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Purpose Intraoperative 3D imaging has become a valued tool in assessing the quality of reduction and implant placement in orthopedic trauma surgery. In our institution, 3D imaging is used routinely since 2001. To evaluate the intraoperative findings and consequences of this technique, intraoperative revision rates in cases with 3D imaging were analyzed. Methods All operative procedures carried out with intraoperative 3D imaging between August 2001 and December 2016 were included. The scans were assessed intraoperatively and documented thereafter. In case of malreduction or misplaced implants, an immediate revision was performed. The number of scans per case as well as the findings and consequences drawn regarding the anatomical region were analyzed. Results 4721 cases with 7201 3D scans were included in this study. The most common anatomical regions were the ankle (22.3%), the calcaneus (14.8%) and the tibial head (9.5%). In 19.1% of all cases, an intraoperative revision was performed. The highest revision rates were found with 36.0% in calcaneal fractures, 24.8% in fractures of the tibial plateau, 22.3% in injuries of the ankle. In 52.0% of revisions, the reduction was improved regarding intra-articular steps or joint congruency. In 30.5% an implant was corrected. Conclusion Intraoperative revision due to results of 3D imaging was performed in almost one-fifth of cases. This illustrates the improved possibilities to detect malreduction and implant misplacements intraoperatively and thus the abilities to improve surgical outcome. Level of evidence III.

BACKGROUND Medical photography is an integral part of patient care, playing an important role in wound management, in particular, but also in planning surgical therapy or patient and medical education. Smartphones are increasingly used and due to medicolegal reasons, usability, and efficiency, in particular, it may be superior to digital cameras. OBJECTIVE Aim of this panel study was to assess if implementation of a specialized smartphone app for medical photography would lead to an increase usage and efficiency of it. METHODS With the help of weekly questionnaires, this single center panel study compared the use of digital cameras and smartphones with a specialized app for medical photography. The study took place at a level 1 trauma center from June to November 2020. RESULTS 65 questionnaires were assessed for digital camera use and 68 for smartphone use. Usage increased significantly by 5.4±1.9 times/week (95% CI [1.7;9.2]; P=.005) when the smartphone was used. The time it took to upload pictures to the PACS was significantly shorter for the app (1.8±1.2min) than for the camera (14.9±24.0h) (P CONCLUSIONS Specialized smartphone apps offer a secure, fast, and easy way to acquire medical photos and could possibly improve patient education and care in terms of wound management, in particular, while also offering medicolegal and economic benefits.

Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTapeIn eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR).All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG).MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.

Rationale: To our knowledge, no study has investigated concomitant injuries of the sternoclavicular joint (SCJ) in acute clavicle fractures. The purpose of this study was to determine the effect of an ipsilateral clavicle fracture on the SCJ in a systematic computer tomography (CT) morphologic evaluation. Methods: CT scans in the axial and coronal plane of 45 consecutive patients with clavicle fractures were retrospectively analyzed. The scans were assessed regarding anatomic congruence of bilateral SCJs—joint space width (JSW); the position of bilateral medial clavicles (PC); and the non-fusion of epiphyses, arthritis, calcifications, and intra-articular gas. Results: The mean SCJ JSW was significantly different in the coronal (cJSW; 8.70 mm ± 2.61 mm in affected vs. 7.63 mm ± 2.58 mm in non-affected side; p = 0.001) and axial plane (aJSW; 9.40 mm ± 2.76 mm in affected vs. 9.02 ± 2.99 in non-affected SCJs; p = 0.044). The position of the medial clavicle showed a significant difference in the coronal plane (cPC; 14.31 mm ± 3.66 mm in the affected vs. 13.49 ± 3.34 in the non-affected side; p = 0.011), indicating a superior shift. Conclusion: Acute clavicle fractures may be associated with an enlargement of the ipsilateral SCJ space width and a superior shift of the proximal clavicle. Both morphologic alterations could indicate concomitant injuries of the SCJ as well as a potential increase in the risk of SCJ instability.

Reconstruction of the medial patellofemoral ligament (MPFL-R) with nonresorbable suture tape (FiberTapeIn ten human, fresh-frozen knee joint specimens (m/f 6/4; age 74 ± 9 a), the MPFL was identified and dissected near the femoral insertion site. In five knee joints, the MPFL-R using FT was performed with soft-tissue fixation at the patella (study group; SG), and in five knee joints, the FT was fixed via suture anchors (control group, CG). All reconstructions were evaluated until load to failure of the patella-side fixation with a displacement rate of 200 mm/min.The mean maximum load to failure in the SG was 395.3 ± 57.9 N. All reconstructions failed by complete tearing off the medial patellar retinaculum from its medial patellar margin, but fixation of the FT remained stable. In the CG, the mean maximum load to failure was 239.4 ± 54.5 N and was significantly different compared to the SG (p = 0.04). All reconstructions failed via pullout of the suture anchors. Stiffness and elongation did not differ between the groups, and no failure of the FT was observed in any of the specimens.Primary stability of soft-tissue MPFL-R using FT was superior to suture-anchor fixation. Both fixation techniques provided sufficient primary stability, superior to previously reported native MPFL tensile strengths. MPFL-R with FT could be a possible alternative procedure for MPFL-R, eliminating potential complications due to autologous tendon graft harvesting.

Background To evaluate reliability, practicability and precision of a novel intraoperative computed tomography(iCT)-based (Airo mobile CT scanner, Brainlab, Munich, Germany) navigated procedure to minimally-invasive positioning of cervical pedicle screws.Methods Ten consecutive patients that suffered from a cervical traumatic instability needing posterior fixation were included in this retrospective analysis. Posterior pedicle screws were positioned iCT-navigated percutaneously. After positioning of the screws, a control scan was performed to assess screw placement and correction if needed. All CT scans were randomly evaluated by two investigators with experience in skeletal CT diagnostics. In the iCT scans, positioning of the screws regarding affection of the medial pedicle cortex as well as the neuroforamina were measured. Additionally, image quality was evaluated with a subjective Likert-Scale (0-5) and a semi-objective Assessability score (0-4).Results 44 screws were placed in an average duration of surgery of 139min [83-209]. The average subjective image quality was 3.9 [2-5], the average assessability score was 3.7 [2-4]. 27 screws (61%) were positioned exactly centered in the pedicle. 4 screws perforated the medial wall by more than 2mm [2.8-2.9]. 9 screws were positioned laterally by more than 2mm [2.5-4.9]. No postoperative neurological deficits were observed.Conclusion iCT-navigated percutaneous placement of pedicle screws is a rather safe and reliable method for posterior fixation of the cervical spine that allows fixation of traumatic cervical instabilities with minimal additional trauma. Even in shallow anatomic structures, visualization of instruments and implants allows for minimally invasive surgery.

BackgroundFor the acquisition of intraoperative fluoroscopic images, standard projections have to be manually adjusted. This process resembles a trial-and-error process and is therefore time-consuming and leads to increased radiation exposure for both patient and staff. In addition, the standard projections adjusted are subject to intra- and interindividual variance. However, to date, only very limited data exist in the literature quantifying the time and radiation exposure caused by the process of manually setting standard projections as well as the intra- and interindividual variance for the manual adjustment of standard projections.Material and MethodsA.p. and lateral standard projections of the vertebral bodies of two fresh-frozen specimen were manually adjusted by two examiners with a different level of experience using a mobile C-arm. The time needed for manual adjustment as well as the number of X-ray shots acquired and the radiation dose caused during this process were documented. Intra- and interindividual variance of the central beam, the orbital rotation and angulation of the C-arm was analyzed.ResultsThe median time needed was 75.9s, with no significant difference between the examiners (p=0.13). 7.1 x-ray images were acquired in average to reach subjective satisfaction with the standard projection with significantly more x-ray shots for the lateral standard (p=0.04) and for the examiner with less experience (pConclusionIn summary, this study investigated the interrater and intrarater variance for standard manual level setting in the thoracic and lumbar spine. Additionally, we were able to quantify the time and number of radiographs required for this procedure for different levels of experience, as well as the resulting radiation dose.

Background Despite a substantial improvement in the operative treatment of tibial plateau fractures, the surgical procedure remains controversial and is generally challenging, as patients may develop postoperative arthritis and functional impairment of the knee joint. Hypothesis In the surgical treatment of tibial plateau fractures the intraoperative reposition quality has the greatest influence on the postoperative outcome, whereby misalignments of ≥ 2 mm lead to a worse result. Patients and methods Forty-one patients with tibial plateau fractures were postoperatively examined. The operative treatment was performed under reduction control using an intraoperative 3D C-arm. The follow-up collective was divided into two groups depending on the intraoperative reduction result. The postoperative results were then evaluated using the following parameters: Lysholm score, Rasmussen score, Tegner score, SF-36 score, range of motion and pain level. Results Group 1 (articular surface incongruencies Discussion Both study groups achieved a very good result compared to the available literature. It appears that reduction quality – which can be analyzed with intraoperative 3D imaging – plays the most important role in postoperative quality of life and functional outcome. Intraoperative adjustments of the reduction should therefore be performed on joint surface irregularities with a size above 2 mm. Level of evidence III; retrospective case control study.

Despite a substantial improvement in the operative treatment of tibial plateau fractures, the surgical procedure remains controversial and is generally challenging, as patients may develop postoperative arthritis and functional impairment of the knee joint.In the surgical treatment of tibial plateau fractures the intraoperative reposition quality has the greatest influence on the postoperative outcome, whereby misalignments of≥2mm lead to a worse result.Forty-one patients with tibial plateau fractures were postoperatively examined. The operative treatment was performed under reduction control using an intraoperative 3D C-arm. The follow-up collective was divided into two groups depending on the intraoperative reduction result. The postoperative results were then evaluated using the following parameters: Lysholm score, Rasmussen score, Tegner score, SF-36 score, range of motion and pain level.Group 1 (articular surface incongruencies2mm) tended to achieve a better result in all scores than group 2 (articular surface incongruencies≥2mm), in the Lysholm score (p=0.039), in the comparison of the range of motion (p=0.012) and the pain level (p=0.039) this was significant. Group 1 achieved an average of 90.71 points (group 2: 78.74) in the Lysholm score. The average range of motion of the knee joint was 138.93° in group 1 (group 2: 127.78°). The average value of the current pain level in group 1 was 1.14 (group 2: 2.63).Both study groups achieved a very good result compared to the available literature. It appears that reduction quality - which can be analyzed with intraoperative 3D imaging - plays the most important role in postoperative quality of life and functional outcome. Intraoperative adjustments of the reduction should therefore be performed on joint surface irregularities with a size above 2mm.III; retrospective case control study.