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Introduction Acetabular defect recognition and classification remains a challenging field of practice for orthopedic surgeons. Recently, the Acetabular Defect Classification (ADC) has been introduced to provide a reliable, reproducible and intuitive classification system. In order to improve ease of use and efficiency of the ADC, a browser-based application has been created. We hypothesized that the ADC application can improve rating performance of non-specialists (medical students) to achieve good inter- and intra-rater agreement and will compare favorable to the results of specialists (experienced surgeons) without the help of the application. Materials and methods The ADC is based on the integrity of the acetabular rim and the supporting structures. It consists of four main types of defects ascending in severity. These defects are further subdivided in A–C, narrowing down defect location. 80 randomized radiographs were graded according to ADC by three non-specialists (medical students) with help of the ADC application and by three specialists (orthopedic surgeons) without help of the application to evaluate the difference in inter-rater agreement between groups. To account for intra-rater agreement, the rating process was repeated after a reasonable wash-out period. Results Inter-rater and intra-rater agreement within the non-specialist group rated lower when compared to the specialist group while still falling into the good agreement range. The student group presented with k values of 0.61 for inter-rater agreement and 0.68 for intra-rater agreement, while the surgeon group displayed k values of 0.72 for inter-rater agreement and 0.83 for intra-rater agreement. Conclusion The app-guided assessment of acetabular defects offers a promising innovative approach to simplify complex situations. It makes the challenging field of acetabular revision arthroplasty more approachable especially for less experienced surgeons and offers insight and guidance in the planning stage as well as intra-operative setting.

To evaluate the comparative effectiveness and safety of open-door laminoplasty (OLP), French-door laminoplasty (FLP), laminectomy and fusion (LF), and laminectomy alone (LA) in treating multilevel degenerative cervical myelopathy (MDCM). Embase, PubMed, and Cochrane library were searched from their inception date to 7 January 2021. Randomized controlled trials and cohort studies comparing OLP, FLP, LF, and LA were identified to perform a network meta-analysis (NMA). A total of 30 studies with 2671 patients were included. Our NMA results showed no significant difference between LF and OLP, but both are superior to LA and FLP in the comparison of JOA (Japanese Orthopaedic Association) score improvement. LF showed a most unsatisfactory outcome in postoperative range of motion (ROM) compared with LA or OLP or with FLP. For the complication outcome, no significant differences were found. The surface under the cumulative ranking curves (SUCRA) for JOA improvement was as follows: LF, OPL, LA, and FLP. For ROM reduction it was LA, OPL, FPL, and LF. For complications it was LF, LA, OLP, and FLP. Considering all the evaluated criteria, none of the procedures showed the best outcome with least complications and optimal efficacy. However, OLP can be most recommended because of its second-ranking spectra in both of JOA improvement and ROM reduction, also with an acceptable incidence of complications, with the third least.

Background Cervical spine injuries (CSI) are rare in trauma patients, at about 9.2–16.5/100,000 inhabitants in Scandinavia and Canada, and the annual incidence of CSI surgeries in Norway is around 3.0/100,000 inhabitants. However, despite their rarity, the incidence of CSI has increased, thereby assuming an increasing need for surgery. Outside of Scandinavia, no data about the incidence of CSI and subsequent surgeries exist. Therefore, this study aimed to analyse CSI epidemiology and surgery in a German city with a Level I trauma centre both to understand the injury and improve needs–based planning. Methods This retrospective, monocentre study included all patients who presented with CSI from 2012–2017 at a university hospital with a Level I trauma centre in a major German city and had permanent residency within the city. Based on the assumption that the patients represented all CSI injuries in the city, as they were treated at the only available Level I trauma centre, the annual incidence of surgeries and neurologic deficits due to CSI were calculated. Results A total of 465 patients with 609 CSI were identified. Of these patients, 61 both received surgery and resided in the city (mean age, 68.1 ± 18.3 years; 26 female, 35 male). The incidence of CSI surgeries was calculated as 3.24/100,000 person years (1.75/100,000 in the upper and 1.54/100,000 in the subaxial cervical spine). Neurologic deficits occurred in 0.64/100,000 person years. The incidence of both surgeries and neurologic deficits showed no significant changes over the 6-year study period. Conclusions Compared to Scandinavia, an increasing annual incidence for CSI surgeries and neurologic deficits were found. For long-term demand planning with adaptability to demographic changes, cross-regional studies including long-term follow-up are necessary.

Schmerzreduktion und Verbesserung der Lebensqualitat durch ISG-Fusion. Chronische Iliosakralgelenk-assoziierte Schmerzen. Positive ISG-Testinfiltration mit Lokalanasthetikum. Positive ISG-Provokationstests. Erfolglose konservative Therapie uber 6 Monate. Nicht ISG-assoziierte Beschwerden. Tumor/Infektion/instabile Fraktur im Implantationsareal. Fehlbildungen, Tumor oder Osteolyse des Sakrum- oder Iliumknochens. Aktive Infektion an der Behandlungsstelle. Allergie gegen Metallkomponenten. Sekundarer Krankheitsgewinn, Rentenbegehren. Unzureichend behandelte Osteoporose. Uber einen lateralen minimal-invasiven Zugang bildwandlergesteuertes Einbringen von Kirschner-Drahten transartikular durch das ISG in das Sakrum. Aufmeiseln des Implantatlagers uber die Kirschner-Drahte und Einbringen von insgesamt 3 triangularen Titanimplantaten zur ISG-Arthrodese. Thromboseprophylaxe. Drei Wochen Teilbelastung und anschliesend schrittweise Aufbelastung. Rontgenkontrollen in definierten Intervallen. Physiotherapie. Es wurden 26 konsekutive Patienten nach 48 Monaten untersucht. Die evaluierten Endpunkte waren tieflumbale Schmerzen entsprechend der visuellen Analogskala (VAS 0–10), Funktionseinschrankungen entsprechend Oswestry Disability Index (ODI) und Lebensqualitat entsprechend EuroQOL-5D (EQ-5D). Nach 4 Jahren zeigte sich der Ruckenschmerz im Vergleich zu praoperativ deutlich verbessert (VAS praoperativ 8,4, VAS 4 Jahre postoperativ 4,6). Die Funktionseinschrankungen zeigten sich rucklaufig (ODI praoperativ 58,1, ODI 4 Jahre postoperativ 32,1), und ein Anstieg der Gesundheitsbewertung im EQ-5D war zu verzeichnen (praoperativ 0,5, nach 4 Jahren 0,7). Die Rate an Patienten, welche Opiate zur Schmerztherapie einnahmen, konnte deutlich gesenkt werden (praoperativ 82 %, postoperativ 39 %). Es zeigte sich keine Implantatlockerung im untersuchten Zeitraum.

Injuries of the acetabulum are often challenging in treatment and aftercare. One reason is the required surgical approach, which has high complication rates, including vascular lesion, hernias, and wound infection. We present an alternative endoscopic-assisted approach for the internal fixation of acetabular fractures to avoid the Pfannenstiel incision. An endoscopic approach similar to that used for endoscopic hernia surgery was used. The ilioinguinal approach’s lateral window was used to achieve reduction and insertion of a reconstruction plate. The purpose of this study is to describe a minimally invasive technique as a possible method to reduce hospitalization and complications. Another goal is to give detailed technical recommendations and to assess the potential pitfalls of this surgical approach. The APACHE technique is a safe and suitable minimally-invasive approach for the successful treatment of complex acetabular fractures and can be considered in similar cases., Technique Video Video 1 This video describes the key aspects of the anterior plating of the acetabulum in hemiendoscopic technique. The images show an anterior fracture of the left acetabulum. The first picture shows a schematic drawing of the abdomen and illustrates the approach to visualize the pubic bone and the acetabulum. A balloon trocar is placed in the preperitoneal space to bluntly dissect it for surgery. The second picture shows the infraumbilical midline incision of about 15 mm. One more incision can be seen more caudal also in the midline. The infraumbilical port is used primarily for the endoscope whereas further ports can be used for numerous instruments. The tissue is then dissected from medial to lateral starting from the pubic tubercle, using a raspatory and a laparoscopic scissor. The arcus mortis needs to be identified and clipped. The iliopectineal fascia is released and divided from the pelvic brim and os pubis by careful retraction of the femoral vessels cranially and laterally. This step is essential to place the plate safely beneath the vessels. The fracture reduction is achieved through the lateral window of the ilioinguinal approach. A large-fragment titanium reconstruction plate is used for plate fixation. The distal trocar is used to drill the threaded hole using a 3.2 mm twist drill bicortically into the superior pubic ramus.

Durch die Spinal-Cord-Stimulation (SCS) werden Strukturen der Hinterstrange und Hinterhorner des Ruckenmarks mittels elektrischer Impulse stimuliert und dadurch wird die Schmerzwahrnehmung moduliert. Ziel ist es, bei chronischen Schmerzpatienten, z. B. bei Failed-Back-Surgery-Syndrom (FBSS), das Schmerzniveau zu reduzieren und betroffenen Patienten eine verbesserte Lebensqualitat zu ermoglichen. Failed-Back-Surgery-Syndrom, komplex regionales Schmerzsyndrom (CRPS) Typ I und II, therapierefraktarer Ischamieschmerz, neuropathische Schmerzsyndrome (z. B. Phantomschmerz). Chirurgisch sanierbare Schmerzursache, nicht behandelte psychische Erkrankung. Zweizeitige Implantationstechnik. Beginn mit der Testphase nach perkutaner Implantation von epiduralen Elektroden und Stimulation durch externen Pulsgenerator. Bei Schmerzreduktion Implantation eines subkutanen internen Pulsgenerators zur Dauerstimulation. Fruhfunktionelle Mobilisation und ggf. Anpassung der Stimulationsparameter. Es wurden 19 konsekutive Patienten mit FBSS mittels Hochfrequenz-SCS (HF-SCS) behandelt und in eine prospektiv prognostische Studie eingeschlossen. Bei 18 Patienten wurde ein implantierbarer Pulsgenerator (IPG) zur HF-SCS permanent implantiert. Der Therapieerfolg wurde mittels Oswestry Disability Index (ODI), visueller Analogschmerzskala (VAS) und painDetect-Fragebogen erfasst. Bei den Patienten dominierten neuropathische Schmerzen der Beine gegenuber dem Rucken (Mittelwerte: VAS Bein 71 mm, VAS Rucken 69 mm) bei praoperativem mittlerem ODI von 63 %. Unter der HF-SCS zeigte sich eine deutliche Schmerzreduktion und persistierte auch im Follow-up nach 6 Monaten (VAS Bein 18 mm, VAS Rucken 24 mm). Im ODI zeigte sich eine Verbesserung auf einen Mittelwert von 24 % nach 6 Monaten.

In Middle Europe developmental dysplasia of the hip (DDH) has an incidence of up to 5.9 %. The rate of congenital hip dislocation as the worst complication of a growth disorder of the hip is between 1.5 % and 2.5 %. Among known risk factors of DDH are breech position, multiples, foot deformities and family history. The aim of this retrospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). The hips of 283 infants who were born before the 38 Surprisingly, the difference in alpha angles between the two groups was statistically extremely significant, favoring the preterm infants. Moreover, we found a physiological curve of alpha angle development with a peak after the 31 Our results suggest that prematurity is not a predisposing factor for DDH, but rather is protective for hip development.ZIEL: Die Inzidenz der kongenitalen Hüftdysplasie in Mitteleuropa beträgt bis zu 5,9 %. Die kongenitale Hüftluxation als schwerste Komplikation liegt zwischen 1,5 und 2,5 %. Zu den akzeptierten Risikofaktoren der Hüftdysplasie werden die Beckenendlage, Mehrlingsgeburten, Fußdeformitäten und familiäre Häufung gezählt. Das Ziel dieser retrospektiven Datenerhebung ist die Untersuchung der Frühgeburtlichkeit als Risikofaktor für das Vorliegen einer Hüftdysplasie. Daher wurden die Hüften von 283 Neugeborenen, welche vor der 38. Schwangerschaftswoche oder früher, und jene von 377 Neugeborenen, welche nach der 37. Schwangerschaftswoche geboren wurden, mit der Hüftultraschallmethode nach Graf et al. in der ersten Woche postpartal untersucht. Überraschenderweise war der Unterschied der Alpha-Winkel zwischen den beiden Gruppen äußerst signifikant zugunsten der Frühgeborenen. Darüber hinaus konnten wir eine physiologische Entwicklungskurve mit einem Höchstwert nach der 31. SSW darstellen. Die Inzidenz der Hüftdysplasie war nicht statistisch signifikant unterschiedlich in beiden Gruppen. Unsere Daten deuten darauf hin, dass die Frühgeburtlichkeit kein Risikofaktur für die Hüftdysplasie darstellt, sondern wahrscheinlich protektiv auf die Hüftentwicklung wirkt.

Der Kostendruck in einem kompetitiven Umfeld zwingt Krankenhauser und Arzte, Ablaufe zu optimieren. Um sich Wettbewerbsvorteile zu sichern, ist die standige Evaluation relevanter Prozesse notwendig. Administrativer und medizinischer Ablauf in einer unfallchirurgischen Hochschulambulanz wurden mithilfe der „Lean“-Methode evaluiert, um Patientenwartezeiten zu reduzieren. Im Zeitraum von 2 Wochen wurden alle Patienten, die in der orthopadisch-unfallchirurgischen Klinik ambulant behandelt wurden, in die Bewertung des Prozesses einbezogen. Mitarbeiter der Poliklinik wurden vorbereitet und geschult, um den telefonisch vereinbarten Termin, Zeitpunkt des Erscheinens in der Poliklinik, ersten Kontakt, Administrationsprozess, ersten Arztkontakt, Dauer des Aufenthalts in der radiologischen und anasthesiologischen Klinik sowie Abschluss der Behandlung zu erfassen. Zusatzlichen wurden potenzielle Ineffizienzen durch eine Patientenflussanalyse sowie die personliche Befragung von Mitarbeitern in der Administration, in der Ambulanz sowie von Assistenz- und Facharzten identifiziert. Es wurden 126 Patienten in die Studie aufgenommen. Die durchschnittliche Verweildauer eines Patienten in der Ambulanz betrug 144 min (Range 30–371 min). Eine notwendige bildgebende Untersuchung erhohte die Verweildauer um durchschnittlich 53 min, eine notwendige Pramedikation im Mittel um 78 min, im Vergleich zu Patienten ohne erforderliche weitere Konsultationen. Mithilfe der Analyse der Patientenwege und -zeiten konnten verschiedene Grunde fur die Wartezeiten in der Hochschulambulanz dargelegt werden. Diese Arbeit zeigt, dass eine strukturierte Anwendung des Lean management sowie eine dezidierte Analyse einen Mehrwert fur den Patienten durch die Reduktion von Wartezeiten schaffen.

Der OP stellt den grosten Kostenblock und Kern der Leistungserbringung einer operativen Klinik dar. Steigerungen von Behandlungsqualitat und wirtschaftlichem Erfolg sind klassische Ziele der Prozessoptimierungen. Da der Abbau qualifizierten Personals jahrelang als erfolgversprechendster Faktor zur Kostenersparnis favorisiert wurde, bedroht der Mangel an Pflegekraften heutzutage den Betrieb in vielen deutschen Kliniken. Welche Verbesserungen sind moglich, bei bereits bestehender Einschrankung des OP-Betriebs? Was sind kritische Ressourcen, welche ihre kritische Belastung, und wie konnen diese optimiert werden? Der Analyse der OP-Organisation einer orthopadisch-unfallchirurgischen Klinik mit bereits erfolgter Reduktion von OP-Kapazitaten aufgrund des Mangels an OP- und Anasthesiepflegekraften folgte die Evaluierung moglicher Veranderungen mit den jeweiligen Vor- und Nachteilen. Nach Auswahl und Umsetzung wurden qualitative und quantitative Unterschiede vor und nach den Veranderungen untersucht. Vielschichtige Problemfelder konnten identifiziert werden. Ausgewahlt und umgesetzt wurden die Etablierung eines „Fast-track“-OP mit Konzentration zusatzlicher Ressourcen auf viele schnelle Eingriffe in einem OP statt auf wenige komplexe Falle. Die Einrichtung einer „holding area“ fur Patienten beseitigte transportbedingte Verzogerungen nahezu vollstandig. Anderungen in der OP-Planung und -kapazitatszuteilungen am Abend reduzierten nachtliche Operationszeiten. Trotz Reduktion der OP-Kapazitat konnten sowohl die Zahl der durchgefuhrten Operationen als auch die Schnitt-Naht-Zeit gesteigert werden. Optimierungen der Prozesse im OP sind trotz Personalmangel moglich und notwendig. Bereits wenige strukturelle Veranderungen konnen Flaschenhalse beseitigen sowie qualitative und quantitative Verbesserungen erbringen.

Objective Olecranon fractures are common injuries in patients of any age. The vast majority are treated with two operation techniques: a plate fixation (PF) or tension band wiring (TBW). The objective of this study is to compare the outcomes of surgically treated olecranon fractures with plate fixation or tension band wiring. We hypothesise that PF patients would show significantly inferior outcomes due to more complex injuries. Patients and methods Between 2010 and 2017, a total of 108 patients were treated with plate fixation and or tension band wiring. Clinical data of 40 surgically treated olecranon fractures were collected and analysed. Clinical and functional evaluations were performed using Mayo-Score, DASH-Score, Weseley -Score and subject elbow value (SEV). Furthermore, complication rates, time to return to work and operation duration were documented. Results The mean follow-up was 70.5 ± 45.6 months. Time of return to work was 6.5 ± 2.2 weeks in the TBW group and 10.9 ± 6,6 in the PF group (p = 0.372). The mean duration of surgery was 95.2 ± 47.0 min in the TBW group and 192.5 ± 113.0 min in the PF group (p = 0.001). In the TBW group, the mean hospitalisation period was 7.9 ± 10.1 days and 11.2 ± 9.8 days in the PF group. Revisions were required in 0.3 ± 0.6 of cases (0.2 ± 0.5 in TBE and 0.4 ± 0.7 in PF). The median DASH Score was 7.0 (3.6–13.7) in the TBW group and 12.1 (5.5–24.8) in the PF group (p = 0.948) Conclusion Tension band wiring and plate fixation are both practical treatment options with mostly positive outcomes, even though high complication rates can occur. There were no significant differences in either group concerning functional outcome or time back to work. The duration of surgery was significantly higher in the PF group, whereas the incidence of metalwork-associated complications was higher in the TBW group.

In the course of the corona pandemic, resource conservation and the protection of further infections have made it necessary to break new ground in the organisation of orthopaedic and trauma surgery consultations. One solution is consistent digitisation and the offer of video consultation hours. In this study, non-contact examination of patients with shoulder disorders is described and critically examined.Thirty patients who presented with pathologies of the shoulder joint in a university outpatient clinic were subjected to a physical examination in a conventional and contactless manner. The data obtained on mobility, function and provocation test of both examinations were compared to draw conclusions about the virtual feasibility.46% of the patients suffered from a traumatic shoulder lesion, and 54% showed degenerative lesions. The assessment of mobility showed a high correlation of 70 - 90% between the two examinations. Common tests to evaluate the supraspinatus, infraspinatus, subscapularis and the long head of the biceps could be adequately performed in a contactless version by more than three quarters of the patients, but with low-to-moderate performance values.Contact-less examination is particularly disadvantageous when evaluating stability criteria. For the medical history and functional test, there were no significant differences between the classic consultation and contactless consultation. Although virtual consultation is a widespread and valuable addition in pandemic times, it cannot replace a safe assessment and indication by personal examination.In der Coronapandemie ist es zur Vermeidung weiterer Infektionen sowie zur Optimierung des Einsatzes von medizinischem Klinikpersonal erforderlich, neue Wege bei der Ablauforganisation von orthopädischen und unfallchirurgischen Sprechstunden zu gehen. Ein Lösungsansatz ist eine konsequente Digitalisierung und das Angebot von Videosprechstunden. In dieser Arbeit soll die Durchführung von Anamnese und Untersuchung von Patienten mit Schultergelenkspathologien beschrieben und kritisch hinterfragt werden.30 Probanden, die sich mit Pathologien im Bereich des Schultergelenks in einer Hochschulambulanz vorstellten, wurden auf herkömmliche Weise und kontaktlos einer Untersuchung unterzogen. Die gewonnenen Daten von Beweglichkeit, Funktion und Provokationstests beider Untersuchungen wurden verglichen, um Rückschlüsse auf die virtuelle Durchführbarkeit zu ziehen.46% der Probanden litten an einer traumatischen Schulterläsion und 54% an einer degenerativen Erkrankung. Die Bewertung der Beweglichkeit zeigte eine hohe Korrelation (70 – 90%) zwischen beiden Untersuchungen. Herkömmliche Tests für die Evaluierung der Supraspinatussehne, der Infraspinatussehne, der Subscapularissehne und der langen Bizepssehne konnten von mehr als ¾ der Patienten in ihrer kontaktlosen Anpassung angemessen durchgeführt werden, zeigten jedoch geringe bis milde Performance-Werte.Insbesondere bei der Bewertung von Stabilitätskriterien ist die kontaktlose Untersuchung nachteilhaft. Bei der Durchführung von Anamnese und Funktionsprüfung zeigten sich keine signifikanten Unterschiede zwischen der klassischen Konsultation und einer kontaktlosen Konsultation. Obwohl die digitale Konsultation in Pandemiezeiten eine verbreitete und wertvolle Ergänzung darstellt, kann Sie eine sichere Bewertung und Indikationsstellung durch persönliche Untersuchung nicht ersetzen.

Proximal femoral osteotomies are common surgical interventions to treat hip deformities in pediatric orthopedics. The aim of proximal femoral osteotomies is to optimise hip containment by using varus or valgus osteotomy, flexion or extension osteotomy with shortening, lengthening or derotation of the femoral neck. Furthermore improved muscular dysbalance by enhancing the femoral offset, extension of the range of motion and pain reduction are important surgical intentions. In the long term, a proximal femoral osteotomy is meant to minimize the probability of an early osteoarthritis of the hip. In the current literature many different types of proximal femoral osteotomies are described. They can be divided concerning their anatomical localization into subcapital, base of the femoral neck, intertrochanteric and subtrochanteric osteotomies. A profound knowledge about the deformity and the anatomical situation is essential to choose the appropriate osteotomy. The aim of this review is to show the different ways of proximal femoral osteotomies and their indications after having done a selective literature research. Furthermore over the last years the osteosynthesis materials have changed from blade plates (non-locking) to locking compression plates which allow an early re-mobilization without hip spica casts.Proximale Femurosteotomien sind in der Kinderorthopädie ein häufiger Eingriff zur Korrektur hüftgelenksnaher Deformitäten. Ziel der proximalen Femurosteotomien ist i. d. R. die Optimierung des Containments der Hüfte durch Varisierung oder Valgisierung, Extension oder Flexion mit ggf. begleitender Verkürzung, Verlängerung oder Derotation. Weitere operative Ziele sind die Verbesserung einer möglichen muskulären Dysbalance durch Optimierung des femoralen Offsets, Erweiterung des Bewegungsumfangs und Schmerzreduktion. Langfristig gilt es, durch die proximale Femurosteotomie den Progress einer frühzeitigen Koxarthrose zu minimieren. In der Literatur ist die Bandbreite der beschriebenen proximalen Femurosteotomien groß. Grob lassen sie sich anhand ihrer anatomischen Lokalisation in subkapital, basozervikal, intertrochantär und subtrochantär unterteilen. Zur richtigen Wahl des operativen Verfahrens ist ein profundes Wissen über die Genese der Erkrankung und Indikationsstellung notwendig. Ziel der vorliegenden Literaturübersicht ist es, anhand einer selektiven Literaturrecherche die unterschiedlichen Osteotomieverfahren am proximalen Femur sowie ihre Indikationen darzustellen. Zusätzlich zeigt sich in den letzten Jahren ein Wechsel hinsichtlich des verwendeten Osteosyntheseverfahrens hin zu winkelstabilen Implantaten. Aufgrund der Winkelstabilität entfällt i. d. R. die postoperative Ruhigstellung im Becken-Bein-Gips und erleichtert somit dem jungen Patienten eine zügige Remobilisation.

Olecranon fractures are common injuries that can occur in patients of any age. To assess the postoperative outcome, multiple scoring systems like the DASH, MEPS und Morrey Score have been described. The goal of this paper is to compare the subjective elbow value (SEV) to these commonly used scoring systems. We hypothesized that the SEV would have a high correlation and practicability for the evaluation of elbow function after isolated olecranon injury.Clinical data of 40 patients were collected and retrospectively analysed. All patients suffered an isolated olecranon fracture and were surgically treated by tension band wiring or plate fixation. In the follow-up examinations the Mayo Score, DASH Score, Morrey Score and SEV were measured for correlation purposes.The mean follow-up time was 70.5 ± 45.6 months. The median DASH Score was 9.9 (4.1 - 20.4) and 100 (85 - 100) for the MEPS. The median Morrey Score was 98 (92 - 100). The median SEV was 90% (80 - 95%). The Pearson correlation between the DASH and SEV was -0.85 and 0.80 between the MEPS and the SEV.The SEV shows a high correlation to the most commonly used scoring systems for outcome evaluation after elbow injury. It is easy to use and can be seen as a valuable tool to assess patients after olecranon fractures.Olekranonfrakturen sind häufige Verletzungen bei Patienten aller Altersgruppen. Für die Beurteilung des postoperativen Ergebnisses werden in der Literatur verschiedene, teils komplexe Scoring-Systeme beschrieben wie DASH-Score, MEPS und Morrey-Score. Ziel der vorliegenden Arbeit ist ein Vergleich der subjektiven Ellenbogenfunktion (SEF) mit gängigen Scoring-Systemen unter der Hypothese einer hohen Korrelation und der praktikablen klinischen Anwendung der SEF.Klinische Daten von 40 Patienten nach operativer Versorgung von Olekranonfrakturen wurden erhoben und retrospektiv ausgewertet. Die Patienten wurden zwischen 2010 und 2017 mittels Plattenosteosynthese oder Zuggurtungsosteosynthese operativ therapiert. In der klinischen und funktionellen Nachuntersuchung wurden der Mayo-, DASH-, Morrey-Score sowie die subjektive Ellenbogenfunktion erfasst und die Pearson-Korrelation für alle möglichen Kombinationen der Scores berechnet.Der mittlere Nachuntersuchungszeitraum lag bei 70,5 ± 45,6 Monaten. Der Median des DASH-Scores lag bei 9,9 (4,1 – 20,4) und bei 100 (85 – 100) für den MEPS. Der Median des Morrey-Scores betrug 98 (92 – 100). Der Median der subjektiven Ellenbogenfunktion betrug 90% (80 – 95%). Die Pearson-Korrelation zwischen dem DASH und der SEF lag bei −0,85 und zwischen dem MEPS und der SEF bei 0,80.Die SEF zeigt eine hohe Korrelation mit den beiden am meisten verwendeten Scoring-Systemen. In der klinischen Praxis ist die Anwendung und Dokumentation der SEF daher als ein wertvoller Parameter in der Qualitäts- und Verlaufskontrolle nach operativ versorgter Olekranonfraktur anzusehen.

Spinal cord stimulation (SCS) is an evidence-based, reversible but invasive procedure for the treatment of chronic pain syndromes: for example, in patients with failed-back-surgery syndrome or complex regional pain syndrome. A more recent, similar technique uses high-frequency stimulation for SCS and follows a different mechanism of action that does not result in paresthesia. This Technical Note and video present surgical instructions of a “2-way cut-down” technique for a high-frequency SCS trial period and permanent implantation of an implantable pulse generator.

Introduction The complex field of femoral defects in revision hip arthroplasty displays a lack of standardized, intuitive pre- and intraoperative assessment. To address this issue, the femoral defect classification (FDC) is introduced to offer a reliable, reproducible and an intuitive classification system with a clear therapeutic guideline. Materials and methods The FDC is based on the integrity of the main femoral segments which determine function and structural support. It focuses on the femoral neck, the metaphysis consisting of the greater and lesser trochanter, and the femoral diaphysis. The four main categories determine the location of the defect while subcategories a, b and c are being used to classify the extent of damage in each location. In total, 218 preoperative radiographs were retrospectively graded according to FDC and compared to intraoperatively encountered bone defects. To account for inter-rater and intra-rater agreement, 5 different observers evaluated 80 randomized cases at different points in time. Results A Cohens kappa of 0.832 ± 0.028 could be evaluated, accounting for excellent agreement between preoperative radiographs and intraoperative findings. To account for inter-rater reliability, 80 patients have been evaluated by 5 different observers. Testing for inter-rater reliability, a Fleiss Kappa of 0.688 could be evaluated falling into the good agreement range. When testing for intra-rater reliability, Cohens Kappa of each of the 5 raters has been analyzed and the mean was evaluated at 0.856 accounting for excellent agreement. Conclusion The FDC is a reliable and reproducible classification system. It combines intuitive use and structured design and allows for consistent preoperative planning and intraoperative guidance. A therapeutic algorithm has been created according to current literature and expert opinion. Due to the combination of the FDC with the recently introduced Acetabular Defect Classification (ADC) a structured approach to the entire field of hip revision arthroplasty is now available.

Background In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time. Patients and Materials A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed. Results A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009–2017 (65% less; p = 0.003) than in 2000–2008. Conclusion Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

During the current COVID-19 pandemic video consultations are increasingly common in order to minimize the risk of infection for staff and patients. The aim of this study was to evaluate the feasibility of a spine examination via video.A total of 43 patients were recruited. Each participant underwent a video-based (VB) and a conventional face-to-face (FTF) spine examination. Pain intensity, active range of motion, inspection, a neurophysiologic basic exam and provocations tests were evaluated using video-based and face-to-face methods.The intra-rater reliability (IRR) was measured between both examinations. Good to very good IRR values were obtained in inspection (Kappa between 0,752 und 0,944), active range of motion and basic neurophysiological examination (Kappa between 0,659 und 0,969). Only moderate matches were found in specific provocation tests (Kappa between 0,407 und 0,938). A video-based spine examination is a reliable tool for measuring pain intensity, active range of motion and a basic neurophysiologic exam.A basic spine examination during a video consultation is possible. A good agreement of the test results between video-based and face-to-face examination could be found.Während der aktuellen COVID-19-Pandemie sind Videosprechstunden zur Kontaktvermeidung zunehmend verbreitet. Die vorliegende Studie soll die Machbarkeit einer Wirbelsäulenuntersuchung im Rahmen einer Videosprechstunde evaluieren.Es wurden 43 Patienten in unserer Klinikambulanz untersucht. Die Patienten wurden zunächst videogestützt und unmittelbar später mit direkten Arzt-Patienten-Kontakt untersucht. Zur Strukturierung der Untersuchungsergebnisse wurde bei allen Untersuchungen ein systematischer Frage- und Untersuchungsbogen verwendet. Gemessen wurde die Intrarater-Reliabilität (IRR) zwischen beiden Untersuchungsdurchgängen.Gute bis sehr gute IRR-Werte ergaben sich bei Inspektion (Kappa zwischen 0,752 und 0,944), Bewegungsausmaßen und neurophysiologischer Basisuntersuchung (Kappa zwischen 0,659 und 0,969). Nur moderate Übereinstimmungen konnten bei spezifischen Provokationstests (Kappa zwischen 0,407 und 0,938) gefunden werden.Eine Basisuntersuchung der Wirbelsäule ist im Rahmen einer Videosprechstunde möglich. Es konnte eine gute Übereinstimmung der Testergebnisse zwischen videogestützter und direkter Arztuntersuchung gefunden werden.

To evaluate the comparative effectiveness and safety of anterior cervical corpectomy with fusion (ACCF), laminoplasty (LP), and laminectomy and instrumented fusion (LF) in the treatment of ossification of the posterior longitudinal ligament (OPLL).Embase, Pubmed, and Cochrane library were searched from their date of inception to June 13, 2020. Relevant randomized controlled trials (RCTs) and cohort studies comparing different procedures among ACCF, LP, and LF were identified, data were extracted to perform a network meta-analysis (NMA). The outcomes were the Japanese Orthopedic Association (JOA) score and complications.We deemed 14 trials eligible, including 877 patients. In NMA, ACCF showed a significant improvement of JOA score compared with LP [MD= -0.89, 95% CI (-1.73, -0.18)], but no significant difference was found when compared LF with ACCF or LP. No significant differences in complications were found when compared LF with LP or ACCF, while ACCF showed significantly higher in complications than LP [OR = 1.99, 95% CI (1.10, 3.35)]. The surface under the cumulative ranking curves (SUCRA) showed that the rank of JOA score improvement is as follows: ACCF (82.5%), LF (79.5%), and LP (2.3%). And the rank of complication rate is as follows: LF (65.8%), ACCF (68.4%), and LP (2.1%).The biggest limitation was that none of the included studies were RCTs.Despite the higher probability of complications than LP, ACCF was the more recommended procedure for its highest ranking spectrums of JOA score improvement to treat the OPLL.

A Symptomatic Minor Instability of the Lateral Elbow (SMILE) is a possible etiology of recalcitrant lateral elbow pain: in this condition, the deficiency of the radial band of the lateral collateral ligament as a static elbow stabilizer plays a relevant role, determining hypermobility of the radial head, chondral abrasions, and synovitis associated to intra-articular pain and tendinopathy of the extensor carpi radialis brevis associated to extra-articular pain.

Periprosthetic joint infection (PJI) is a feared complication after arthroplasty. Our hypothesis was that PJI caused by difficult-to-treat (DTT) pathogens has a worse outcome compared with non-DTT PJI. Routine clinical data on 77 consecutive patients with confirmed PJI treated with 2-stage exchange arthroplasty were placed in DTT and non-DTT PJI groups and analyzed. The main outcome variable was that the patient was definitively free of infection after 2 years. We found definitive infection resolution in 31 patients in the DTT group (68.9%) and 28 patients (87.5%) in the non-DTT group (P < 0.05). The necessity for revision surgery until assumed resolution of infection was significantly more frequent in the DTT group with 4.72 ± 3.03 operations versus 2.41 ± 3.02 operations in the non-DTT group (P < 0.05). PJI caused by DTT bacteria is associated with significantly higher numbers of revision operations and significantly inferior definitive infection resolution.

Durch Storung des Wachstums, z. B. im Rahmen einer kongenitalen Huftluxation, eines Morbus Perthes oder einer bakteriellen Coxitis, kann bei Kindern und Jugendlichen durch Fehlwachstum eine typische Deformitat des proximalen Femur mit verkurztem Schenkelhals und hochstehendem Trochanter major entstehen. Von Morscher und Buess wurde bereits 1988 eine Schenkelhalsverlangerungsosteotomie zur Therapie Erwachsener beschriebenen. Wir zeigen erstmalig die Modifikation der „Morscher-Osteotomie“ bei Kindern und Jugendlichen mit einem winkelstabilen Osteosynthesesystem. Ziel der schenkelhalsverlangernden Osteotomie ist die bestmogliche Wiederherstellung der normalen Anatomie mit anatomischer Schenkelhalslange und einer weitgehend artikulotrochantaren Distanz bei Kindern und Jugendlichen. Alle klinisch relevanten Deformierungen des proximalen Femur mit kurzem Schenkelhals und konsekutivem Trochanterhochstand. Eitrige Koxitis innerhalb der letzten zwei Jahre; erhohte Infektparameter. Unzureichende Zentrierung des Femurkopfs im Azetabulum. Zwei Osteotomieschnitte. Erste Osteotomie im Bereich des Trochanter major. Distalisierung des Trochanterfragments, anschliesende intertrochantare Femurosteotomie. Stabilisierung mittels winkelstabiler Platte (130°-Padiatrie-Huftplatte, Fa. Synthes, Oberdorf, Schweiz). Bis 55 kg Korpergewicht schmerzadaptierte Vollbelastung; >55 kg Korpergewicht Teilbelastung fur 6 Wochen postoperativ. Bei 5 weiblichen Patienten (mittleres Alter 11,67 Jahre) traten intra- und postoperativ keine Komplikationen auf; nach 6–12 Wochen negatives Trendelenburg-Zeichen; nach 3–6 Monaten nahezu freier Bewegungsumfang.

Failed total knee arthroplasty (TKA) with significant bone loss and compromised soft-tissues is challenging and the final results are often inferior to patient’s expectation. The objective of this study was to present a comparison of outcomes in patients with failed infected TKA treated with two-stage revision TKA or knee arthrodesis and to assess clinical and functional results, implant survival and infection recurrence. The hypothesis was that an arthrodesis may result in beneficial effects on patients’ outcome. Clinical data of 81 patients with periprosthetic joint infection (PJI) of the knee joint were collected and analyzed retrospectively. Between 2008 and 2014, a total of 36 patients had been treated within a two-stage exchange procedure and reimplantation of a modular intramedullary arthodesis nail and 45 patients with revision TKA. Patients were treated according to the same structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford knee score (OKS) and the visual analogue scale (VAS). The mean follow-up was 32.9 ± 14.0 months. The rate of definitely free of infection at last follow-up in the arthrodesis group was 32 of 36 (88.9%) and 36 of 45 (80.0%) in the revision TKA group (p = 0.272). Mean VAS for pain in the arthrodesis group was 3.1 ± 1.4 compared to 3.2 ± 1.6 in the revision TKA group (p = 0.636). The OKS in the arthrodesis group was 38.7 ± 8.9 and 36.5 ± 8.9 (p = 0.246) in patients with revision TKA. Rate of revisions in the revision-TKA group was 2.8 ± 3.7 compared to 1.2 ± 2.4 in the arthrodesis group (p = 0.021). Treatment of PJI needs a distinct therapy with possible fallback strategies in case of failure. A knee arthrodesis is a limb salvage procedure that showed no significant benefits on the considered outcome factors compared to revision TKA but is associated with significantly lower revision rate. After exhausted treatment modalities, a knee arthrodesis should be considered as an option in selected patients. Level III, retrospective cohort study.

Surgical equipment, and especially the so-called ‘splash basins’ that are used intraoperatively, are a potential source of bacterial contamination in primary total hip arthroplasty (THA). With this risk in mind, many commercially available draping kits include plastic bags that can be used to collect fluid or to temporarily store instruments. Following this rationale, we hypothesised that first: the fluid collection bags are a potential reservoir of bacteria and second: there is a time dependency for bacterial contamination. After ethics approval, we investigated in a prospective, internally controlled, non-blinded trial 43 patients who received primary THA. At the beginning of the surgery, we took deep, representative, intracapsular tissue samples, which served as negative controls. At the end of surgery, tissue samples were taken from the bottom of the ‘fluid collection bag’ for microbiological analysis. All 86 control samples were negative. Out of the samples taken from the bags, a pathogen could be detected in four patients (9.3%). All pathogens were detected after a surgery time lasting longer than 90 min. We were able to show that fluid collection bags are a potential reservoir for bacteria in THA when surgery time was greater than a 90-min threshold. Our data suggest that the risks from fluid collection bags outweigh the advantages of using them. Therefore, we recommend against the use of fluid collection bags intraoperatively in primary THA.

The use of Ceramic-on-Ceramic (CoC) bearings in primary total hip arthroplasty (THA) is increasing and has been intensively analysed. This bearing plays a particularly relevant role in young, active patients and shows advantages over other bearings in biocompatibility, wear rate and lubrication properties. On the contrary, CoC bearings in revision THA are seldom used and scarcely analysed. The aim of this study is to systematically review the available literature on CoC bearings in revision THA.A systematic research in the English literature was performed to identify all studies reporting results of THA revisions using ceramic-on-ceramic bearing. The initial search strategy revealed 555 articles for consideration. On the basis of eligibility criteria, 26 studies were included in this review.Twenty-six studies, accounting for 1846 procedures, were eligible and included in the review. No studies of Level I were identified. Eighteen studies reported on revisions of CoC implants for various reasons, performed either with CoC or different bearings. In 111 patients a CoC bearing was used for the revision. Six studies consistently reported outcome measures for CoC bearing THA revisions, so that a quantitative synthesis of the data was possible. The range of follow-up across the six studies varied between 2.1 and 19 years, with a cumulative avearage follow-up of 9.3 years. A good functional result was documented, with a cumulative weighted mean for postoperative Harris Hip Score (HHS) of 87 points. The rate of dislocation in this group was 3.45% and the risk of fracture of an alumina ceramic head was 0.35% (1 study). Squeaking was reported as complication of CoC bearing THA revisions in three studies, with a calculated incidence of 0.52%.Modern CoC bearings show advantages in preclinical and retrospective studies over other bearings also in revision cases and are therefore to be considered a promising alternative for this kind of operation. Reasonable indications for CoC bearing in revision THA are revisions for aseptic loosening or recurrent dislocation in young patients, fractures of ceramic components, large acetabular defects or in patients that are allergic to bone cement components. Nevertheless, prospectively designed or randomized studies are lacking and needed to confirm CoC as optimal solution for revision THA cases.Die Anwendung von modernen Keramik-Keramik-Gleitpaarungen (Ceramic-on-Ceramic, CoC) in der primären Hüftendoprothetik ist zunehmend und gut dokumentiert. Sie hat ihren Stellenwert insbesondere bei jungen und aktiven Patienten und zeigt Vorteile hinsichtlich Biokompatibilität, Abriebrate und Lubrikationseigenschaft. Dagegen ist die Gleitpaarung in der Revisionsendoprothetik seltener genutzt und unzureichend untersucht. Ziel dieser Übersichtsarbeit ist eine Analyse der vorliegenden Literatur zu CoC-Gleitpaarungen in der Revisionsendoprothetik des Hüftgelenks.Es erfolgte eine systematische Literaturrecherche der MEDLINE-Datenbank, wobei ausschließlich Artikel in englischer Sprache eingeschlossen wurden. Die initiale Suche ergab 555 Artikel, die nach Analyse definierter Ein- und Ausschlusskriterien auf 26 reduziert wurden und zur Metaanalyse dieser Arbeit eingeschlossen werden konnten.In den analysierten Studien wurden insgesamt 1846 Operationen eingeschlossen, wobei keine Level-I-Studie identifiziert werden konnte. In 18 Studien wurde auf Revisionen mit Verwendung von CoC-Gleitpaarungen bei 111 Patienten aufgrund unterschiedlicher Indikationen eingegangen. Bei insgesamt 6 dieser Studien wurden Outcome-Parameter mittels Harris Hip Score (HHS) oder eines anderen Scoring-Systems erhoben, sodass hier eine quantitative Datenanalyse durchgeführt werden konnte. Die Zeitspanne des Follow-ups lag bei 2,1 – 19 Jahren mit einer mittleren Nachuntersuchungsdauer von 9,3 Jahren. Es zeigte sich ein gutes funktionelles Ergebnis, mit einem kumulativen Mittelwert für den HHS von 87 Punkten. Die Luxationsrate lag bei 3,45% und das Risiko eines Keramikbruchs des Aluminiumoxidkopfes bei 0,35% (1 Studie). Squeaking wurde als Komplikation der CoC-Gleitpaarung bei Revisionen in 3 Studien berichtet, mit einer kalkulierten Inzidenz von 0,52%.Moderne CoC-Gleitpaarungen zeigen in präklinischen und retrospektiven Studien im Revisionsfall Vorteile und sind eine vielversprechende Alternative zu herkömmlichen Verfahren. Dies gilt insbesondere für jüngere Patienten und Wechselsituationen mit erhöhtem Luxationsrisiko, Zementallergien, Protheseninfektion und stattgehabten Keramikbrüchen. Es fehlen randomisierte kontrollierte Studien, die Gleitpaarungen hinsichtlich Luxationsraten, Materialversagen oder klinischem Outcome vergleichen, um eine optimale Lösung im Revisionsfall empfehlen zu können.

Segmental tibia fractures are demanding injuries with high complication rates that should be treated in specialized trauma centers. The fracture pattern is often seen ager high-energy traumas and can be accompanied with severe tissue damages. The reported incidences of segmental fracture is 3–12%, and even experienced surgeons may find reduction and definitive fracture fixation challenging. Nonunion, anterior knee pain, or varus-valgus malalignment are some possible complications that can occur and lead to revision surgery or a poor functional outcome. Due to new nail designs and multiple interlocking possibilities, the spectrum of nailing has significantly increased. An interdisciplinary approach can be the key for a fast and proper fracture treatment. The following chapter guides through the required steps during surgery and provides tips and tricks for reduction and intramedullary fixation.

BACKGROUND Leiomyosacromas in the Extremities are rare malignant smooth muscle tumors. Adjuvant radiation therapy, in combination with wide surgical excision allows the best chance of treatment. During the follow up pathological fractures are common complications that can be accompanied by Implant failure and defect situations that are most challenging in their management. CASE SUMMARY We present a case of a 52-year-old female suffering from a pathological fracture of the humeral shaft 10 yr after resection of a Leiomyosarcoma and postoperative radiotherapy. She developed implant failure after retrograde nailing and another failure after revision to double plate fixation. In a two-stage revision, the implants were removed and the huge segmental defect created after debridement was bridged by a compound osteosynthesis with nancy nails and bone cement for formation of the induced membrane. Due to the previous radiotherapy treatment, 20 cm of the humeral shaft were declared devascularized but were left in situ as a scaffold. In the second stage, a vascularized fibula graft was used in combination with a double plate fixation and autologous spongiosa grafts for final reconstruction. CONCLUSION This combinatory treatment approach led to a successful clinical outcome and can be considered in similar challenging cases.

Background High ankle sprains are insidious injuries associated with a long recovery period, functional impairment and long-term sequelae if mistreated. This systematic review investigates the biomechanical knowledge on the kinematic consequences of sequential syndesmotic ligamentous injuries, aiming to furnish an updated and objective contribution for the critical appraisal and further elaboration of current diagnostic algorithms for high ankle sprains. Methods A systematic review was performed to identify human biomechanical studies evaluating the stabilizing role of the syndesmotic ligaments. Special attention was paid to identify the smallest lesion within the progressive simulated injuries able to provoke statistically significant changes of the syndesmotic kinematic on the specimen, the mechanical solicitation that provoked it, and the measurement methodology. Findings Fourteen studies were included. In eight articles already an isolated injury to the anterior inferior tibiofibular ligament provoked significant changes of the syndesmotic kinematic, which was always depicted under an external rotation torque. In three articles an isolated deltoid ligament injury provoked significant changes of the syndesmotic kinematic. Four articles described a direct measure of the bony movements, whereas seven collected data through conventional radiography or CT-scan imaging and three via a 3D motion analysis tracking system. Interpretation An isolated lesion of the anterior inferior tibiofibular ligament can provoke significant kinematic modifications in ex vivo syndesmotic models and may be responsible of subtle patterns of dynamic instability, regardless of further syndesmotic ligamentous injuries. The data observed support efforts to define reliable CT imaging parameters to improve non-invasive diagnostic of subtle forms of syndesmotic instability.

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Complex tracheobronchial injuries, especially if both main bronchi are involved, are life threatening and their diagnosis and successful treatment concerning short-term as well as long-term results are most challenging. This is the first report on a successful reconstruction of a complex bilateral bronchial injury under extracorporeal membrane oxygenation (ECMO) support. We present the course from prehospital treatment, establishment of ECMO in the emergency room to initial bronchoscopy, operative reconstruction, and intensive care therapy. Under these special circumstances ECMO provided a stable respiratory situation not only preoperatively but also intraoperatively without aggravating a compensated bronchial situation under aggressive ventilation.

BACKGROUND The objective was to evaluate whether the new intraoperative C-arm guiding system ClearGuide® (CG) reduces radiation exposure of the staff in an Orthopaedic and Trauma operation theatre. METHODS Data of 95 patients CG was used were retrospectively compared using matched-pair analysis with controls without CG. Radiation dose (RD), fluoroscopic time (FT) and operation time (OT) were analysed in ten types of operative procedures. RESULTS Use of CG led to a significant reduction (p ≤ 0.05) of the RD in intramedullary nailing and plate fixation of femoral shaft fractures as well as plating of tibia shaft fractures. Concerning FT, use of CG led to a significant reduction (p ≤ 0.05) while performing kyphoplasties and plate fixation of femoral shaft fractures. Regarding OT, no statistical significance was observed. CONCLUSIONS CG as a simple, reproducible and intuitive communication tool for C-arm guidance reduces intraoperative staff radiation exposure especially while fixation of long bone fractures and in spine surgery.

Erratum to:Oper Orthop Traumatol 2018 https://doi.org/10.1007/s00064-018-0561-9 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to authors and readers.