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Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region.The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach.The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia.The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

This study aims to analyze the ligaments of the dorso-lateral calcaneo-cuboid joint and to assess the biomechanical relevance of the bifurcate ligament.16 specimens were analyzed for their ligamentous anatomy of the dorso-lateral calcaneo-cuboid joint and side-alternating assigned to two groups with varying ligamentous dissection order. The Chopart joint was stressed in plantar, medial, and lateral direction measuring the displacement by an 3D motion tracker for every dissection step.37.5% of specimens had all ligaments (lateral calcaneo-cuboid, dorsal calcaneo-cuboid, bifurcate calcaneo-cuboid, bifurcate calcaneo-navicular), 37.5% were lacking bifurcate´s calcaneo-cuboid-portion, and 25% presented without dorsal calcaneo-cuboid. Biomechanical testing revealed no significant displacement within the calcaneo-cuboid or talo-navicular joint for any stressed state except for axial compression with dissected dorsal talo-navicular joint capsule in Group 2.Broad morphological variability and missing significant displacement regardless of its integrity, make the bifurcate ligament appear of limited biomechanical relevance.

While long standing radiographs (LSR) represent the gold standard for preoperative alignment assessment and planning of lower limb deformity corrections, there is no consensus about the intraoperative alignment assesments (IAC) due to various limitations of the common methods. The present study introduces a radiolucent X-ray grid with integrated radiopaque lines explicitly designed for fluoroscopic IAC and evaluates its reliability in comparsion to the LSR.Patients with posttaumatic and congenital lower limb deformity surgery and preoperative LSR as well as fluoroscopic IAC utilizing the X-ray grid were retrospectively included to the study. The mechanical axis deviation (MAD) in percentage of the maximum tibial width from the medial to the lateral in comparison between the image pairs was set as primary outcome parameter. Multiple rater and measurements determined intra- and interobserver reliabilit of both imaging methods. In addition, the effects of age, gender, body mass index (BMI), etiology, joint line convergence angle (JLCA), and extent varus or valgus deformity were analysed.A total of 84 patients were finally included. The mean absolute difference of MAD between the two techniques was 7.2 ± 0.8%. MAD between the LSR and IAC correlated at a high level (R = 0.96, p0.001). The agreement decreased with increasing extent of deformity (p0.01) and with higher deviation of JLCA between LSR and IAC (p0.01). Intra- and interobserver concordance correlation coefficient (CCC) for MAD measurements were 0.99 for both imaging techniques.Fluoroscopy combined with the X-ray grid method is a valid tool for intraoperative assessment of lower limb alignment in deformity correction surgery, and the correlation between LSR and IAC is better than in other similar techniques described in the literature. However, in case of severe coronal alignment deformity and highly divergent JLCA, the agreement between both imaging techniques decreases significantly.

The new software, mediCAD® 3D Knee Sport (mediCAD Hectec GmbH, Altdorf/Landshut, Germany), promises to combine automated digital 3D bone model generation, 3D analysis of lower limb geometry including analysis of the patellofemoral joint, and osteotomy planning. The aim of this study was to evaluate its reliability and accuracy.In this retrospective multi-observer study, three post-mortem CTs were analysed by three observers at three points in time. Reliability was evaluated by calculating the intraclass correlation coefficient (ICC) of interobserver agreement. Accuracy was evaluated using the mean deviation D from the mean and the standard deviation SD from D.Ten of 18 alignment parameters showed excellent, two good and three moderate interobserver agreement. Poor agreement was found for the mechanical medial proximal tibial angle, the trochlear sulcus angle and trochlea depth. Mean interobserver ICC of all parameters ranged from 0.32 to 0.99. Fifteen of 18 parameters showed a low mean deviation D from the mean of 2 mm / 2°. Three parameters related to the patellofemoral joint showed medium or high D (patella tilt, trochlear sulcus angle, patellar ridge angle). These parameters also showed the highest values for the SD of D. The trochlear sulcus angle was found to be the only parameter with high mean deviation (D ≥ 5 mm/5°) with D being 5.67 ± 3.23°.The current version of the software achieves good interobserver reliability and accuracy with the exception of a few measurement parameters.

Background An early postoperative mobilisation shows beneficial effects in terms of complications and mobilisation scores in older adult proximal femur fracture patients. An adequate load-bearing capacity of the operated extremity is essential for early mobilisation. We hypothesize that cement augmentation of the Proximal Femoral Nail antirotation (PFNA) leads to a higher load capacity during postoperative mobilisation compared to a non-cemented PFNA. Methods Forty-nine orthogeriatric patients with pertrochanteric fractures were enrolled consecutively in a maximum care hospital in a pre–post study design (level of evidence 2). A study group of 25 patients received nailing (PFNA) with additional cement augmentation (CA group), whereas the control group of 24 patients received the same fracture fixation without cement augmentation (NCA Group). All patients participated in a gait analysis using an insole force sensor to measure the loading rate (loadsol®, Novel, Munich, Germany) on the fifth postoperative day. Results The NCA group showed a mean age of 75,88 years (SD ± 9.62), the CA a mean age of 81,44 years (SD ± 7.77). The most common fracture type was a pertrochanteric fracture in both groups (NCA: n=20, CA: n=21) Both groups showed no differences with regards to the ASA (NCA: 2.67; CA: 2.68) score and the postoperative Parker Mobility Score (NCA: 2.67; CA: 2.68). Patients who received cement augmentation showed a significant (p=0.004) higher loading rate in the postoperative gait analysis. The CA group showed a loading rate of 58.12% (SD ± 14.50) compared to the uncemented PFNA group with 43.90% (SD ± 18.34). Conclusions Cement augmentation in elderly patients with a proximal femur fracture increased the early postoperative loading rate. Especially in frail patients with poor bone quality cement augmentation should therefore be considered to enhance early mobilisation with full weight bearing in order to reduce complications and improve survival.

The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures.Data of 685 patients with a mean age of 67±15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or10° of varus or valgus malposition, group B: 10-20° of varus malposition and group C:20° varus malposition, while anatomic head-shaft-angle was defined 135° The groups were compared with regards to functional outcomes by means of the Constant Score (CS).In 565 patients with anatomic to minor10° varus or valgus malposition (Group A), the mean CS was 72.5 ± 18.8 points. The %CS to the uninjured side was 87.2 ± 24.1 and the age and gender normalized nCS was 84.7 ± 21.7. In comparison, in group B (10-20° varus) the mean CS was 64.7 ± 16.9, the mean %CS was 84.5 ± 18.3 and the mean nCS was 76.2 ± 20.6. In group C (20° varus) the mean CS was 54.1 ± 19.5, the mean was %CS: 72.3 ± 26.4 and the mean nCS was 64.8 ± 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25).Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe20° of varus malposition, revision surgery should be considered.

Bike sharing systems are increasingly promoted as a quick, accessible, affordable, and healthy transport alternative in a less car-dependent urban mobility system. The objective of this article is to elucidate the social and spatial inclusiveness of bike sharing, by exploring its intersectionality with user backgrounds and residential contexts, and its mechanisms of mediation by attitudes, mobility resources and daily mobility patterns. Hereto, the paper examines and cross-compares the discrepancies between stated bike sharing interest and reported bike sharing membership, amongst a sample of 3672 residents of urban regions in Norway in structural equation models (SEM). Our results indicate that interest is positively influenced by early adopter characteristics, such as young age, full-time work, environmental consciousness, urban outlook, urban residential locations, and the current adoption of combined bicycle and public transport use. In contrast, reported bike sharing membership is explained more typically as a travel behaviour: with reduced effects of attitudes; enhanced effects of residential urban form and bicycle-public transport use; and additional negative effects of car and bike ownership. The paper concludes by discussing these and other interest-adoption discrepancies across social and spatial categories, to derive policy and research directions for inclusive bike sharing.

Introduction The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients. Patients and Methods Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%). Results The mean DASH-Scores at 24 months was 32.6±9.7 points in Group LP versus 37.8±8.3 points in Group IN (p=0.04). The mean Constant Murley Score at 24 months follow-up was 76.2±7.7 points in Group LP compared to 72 ±9.1 points in Group IN (p=0.08). The ASES at 24 months follow-up was 75.1±9 points in Group LP versus to 73.5±8.9 in Group IN (p=0.51). The OSS at 24 months was 43.7±8.1 in Group LP compared to 38.2±10 in Group IN (p=0.03). The SF-36 at 24 months was 74.7±12.5 in Group LP versus to 70.9±12.8 in Group IN (p=0.29). Screw cutting out was observed in n=2 (6,7%) cases of Group LP, and in none of Group IN (p=0.49). Revision surgery was necessary in n=2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p=1). Conclusion Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.