what extent. Children and their families urgently need much more reliable and methodologically robust evidence to address their concerns and improve care.

BackgroundTranscatheter aortic valve implantation (TAVI), widely used to treat high-risk patients with severe symptomatic aortic stenosis, has recently been extended to younger patients at lower operative risk in whom long-term durability of TAVI devices is an important concern. Therefore, we conducted a systematic review and meta-analysis of observational studies addressing the frequency of structural valve deterioration (SVD) after TAVI.MethodsWe searched Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to September 2016. We included observational studies following patients with TAVI for at least 2 years. Independently and in duplicate, we evaluated study eligibility, extracted data, and assessed risk of bias for SVD post-TAVI. Our review used the GRADE system to assess quality of evidence. We pooled incidence rates using a random effects model.ResultsThirteen studies including 8914 patients, with a median follow-up between 1.6 and 5 years, reported an incidence of SVD post-TAVI between 0 to 1.34 per 100 patient years. The pooled incidence of SVD was 28.08 per 10 000 patients/year (95% CI 2.46 to 73.44 per 100 patient years). Of those who developed SVD, 12% underwent valve re-intervention. Confidence in the evidence was moderate due to inconsistency among studies.ConclusionStructural valve deterioration is probably an infrequent event within the first 5 years after TAVI. Ascertaining the impact of SVD and the need for valve-related re-interventions to inform recommendations for patients with a longer life-expectancy will require studies including a large number of patients with longer follow-up (>10 years).

Supplemental Digital Content is Available in the Text.We evaluated early discontinuation and nonpublication of surgical trials approved in Canada, Germany, and Switzerland. Forty-three percent were stopped early, 18% for slow recruitment. Trial discontinuation was strongly associated with nonpublication. These findings are relevant when interpreting surgical literature, and surgical trialists should consider feasibility studies before starting full-scale trials.

The prognosis of Fabry disease has changed since enzyme-replacement treatment was introduced. Therefore, early diagnosis is instrumental. We describe a family presenting with chronic renal failure and proteinuria in which classic skin and neurological features were absent and the diagnosis of Fabry disease was difficult and not established until a second family member developed renal abnormalities. A 35-year-old man was admitted because he was overweight and had hypertension, with a serum creatinine level of 1.3 mg/dL (115 µmol/L) and protein excretion of 870 mg/d. Because 1 brother, who died years ago at the age of 32 years of acute myeloid leukemia, also had chronic renal failure and proteinuria, the diagnosis of Fabry disease was entertained. In the index patient, acroparesthesia, hypohidrosis, pain, angiokeratomas of the skin, and cornea verticillata suggesting Fabry disease were absent. Conversely, renal biopsy showed typical globotriaosylceramide deposits, and leukocyte a-galactosidase (a-GLA) A activity was decreased. Analysis of the a-GLA gene showed the mutation E66K. The mutation also was found in another asymptomatic 30-year-old brother who also had chronic renal failure and proteinuria, but normal extrarenal findings. In the brother who died, Fabry disease, missed at autopsy because of cancer-related findings, could be confirmed after repeated review of histological slides. Mutation carriers also included the mother, a sister (both without abnormalities), and a nephew (with episodic pains in his feet). We conclude that familial chronic renal failure combined with proteinuria is suggestive of Fabry disease, and such specific mutations as E66K predominantly may affect the kidneys.

To compare the vertical subsidence in a bicondylar tibial plateau fracture model stabilized either by a unilateral locked screw plate (LSP) or by double plating.

Die Technik der operativen Stabilisierung am distalen Femur hat sich in den letzten Jahren gewandelt. Durch diesen Wandel hat die Zahl der Frakturheilungsstörungen und der zur Heilung notwendigen Knochentransplantationen drastisch abgenommen. Nachdem die Entwicklung minimal invasiver Operationstechniken mit gedeckter Plattenplatzierung die anatomische Reposition im Schaftbereich abgelöst hat und die Rekonstruktion des Gelenkbereiches über eine Arthrotomie deutlich vereinfacht wurde, verblieben als Probleme die Operationstechnik und das Implantat. Hier haben sich in den letzten Jahren neue Möglichkeiten eröffnet.Mit dem Less Invasive Stabilization System (LISS) ist die perkutane Plattenosteosynthese in der Operationstechnik wesentlich vereinfacht worden. Hierbei werden monokortikale, selbstschneidende Schrauben mit Hilfe eines Zielbügels über Stichinzisionen eingebracht. Die winkelstabile Verankerung dieser Schrauben erfolgt über ein Gewinde in der Platte.Der distale Femurnagel erlaubt bei extraartikulären Frakturen und gering dislozierten intraartikulären Frakturen eine intramedulläre Stabilisierung.Der schlechte Halt der Verriegelungsbolzen im Kondylenmassiv ist durch die winkelstabile Spiralklingenverriegelung verbessert.Auch mit den erweiterten Möglichkeiten der Operationstechnik und der Implantate verbleibt besonders bei den intraartikulären Trümmerfrakturen bei einem hohen Anteil der Patienten ein funktionelles Defizit.Bei den älteren Patienten mit hochgradiger Osteoporose stellt die Verbindung von Implantat und Knochen ein Problem dar.Das LISS ist hier eine gute Möglichkeit, einer Verbundosteosynthese auszuweichen.:

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection.At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus.

Zusammenfassung In einer prospektiven, nicht randomisierten Studie wurden zwischen Februar 1997 und September 1998 29 frische distale Femurfrakturen mit dem LIS-System versorgt. In die Nachuntersuchung wurden 29 Frakturen eingeschlossen. Die durchschnittliche Nachuntersuchungszeit betrug 6 Monate (1,5-16 Monate). Postoperativ kam es in 1 Fall zu heterotopen Ossifikationen mit Einschränkung der Kniegelenkbeweglichkeit, in 1 Fall zu einer tiefen Beinvenenthrombose mit Lungenembolie und in 3 Fällen zu tiefen Infekten, davon 2-mal als Folge offener Frakturen. In 2 Fällen kam es zu Schraubenausrissen. Die Zeit bis zur knöchernen Durchbauung betrug durchschnittlich 3,1 Monate (2,5-4,5 Monate), die Zeit bis zur Vollbelastung 3 Monate (1,5-5 Monate). Die Kniegelenkbeweglichkeit war in 15 Fällen - mit einer Nachuntersuchungszeit >3 Monate - 121° (mindestens 20°, maximal 140°). Der Lysholm-Score konnte für 9 Patienten ermittelt werden und ergab im Durchschnitt 67,5 Punkte (48-92 Punkte), der Neer-Score 69,8 Punkte (49-88 Punkte). Die Anwendung des LISS ermöglicht eine komplikationslose Ausheilung ohne Notwendigkeit der Knochentransplantation. Abstract In a prospective nonrandomized study conducted between February 1997 and September 1998, 29 displaced fractures of the distal femur were stabilized with an angular stable interlocking plate system (Less Invasive Stabilization System, LISS) designed for minimally invasive placement. The average age of these patients was 54 (range 20-92) years, and they were followed up for a mean of ¶6 months (1.5-16 months). Postoperative complications included heterotopic ossification (HO) limiting knee motion (1 case), deep thrombosis with pulmonary embolism (1) and deep infection (3 cases). Implant- and technique-related complications included proximal screw pull-out in the first 2 months after injury in 2 cases, which was treated by proximal screw exchange. In a 37-year-old woman with an increased antetorsion angle of 32° (internal rotation deformity) postoperatively a rotational correction was performed. Time to fracture healing averaged 3.1 (range 2.5-4.5) months in 23 cases. Time to full weight-bearing averaged 3 (range 1.5-5) months. The Lysholm score was available for 9 patients, and the mean calculated for these patients was 67.5 points (range 48-92), while the Neer (28) score for 9 patients with follow-up of more than 1 year averaged 69.8 (range 49-88) points (1 failure, 3 unsatisfactory, 4 satisfactory, 1 excellent result). The use of the LISS applied for distal femoral fractures with a correct technique led to uneventful bony healing with no necessity for the additional morbidity of a bone graft.

Zusammenfassung In einer prospektiven, nicht randomisierten Studie wurden zwischen Februar 1997 und September 1998 29 frische distale Femurfrakturen mit dem LIS-System versorgt. In die Nachuntersuchung wurden 29 Frakturen eingeschlossen. Die durchschnittliche Nachuntersuchungszeit betrug 6 Monate (1,5-16 Monate). Postoperativ kam es in 1 Fall zu heterotopen Ossifikationen mit Einschränkung der Kniegelenkbeweglichkeit, in 1 Fall zu einer tiefen Beinvenenthrombose mit Lungenembolie und in 3 Fällen zu tiefen Infekten, davon 2-mal als Folge offener Frakturen. In 2 Fällen kam es zu Schraubenausrissen. Die Zeit bis zur knöchernen Durchbauung betrug durchschnittlich 3,1 Monate (2,5-4,5 Monate), die Zeit bis zur Vollbelastung 3 Monate (1,5-5 Monate). Die Kniegelenkbeweglichkeit war in 15 Fällen - mit einer Nachuntersuchungszeit >3 Monate - 121° (mindestens 20°, maximal 140°). Der Lysholm-Score konnte für 9 Patienten ermittelt werden und ergab im Durchschnitt 67,5 Punkte (48-92 Punkte), der Neer-Score 69,8 Punkte (49-88 Punkte). Die Anwendung des LISS ermöglicht eine komplikationslose Ausheilung ohne Notwendigkeit der Knochentransplantation. In a prospective nonrandomized study conducted between February 1997 and September 1998, 29 displaced fractures of the distal femur were stabilized with an angular stable interlocking plate system (Less Invasive Stabilization System, LISS) designed for minimally invasive placement. The average age of these patients was 54 (range 20-92) years, and they were followed up for a mean of ¶6 months (1.5-16 months). Postoperative complications included heterotopic ossification (HO) limiting knee motion (1 case), deep thrombosis with pulmonary embolism (1) and deep infection (3 cases). Implant- and technique-related complications included proximal screw pull-out in the first 2 months after injury in 2 cases, which was treated by proximal screw exchange. In a 37-year-old woman with an increased antetorsion angle of 32° (internal rotation deformity) postoperatively a rotational correction was performed. Time to fracture healing averaged 3.1 (range 2.5-4.5) months in 23 cases. Time to full weight-bearing averaged 3 (range 1.5-5) months. The Lysholm score was available for 9 patients, and the mean calculated for these patients was 67.5 points (range 48-92), while the Neer (28) score for 9 patients with follow-up of more than 1 year averaged 69.8 (range 49-88) points (1 failure, 3 unsatisfactory, 4 satisfactory, 1 excellent result). The use of the LISS applied for distal femoral fractures with a correct technique led to uneventful bony healing with no necessity for the additional morbidity of a bone graft.

A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails.

In recent years, the technique of surgical stabilization in the distal femur has changed. This change decreased the number of non unions and the need for bone grafting. Minimally invasive surgical techniques with a submuscular plate placement have replaced the emphasis on anatomical reduction in the shaft area. Reconstruction of complex articular injuries has been simplified by more direct visualization of the articular surface with the lateral peripatellar approach. Problems remaining are surgical technique and implant considerations. The Less Invasive Stabilization System (LISS) simplifies the surgical technique for percutaneous plate osteosynthesis. An insertion guide is used to insert monocortical, self-tapping screws through a stab incision. A thread in the plate provides the angular stability for the anchoring of these screws. In extra-articular fractures and simple intra-articular fractures, the distal femoral nail permits intramedullary stabilization. A spiral blade improves fixation of the distal femoral condylar block. Despite the enhanced surgical technique and implant possibilities, a great number of patients show a functional deficiency. These are particularly patients with complex intra-articular fractures. The 'fatigue failure' of the osteoporotic implant-bone construct is a problem in elderly patients. The LISS represents a good option to avoid the addition of bone cement to an osteosynthesis.

Abstract Besides the surgical debridement of open fractures, also the prophylactic antibiotic therapy has become a standard procedure. Recently it was hypothesized that this strategy may lead to a selection of more virulent and also antibiotic resistant bacteria which subsequently would result in an increased infection rate over years. In a prospective study bacterial cultures, infection rate and the clinical outcome were examined in 269 open fractures in 230 patients who were admitted to our institution in the years 1993 to 1998. All fractures were treated according to the general principles of open fracture management including antibiotic prophylaxis by the administration of cefazolin 3 time 2g for 3 days starting at the time of surgery. As soon as bacteria were cultured specific antibiotics were applied. According to the Gustilo classification the majority of fractures were scored as Grade O2 followed by O1, O3C, O3A and O3B. In average 78.7% of all open fractures were tested positive for bacterial contamination initially which clearly correlated with the fracture type (24.5% in O1 fractures and 86.8% in O3C fractures ). This bacterial contamination resulted in a mean osteitis rate of 8.2%, again depending on the fracture type. In O1 fractures no case of osteitis was noted, whereas in O3C fractures the osteitis rate was as high as 23.7%. In 21.3% of all open fractures no bacilli were recovered initially but all of these were tested positive in subsequent cultures. But only 3.4% out of these patients sustained a soft tissue infection and no osteitis. The mixed bacterial flora was dominated by Staphylococcus aureus (52.8%), followed by Escherichia coli and Enterobacter (32.5%), Streptococci (26.0%), Pseudomonas (17.1%) and Proteus (1.6%). Other mainly environmental bacteria were present in 30.1%. Despite specific antibiotics the bacterial flora shifted during therapy in the majority of all infections in favor of Staphylococcus aureus, Enterobacter and Pseudomonas. Compared to data in the literature and our institution the infection rate in open fractures based on this study slightly increased especially in O3B and O3C fractures but not yet significantly. There seems to be a shift of cultured bacteria towards hospital acquired pathogens which may explain the increased infection rate, as the percentage of initially bacterial contaminated and not contaminated open fractures stayed almost the same over the years.

Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model.

To evaluate the mechanical effects of medial and lateral blocking screws in supplementing intramedullary nail fixation of high proximal and low distal tibial fractures treated with small-diameter intramedullary nails.

: In einer prospektiven, nicht randomisierten Studie wurden zwischen Februar 1997 und September 1998 29 frische distale Femurfrakturen mit dem winkelstabilen, minimalinvasiv eingebrachten System LISS (less invasive stabilization system) versorgt. Das Prinzip des LISS ist ein perkutan eingebrachtes Implantat, das anatomisch nach dem rechten und linken lateralen Femurkondylus geformt ist. LISS wird mit winkelstabilen, monokortikalen Schrauben verankert. In dieser Studie wurden 33C3- und 33C2-Frakturen mit intraartikulärer Dislokation über einen transartikulären Zugang mit lateraler parapatellarer Arthrotomie versorgt, während bei den 33A-Frakturen, 33C2- und 32B1-Frakturen ohne intraartikuläre Dislokation ein lateraler Zugang gewählt wurde. In die Nachuntersuchung wurden 29 Frakturen eingeschlossen. Das Durchschnittsalter der Patienten war 54 Jahre (20–92 Jahre). Die durchschnittliche Nachuntersuchungszeit betrug 6 Monate (1,5–16 Monate) und der durchschnittliche ISS 14,1 (9–27). Offen waren 8 Frakturen (5mal Typ I, 2mal Typ II, 1mal Typ IIIB nach Gustilo). Die durchschnittliche Operationszeit lag bei 131 min (40–300 min). Die durchschnittliche Bildwandlerzeit betrug 142 s (31–402 s). Postoperativ kam es in 1 Fall zu heterotopen Ossifikationen mit Einschränkung der Kniegelenkbeweglichkeit, in 1 Fall zu einer tiefen Beinvenenthrombose mit Lungenembolie und in 3 Fällen zu tiefen Infekten, davon 2mal als Folge offener Frakturen. In 2 Fällen kam es zu Schraubenausrissen im proximalen Plattenbereich innerhalb der ersten 2 Monate. In 1 Fall war eine Rotationsdifferenz beider Femora von 32° zu sehen. Die Zeit bis zur knöchernen Durchbauung betrug durchschnittlich 3,1 Monate (2,5–4,5 Monate), die Zeit bis zur Vollbelastung 3 Monate (1,5–5 Monate). Die Kniegelenkbeweglichkeit war in 15 Fällen, mit einer Nachuntersuchungszeit von mehr als 3 Monaten, 121° (Minimum 20°, Maximum 140°). Der Lysholm-Score konnte für 9 Patienten ermittelt werden und ergab im Durchschnitt 67,5 Punkte (48–92 Punkte), der Neer-Score 69,8 Punkte (49–88 Punkte). Die Anwendung des LISS ermöglicht eine komplikationslose Ausheilung ohne Notwendigkeit der Knochentransplantation. Besonderes Augenmerk muß auf eine achsengerechte Reposition gelegt werden, da diese am distalen Femur schwierig ist.

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter.We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29).All fractures had united. Healing was evident radiologically at a mean of 5.4 ± 2.1 months (3 to 12) with a mean varus-valgus alignment of -1.0° (-5 to 3) and mean antecurvatum-recurvatum alignment of 1.6° (-6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5° in the frontal plane and 0.4° in the sagittal plane. There were no complications related to the Poller screw.The clinical outcome, according to the Karström-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%).

Abstract: A cadaveric arterial injection study was performed to study the effects of percutaneous and conventional surgical plating techniques on femoral vascularity. Sixteen-hole dynamic condylar screw and condylar buttress plates were applied on the proximal and distal shafts, respectively, of intact femora in ten human cadavers. On one side, the plate was inserted using a lateral conventional plate osteosynthesis (CPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPPO) technique. After plating, blue silicone dye was injected through the common femoral artery. A dissection was then performed to identify the femoral perforating arteries (PAs). The pattern of periosteal filling of the injected dye was analyzed. The MIPPO technique maintained the integrity of the PAs and exhibited superior periosteal perfusion. The results of this study indicate that the MIPPO technique maintains femoral vascularity and perfusion better than the CPO technique.

Summary.: Recently, radiation-independent aiming devices for the tibia which compensate for insertion-related implant deformation have been developed, but the benefits of such systems have not been determined. This study prospectively evaluated the duration of the nailing procedure, the length of radiation time, and the accuracy of interlocking screw placement with a radiation-independent distal aiming system and the free-hand technique. In an oblique cadaveric tibial fracture, a surgeon inexperienced with either technique performed a statically locked intramedullary nailing. For the aiming system and free-hand technique respectively, the total operation time was 25.4 ± 11.3 vs 30.9 ± 14.3 min (P = 0.029), the distal locking time was 16.7 ± 8.6 vs 21.9 ± 10.5 min (P = 0.004), the total fluoroscopy time was 9 ± 5 vs 93 ± 34 s (P < 0.0001), the distal locking fluorscopy time was 0 versus 88 ± 33 s (P < 0.0001), and the screw destruction was −0.7 ± 5.2 vs 26.8 ± 31.6 μm (P = 0.001). The failure rate was 1.6 % (1 of 60 screws) in both groups. These results suggest that aiming devices can eliminate the need for radiation during distal interlocking screw placement.

Abstract: Today there is a variety of different interlocking intramedullary nail designs available for the femur – each designed with a different approach to achieve stability for fracture fixation. We compared different nail types in the bone-implant complex (BIC) of four unreamed solid nails and a slotted, reamed nail to see if there are major differences in stiffness for axial load, bending and torsion. We simulated comminuted mid-shaft fractures by a 2 cm defect osteotomy in paired human cadaver femora. Each bone was tested intact in a Universal testing machine. The results were recorded, osteotomy and osteosynthesis were performed, and the BIC was tested. Relative stiffness was calculated for each individual bone. For P-values less than 0.01 (`least significance difference test') the difference between groups was considered to be significant. In torque testing the unslotted solid nails showed significantly more stiffness (0.6–1.8 Nm/°) compared to the slotted nail (0.2 Nm/°). Compared to intact bone (6.9 Nm/°), both groups of nails were significantly less stiff (relative stiffness 2–20%). In axial load and bending testing, the large-diameter unreamed nail showed greater higher stiffness (32–68%). This study shows that stiffness of the BIC in interlocking femoral nails is more dependent on nail profile than on the press-fit of nails in the medullary canal. For torque stiffness the absence of a slot is of special importance. According to our study, all of the unslotted nails tested give adequate stability for fracture fixation.

Abstract: To assess the behavior of the LC-DCP with prebending and pretensioning we tested: gap angle vs. tensioning force without prebending; Bending moment for different prebending angles; In a model using a fiber tube to simulate the bone for different prebending angles and pretensioning forces of the LC-DCP the deformation in 4 point bending open was tested. Maximum prebending angle was 24°, maximum pretensioning force was 2400 N; in human cadaver tibiae angles of 3°, 9°, 24° and forces of 300 N, 1000 N and 1500 N, were tested to look for the difference in a less idealized model. — Results: 1. A near linear curve for gap angle vs. force with an angle of 0.45°/100 N was found between 100 N and 1500 N; 2. We did not find a near linear bending moment/bending angle curve up to 8° like in the DCP but an exponential curve development as it had to be expected by the lower modulus of elasticity of titanium; 3. the maximum mechanical stability was found for a angle of 24° and a force of 1500 N. — The titanium LC-DCP shows a different mechanical reaction to prebending and pretensioning in the bone implant complex compared to stul DCP. Optimum prebending and pretensioning for axial compression and mechanical stability in the LC-DCP are by far greater than clinically possible. From our mechanical testing a prebending angle of 24° and a pretensioning force of 1500 N would allow the largest axial compression and show the most resistance against deformation in bending open. In the clinical setting this would result in difficult reduction and therefore, we recommend a prebending angle of 9° and a pretensioning force of 1000 N.

In an effort to limit the amount of soft tissue dissection at the fracture site, indirect reduction and minimally invasive fixation techniques have been developed to treat femoral and tibial fractures. These techniques, which do not rely upon anatomical reduction of the fracture fragments are technically difficult. Correct limb length, axial alignment in the frontal and sagittal plane, and rotation must be assessed using means other than open reduction.

When applying minimally invasive techniques (MIO, Minimally Invasive Osteosynthesis) to the fixation of the distal femur, the surgeon has access to a limited number of anatomical landmarks: namely the articular surface of the distal femur and a small portion of the distal lateral femoral cortex. A detailed knowledge of the local anatomy facilitates the techniques and prevents complications. Using Kirschner wires placed set positions in the distal femur, we analyzed the measurements obtained from the 3D reconstructed helical CT scans of 33 embalmed femora and we report on the anatomy of the distal femur as it relates to supracondylar fracture fixation.

Current methods of distal interlocking of intramedullary femoral nails are dependent on image intensification. However, radiation exposure to the patient, the operating room staff, and the surgeon remains a concern. Proximally mounted, radiation‐free aiming systems for distal interlocking of femoral nails have reportedly failed because of nail deformation with insertion. To better understand this deformation, a threedimensional magnetic motion tracking system was used to determine the position of the distal interlocking hole following nail insertion. The amount and direction of deformation of commercially available smalldiameter implants (unslotted 9‐mm nails inserted without reaming) and large‐diameter implants (slotted 13‐mm nails inserted with reaming) from a single manufacturer were analyzed. Measurements of deformation (three translations and three angles), based on the center of the distal transverse locking hole, were performed on 10 paired intact human cadaveric femora before and after insertion. The technique produced the following results for the small and large‐diameter nails, respectively: lateral translations of 18.1 ± 10.0 mm (mean ± SD, range: 47.8 mm) and 21.5 ± 7.9 mm (range: 26.4 mm), dorsal translations of ‐3.1 ± 4.3 mm (range: 15.2 mm) and 0.4 ± 9.8 mm (range: 30.1 mm), and rotation about the longitudinal axes of −0.1 ± 0.2° (range: 0.7°) and 10.0 ±3.1° (range: 7.8°). This technique is useful for measuring insertion‐related femoral nail deformation. The data for the nails tested suggest that a simple aiming arm, mounted on the proximal end of the femoral nail alone, will not sufficiently provide accurate distal aiming.

When applying minimally invasive techniques (MIO, Minimally Invasive Osteosynthesis) to the fixation of the distal femur, the surgeon has access to a limited number of anatomical landmarks: namely the articular surface of the distal femur and a small portion of the distal lateral femoral cortex. A detailed knowledge of the local anatomy facilitates the techniques and prevents complications. Using Kirschner wires placed set positions in the distal femur, we analyzed the measurements obtained from the 3D reconstructed helical CT scans of 33 embalmed femora and we report on the anatomy of the distal femur as it relates to supracondylar fracture fixation.

In an effort to limit the amount of soft tissue dissection at the fracture site, indirect reduction and minimally invasive fixation techniques have been developed to treat femoral and tibial fractures. These techniques, which do not rely upon anatomical reduction of the fracture fragments are technically difficult. Correct limb length, axial alignment in the frontal and sagittal plane, and rotation must be assessed using means other than open reduction.

We compared different nail types within the Bone/Implant-Complex to look for differences in stiffness for axial load, bending and torsion of the System. We simulated comminuted mid shaft fractures by a 2-cm defect osteotomy in paired human cadaver tibiae. We fixed tibiae with one of nine different interlocking nails [AO Unreamed Tibial Nail 9 mm (UTN9), AO Unreamed Tibial Nail 8 mm (UTN8), Russell & Taylor Delta Tibial Nail 9 mm (RTD), Russell & Taylor Reconstruction Tibial Nail 11 mm (RTR), Brooker & Wills Tibial Nail 11 mm (B&W), Grosse & Kempf Tibial Nail 11 mm (G&K), AO Universal Tibial Nail 11 mm (AOU), Klemm & Schellmann Tibial Nail 11 mm (K&S), and Börner & Mattheck Tibial Nail 11 mm (B-M)] according to the manufacturer's recommendations. In torque testing the unslotted nails (UTN9, UTN8, RTD, RTR, B&W) showed significantly higher stiffness compared to the slotted nails (G&K, AOU, K&S, B-M). Compared to intact bone, both groups of nails were significantly less stiff. In axial load testing large diameter nails interlocked by large diameter interlocking bolts (G&K, K&S, B-M) showed significantly higher stiffness. For A-P bending no significant differences between implants were found, but isolated bones showed significantly higher A-P bending stiffness. In varus-valgus bending large diameter nails (RTR, G&K, K&S, B-M) showed significantly higher bending stiffness compared to low diameter (UTN8, B&W) implants.

Proximally mounted distal aiming systems have failed primarily because of nail deformation during insertion. A mechanical aiming device for the insertion of distal locking screws for solid unreamed AO tibial nails was developed and was tested in twenty unreamed solid tibial nailing procedures in a video-documented prospective clinical study. The rate of accurate screw placement, time expended, complications, and outcome for each patient were recorded. Distal locking was performed successfully in all cases without image intensification. Although a high percentage (55%) of fractures were open, the total mean operative time was 108 minutes (range, 60 to 180 minutes) and the mean time for distal locking (three screws) was 15.5 minutes (range, 8.0 to 39.0 minutes). Notable drill-nail contact occurred in 15 percent of the distal screws placed, demonstrating accurate aiming and drilling. There were no major intra- or postoperative complications related to the distal aiming system.

Zusammenfassung An einem Krankengut von sieben Dermatomyositis-Patienten (fünf Frauen, zwei Männer) wurden Kreatin-Belastungen durchgeführt. Die vergleichenden Kreatin- und Kreatinin-Bestimmungen im Serum und Urin ließen unter entsprechenden Versuchsbedingungen signifikante Unterschiede im Serum (Hyperkreatinämie) und Urin (Hyperkreatinurie — verminderte Kreatininausscheidung) gegenüber Normalpatienten erkennen. Unter Berücksichtigung des Schrifttums wurde der diagnostische Wert dieser Belastung diskutiert.

Background: Even though tumours are considered to occur frequently in pet hamsters, there is only a small number of scientific reports in current literature. Methods: Pathological reports from 177 hamsters were evaluated. Results: Of these, 78 were male and 75 were female. Median age of affected hamsters was 12 months (range 2–34). Integumental tumours were the most common neoplasms (62%, 109/177). As far as species was known, the number of Syrian hamsters (52%, 30/58) affected by tumours seemed to be lower than the number of affected dwarf hamsters (85%, 47/55). Tumours of the hematopoietic system were the second most frequently neoplasms (17%, 30/177). Relative number of neoplasms of the endocrine system, tumours of the digestive system (1.7%, 3/177) and other tumours (4%, 7/177 each) was low. The majority of integumental tumours were epithelial (66%; 91/126). Conclusion: This study aimed to analyze data from veterinary surgeries and pathological institutes about the occurrence of spontaneous tumours in Syrian hamsters and dwarf hamsters to give information about the frequency of tumours, prognosis and survival time. This is the first study about tumours in pet hamsters in Germany so far.

ObjectiveTo develop an instrument to evaluate the credibility of anchor based minimal important differences (MIDs) for outcome measures reported by patients, and to assess the reliability of the instrument.DesignInstrument development and reliability study.Data sourcesInitial criteria were developed for evaluating the credibility of anchor based MIDs based on a literature review (Medline, Embase, CINAHL, and PsycInfo databases) and the experience of the authors in the methodology for estimation of MIDs. Iterative discussions by the team and pilot testing with experts and potential users facilitated the development of the final instrument.ParticipantsWith the newly developed instrument, pairs of masters, doctoral, or postdoctoral students with a background in health research methodology independently evaluated the credibility of a sample of MID estimates.Main outcome measuresCore credibility criteria applicable to all anchor types, additional criteria for transition rating anchors, and inter-rater reliability coefficients were determined.ResultsThe credibility instrument has five core criteria: the anchor is rated by the patient; the anchor is interpretable and relevant to the patient; the MID estimate is precise; the correlation between the anchor and the outcome measure reported by the patient is satisfactory; and the authors select a threshold on the anchor that reflects a small but important difference. The additional criteria for transition rating anchors are: the time elapsed between baseline and follow-up measurement for estimation of the MID is optimal; and the correlations of the transition rating with the baseline, follow-up, and change score in the patient reported outcome measures are satisfactory. Inter-rater reliability coefficients (ĸ) for the core criteria and for one item from the additional criteria ranged from 0.70 to 0.94. Reporting issues prevented the evaluation of the reliability of the three other additional criteria for the transition rating anchors.ConclusionsResearchers, clinicians, and healthcare policy decision makers can consider using this instrument to evaluate the design, conduct, and analysis of studies estimating anchor based minimal important differences.

Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965