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Was macht eine „gute Osteosynthese“ aus? Obwohl die Frage trivial erscheint, ergeben sich bei genauerer Betrachtung doch mannigfaltige Faktoren, welche einen Einfluss auf die Frakturheilung haben, sodass sie sich letztendlich doch nicht so einfach beantworten lasst. Bereits bei der Anamnese und initialen Diagnostik werden die ersten Weichen gestellt. Eine adaquate Analyse der Fraktur mit einem schlussigen praoperativen Konzept zur Stabilisierung unter den wissenschaftlich aktuellsten Erkenntnissen und eine nachfolgend adaquate Umsetzung der Planung im Operationssaal machen den Erfolg einer Osteosynthese und damit die „gute Osteosynthese“ aus. Dabei spielen digitale Unterstutzungen eine immer wesentlichere Rolle. Diese Ubersichtsarbeit setzt sich intensiv mit dem Thema auseinander und fasst die wichtigsten Elemente der notwendigen Kaskade zusammen.

Aims The follow-up interval of a study represents an important aspect that is frequently mentioned in the title of the manuscript. Authors arbitrarily define whether the follow-up of their study is short-, mid-, or long-term. There is no clear consensus in that regard and definitions show a large range of variation. It was therefore the aim of this study to systematically identify clinical research published in high-impact orthopaedic journals in the last five years and extract follow-up information to deduce corresponding evidence-based definitions of short-, mid-, and long-term follow-up. Methods A systematic literature search was performed to identify papers published in the six highest ranked orthopaedic journals during the years 2015 to 2019. Follow-up intervals were analyzed. Each article was assigned to a corresponding subspecialty field: sports traumatology, knee arthroplasty and reconstruction, hip-preserving surgery, hip arthroplasty, shoulder and elbow arthroplasty, hand and wrist, foot and ankle, paediatric orthopaedics, orthopaedic trauma, spine, and tumour. Mean follow-up data were tabulated for the corresponding subspecialty fields. Comparison between means was conducted using analysis of variance. Results Of 16,161 published articles, 590 met the inclusion criteria. Of these, 321 were of level IV evidence, 176 level III, 53 level II, and 40 level I. Considering all included articles, a long-term study published in the included high impact journals had a mean follow-up of 151.6 months, a mid-term study of 63.5 months, and a short-term study of 30.0 months. Conclusion The results of this study provide evidence-based definitions for orthopaedic follow-up intervals that should provide a citable standard for the planning of clinical studies. A minimum mean follow-up of a short-term study should be 30 months (2.5 years), while a mid-term study should aim for a mean follow-up of 60 months (five years), and a long-term study should aim for a mean of 150 months (12.5 years). Level of Evidence: Level I. Cite this article: Bone Jt Open 2021;2(5):344–350.

PurposeThe original Caton-Deschamps index (oCDI) detects functional patella height. It cannot be used in knees with an implanted endoprosthesis. The “modified Caton-Deschamps index” (mCDI) for knee arthroplasty can miss pseudo-patella-infera (PPI), which is common after TKA. A derivate of the oCDI could be a simple analogue to the index published in 1982 using a modified tibial reference point at the anterior proximal point of the inlay, which can indirectly be located on the lateral knee radiograph. It was the aim of this study to determine the intra- and inter-rater agreement of a derived Caton-Deschamps index (dCDI) for knee arthroplasty. We hypothesized that the derived Caton-Deschamps index (dCDI) is a reliable radiological measure for patella height in knee arthroplasty.MethodsSeveral patella height indices were measured by three independent raters in two passes. The second pass was performed after 6 weeks in random order. Intra- and inter-observer agreements were determined and analyzed using the intraclass correlation coefficient (ICC). For radiographic evaluation, digital lateral radiographs of 150 knees before and after primary TKA were used.ResultsWe found high interrater reliability for all analyzed indices. We found the highest agreements for the ISI preop (ICC = 0.914) and postop (ICC = 0.920), respectively. We also found very good intra-rater reliability for the CDI (ICCpreop = 0.954), dCDI (ICCpostop = 0.945), ISI (ICCpreop = 0.960; ICCpostop=0.940) and BPI (ICCpreop = 0.969; ICCpostop = 0.955). Fourteen cases (9.3%) with insignificant PPI were found.ConclusionThe derived Caton-Deschamps index (dCDI) can easily be used in knee arthroplasty and demonstrated high intra- and interrater agreement, which was similar to other commonly used and established patella height indices.

Introduction Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the remaining planes and adjacent joints are still to be defined. It was, therefore, the aim of this study to determine the influence of a distal femoral rotation osteotomy on the coronal limb alignment and on the ischiofemoral space of the hip joint. Materials and methods Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar rotational osteotomies of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip–knee–ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), and the ischiofemoral space were measured. Comparison between means was performed using the Wilcoxon–Mann–Whitney test. Results Twenty-seven patients underwent isolated supracondylar external rotation osteotomy to reduce the overall antetorsion of the femur. The osteotomy resulted in a 2.4° ± 1.4° mean increase in HKA and 2.4 mm ± 1.7 mm increase in the ischiofemoral space (p Conclusion Supracondylar external rotation osteotomy of the femur leads to valgisation of the coronal limb alignment and increases the ischiofemoral space. This is resultant to the reorientation of the femoral antecurvature and the femoral neck. When planning a rotational osteotomy of the lower limb, this should be appreciated and may also aid in the decision regarding osteotomy site.

Aims The anterior cruciate ligament (ACL) is known to have a poor wound healing capacity, whereas other ligaments outside of the knee joint capsule such as the medial collateral ligament (MCL) apparently heal more easily. Plasmin has been identified as a major component in the synovial fluid that varies among patients. The aim of this study was to test whether plasmin, a component of synovial fluid, could be a main factor responsible for the poor wound healing capacity of the ACL. Methods The effects of increasing concentrations of plasmin (0, 0.1, 1, 10, and 50 µg/ml) onto the wound closing speed (WCS) of primary ACL-derived ligamentocytes (ACL-LCs) were tested using wound scratch assay and time-lapse phase-contrast microscopy. Additionally, relative expression changes (quantitative PCR (qPCR)) of major LC-relevant genes and catabolic genes were investigated. The positive controls were 10% fetal calf serum (FCS) and platelet-derived growth factor (PDGF). Results WCS did not differ significantly among no plasmin versus each of the tested concentrations (six donors). The positive controls with PDGF and with FCS differed significantly from the negative controls. However, we found a trend demonstrating that higher plasmin concentrations up-regulate the expression of matrix metalloproteinase 13 ( MMP13), 3 ( MMP3), and tenomodulin ( TNMD). Conclusion The clinical relevance of this study is the possibility that it is not solely the plasmin, but also additional factors in the synovial fluid of the knee, that may be responsible for the poor healing capacity of the ACL. Cite this article: Bone Joint Res 2020;9(9):543–553.

Background: Periacetabular osteotomy (PAO) has become a popular procedure for re-orientation of the acetabulum in patients with a developmental pathomorphology. Since its first description by Reinhold Ganz in 1988, many institutions worldwide have adopted the procedure for the treatment of developmental hip dysplasia (DDH) and have subsequently reported their results. The aim of this study was to provide a meta-analysis of the likelihood of long-term survival of a dysplastic hip after PAO. Methods: A systematic literature review was conducted using Medline, Cochrane and “Web of Science” databases to identify articles reporting survival estimates for PAO in patients with DDH. To be included in the analysis, studies had to include patient cohorts aged Results: Nine relevant articles included 2268 dysplastic hips that underwent PAO in 9 institutions. Of the included studies, 5 presented level III evidence and 4 presented level IV evidence. The MINORS score was 11 for 3 studies, 12 for 4 studies and 13 for 2 studies. The 5-year survival after PAO was 96.1% (95% CI, 94.9–97.3), the 10-year survival was 91.3% (95% CI, 87.7–94.8), 15-year survival 85.0% (95% CI, 78.9–91.1), 20-year survival 67.6% (95% CI, 53.9–81.3). Conclusions: The results provide a representative survival estimate of a dysplastic hip after PAO based on global evidence. This should provide clinicians and patients with an adequate reflection of prognostic expectations after this kind of surgery.

It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports. Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed. Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and patient age have been found to influence the risk of failure. There is sufficient evidence to support that DIS repair may be an effective modality for the treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors. IV.

Revision total knee arthroplasty (RTKA) represents an effective treatment for failed TKA, but with less favorable outcomes. Considering the technical complexity and economic burden of RTKA procedures, it is mandatory to investigate current mechanisms and predictors for RTKA failure. The objective of this study is to evaluate the survivorship and determine the predominant causes of failure of RTKA. A total of 146 patients undergoing RTKA between 2003 and 2013 were identified from the institutional database. Revision was defined as surgery in which the whole prostheses (inlay and both femoral and tibial components) required exchange. Median follow-up was 6.3 ± 2.7 years (range: 2.2–10). Patient demographics, year of primary implantation, reasons for revision surgery, implant type, pain, knee mobility, systemic or local postoperative complications, and treatment of the complications were recorded and evaluated. Infection was a major cause of failure followed by aseptic loosening, instability, pain, malalignment, and inlay wear. Following RTKA, Knee Society Score (KSS) (knee score and functional score) demonstrated a significant improvement (p

Study Design: Retrospective comparative study. Objectives: To assess the effect of vertebral body lavage (VBL) on (1) systemic blood pressure, (2) heart rate, and (3) oxygen saturation following cement augmentation procedures for acute vertebral compression fractures (VCFs). Methods: A total of 145 consecutive patients undergoing cement augmentation for acute VCF (mean age 74 ± 12 years, age range 42-96 years; 70% female; 475 levels treated) were allocated to the “lavage group” (n = 61 patients; VBL prior to cement application) and to the “control group” (n = 84 patients, no VBL). Mean arterial blood pressure (MAP), heart rate, and oxygen saturation were monitored immediately prior and 3 minutes after cement injection. Logistic regression analysis was performed with ΔMAP ≥10 mm Hg before and after cement injection as the dependent outcome variable and demographic, radiographic, and procedural factors as independent variables. Results: MAP decreased by mean 3 ± 7.3 mm Hg before and after cement injection in the “lavage group” and 9 ± 10.5 mmHg in the control group ( P < .001). There were no significant differences in terms of heart rate and oxygen saturation before and after cement application within each group, or between the 2 groups. Multivariate logistic regression analyses revealed VBL as an independent factor influencing MAP (adjusted odds ratio: 3.49 [confidence interval, 1.16-10.50], P = .03). Conclusion: VBL prior to cement augmentation procedures reduces the hemodynamic response, most likely resulting from decreased amounts of bone marrow substance displaced into the circulation thereby decreasing the risk of pulmonary fat embolism syndrome.

PURPOSE It was the aim to assess the influence of synovial sheath disruption on early failure of primary anterior cruciate ligament (ACL) repair. It was hypothesized that more-part ACL tears with disruption of the synovial sheath are associated with a higher risk of failure after primary ACL repair. METHODS A cohort study was conducted comprising patients with primal ACL tears undergoing primary ACL repair and dynamic intraligamentary stabilization (DIS). The patients were stratified into three groups: A-one-part rupture with intact synovial membrane (n = 50), B-two-part ruptures resultant to separation of the ACL into two main bundles with synovial membrane tearing (n = 52) and C-more parts involving multilacerated ruptures with membrane disruption (n = 22). Failure was defined as a retear or residual laxity (anterior posterior translation > 5 mm compared to healthy knee). Adjustment for potential risk factors was performed using a multivariate logistic-regression model. RESULTS The overall failure rate was 17.7% throughout the mean follow-up period of 2.3 ± 0.8 years. The failure rate in patients with one-part ACL tears with an intact synovial membrane was 4% (n = 2) (Group A), which was significantly lower than the failure rates in groups B and C, 26.9% (n = 14) (p = 0.001) and 27.3% (n = 6) (p = 0.003), respectively. Disruption of the synovial sheath in two- or more-part tears was identified as an independent factor influencing treatment failure in primary ACL repair (OR 8.9; 95% CI 2.0-40.0). CONCLUSION The integrity of the ACL bundles and synovial sheath is a factor that influences the success of ACL repair. This needs to be considered intra-operatively when deciding about repair. LEVEL OF EVIDENCE IV.

Introduction Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation. Materials and methods Long-leg standing radiographs of 154 consecutive patients undergoing valgisation or varisation osteotomy around the knee in 2017 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip knee ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), the mechanical medial proximal tibia angle (mMPTA) and five angles around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test. Results One hundred fifty-four patients (96 males, 58 females) underwent osteotomies around the knee for coronal realignment. The mean age was 51 ± 11 years. Correction osteotomies consisted of 73 HTO, 54 DFOs, and 27 double level osteotomies. Of all osteotomies, 118 were for valgisation and 36 for varisation. For valgisation osteotomies, the mean HKA changed from 5.8° ± 2.9° preoperatively to − 0.9° ± 2.5° postoperatively, whereas the mMPTA changed from 85.9° ± 2.7° to 90.7° ± 3.1° and the malleolar-horizontal-orientation-angle (MHA) changed from 16.4° ± 4.2° to 10.9° ± 4.2°. For varisation osteotomies, the mean HKA changed from − 4.3° ± 3.7° to 1.1° ± 2.2° postoperatively, whereas the mLDFA changed from 85.7° ± 2.2° to 89.3° ± 2.3° and the MHA changed from 8.8° ± 5.1° to 11.2° ± 3.2°. Conclusion Osteotomies around the knee for correction of coronal limb alignment not only lead to lateralization or medialization of the weight-bearing line at the knee but also lead to a coronal reorientation of the ankle. This can be measured at the ankle using the MHA. When planning an osteotomy around the knee for correction of genu varum or valgum, the ankle should also be appreciated—especially in patients with preexisting deformities, ligament instabilities, or joint degeneration around the ankle.

Aims The Oswestry-Bristol Classification (OBC) was recently described as an MRI-based classification tool for the femoral trochlear. The authors demonstrated better inter- and intraobserver agreement compared to the Dejour classification. As the OBC could potentially provide a very useful MRI-based grading system for trochlear dysplasia, it was the aim to determine the inter- and intraobserver reliability of the classification system from the perspective of the non-founder. Methods Two orthopaedic surgeons independently assessed 50 MRI scans for trochlear dysplasia and classified each according to the OBC. Both observers repeated the assessments after six weeks. The inter- and intraobserver agreement was determined using Cohen’s kappa statistic and S-statistic nominal and linear weights. Results The OBC with grading into four different trochlear forms showed excellent inter- and intraobserver agreement with a mean kappa of 0.78. Conclusion The OBC is a simple MRI-based classification system with high inter- and intraobserver reliability. It could present a useful tool for grading the severity of trochlear dysplasia in daily practice. Cite this article: Bone Joint Open 2020;1-7:355–358.

Description of a reproducible surgical technique for single-bundle anterolateral reconstruction of the posterior cruciate ligament (PCL) based on a septum-sparing approach. This technique is less traumatic than the trans-septum approach. The article illustrates surgical steps to simplify the technical aspects of the procedure.A complete grade III symptomatic tear of the PCL associated with instability and often discomfort (deceleration, stairs) or subsequent gonalgia arising from the medial compartment or patellofemoral joint. Injury of the peripheral joint stabilizers alongside the PCL including the posterolateral corner or a complete medial knee injury. The procedure is indicated in chronic cases, but also in acute cases of posterior instability 10 mm, if it is an intraligamentous tear with dislocated PCL stumps.Bony avulsions of the PCL suitable for refixation, soft tissue compromise, infection, advanced osteoarthritic disease.After diagnostic arthroscopy of the knee, the ipsilateral semitendinosus and gracilis tendons are harvested and prepared as a 6-strand graft for PCL reconstruction. One high anterolateral viewing portal, one low anterolateral portal, one anteromedial portal, and a posteromedial portal are used for single-bundle reconstruction via one femoral and one tibial bone tunnel and hybrid graft fixation.Weight bearing is restricted to 20 kg for 6 weeks. PCL brace with tibial support for a period of 12 weeks. Flexion is limited to 30° in the first 2 postoperative weeks, then 60° for 2 weeks, and 90° for 2 further weeks. Passive flexion in prone position is performed. Active focused muscle strengthening exercise is begun after 6 weeks postoperatively and participation in competitive sports is not recommended before full muscle strength and coordination is re-established, at the earliest 9-12 months postoperatively.Two isolated and 19 combined PCL injuries were treated. Mean patient age was 27.4 years, and the minimal follow-up was 12 months. On average, we found good clinical outcome with slight degree of posterior laxity (4.1 mm) after PCL reconstruction in comparison with the contralateral knee. No patient showed signs of effusion at follow-up. Range of motion was fully restored in 19 of 21 patients. One patient suffered failure due to persistent posterior instability and persistence of symptoms.OPERATIONSZIEL: Beschreibung einer reproduzierbaren Operationstechnik zur einsträngigen anterolateralen Rekonstruktion des hinteren Kreuzbandes (HBK) auf der Grundlage eines septumerhaltenden Zugangs. Diese Technik ist weniger traumatisch als der transseptale Zugang. Der Beitrag veranschaulicht die Operationsschritte zur Vereinfachung der technischen Aspekte des Verfahrens.Eine vollständige, drittgradige und symptomatische HBK-Ruptur, verbunden mit einem Instabilitätsgefühl und häufigen Beschwerden (Dezeleration, Treppensteigen) oder anschließender, vom medialen Kompartiment oder Patellofemoralgelenk ausgehender Gonalgie. Verletzung der peripheren Gelenkstabilisatoren neben dem HKB einschließlich der posterolateralen Zone oder eine komplette mediale Knieverletzung. Der Eingriff ist indiziert bei chronischen Fällen, aber auch bei akuter posteriorer Instabilität10 mm, wenn es sich um eine intraligamentäre Ruptur mit dislozierten PCL-Stümpfen handelt.Knöcherne HKB-Ausrisse, die sich refixieren lassen, ausgeprägter Weichteilschaden, Infektion, fortgeschrittene Gonarthrose.Nach diagnostischer Arthroskopie des Kniegelenks Entnahme der ipsilateralen Semitendinosus- und Gracilissehne als 6‑fach-Graft zur HKB-Rekonstruktion. Anlage eines hohen anterolateralen Arthroskopieportals sowie weiterer Arbeitsportale: tief anterolateral, anteromedial und posteromedial. Über die Anlage eines femoralen und eines tibialen Bohrkanals erfolgt die einsträngige Ersatzplastik des HKB mit Hybridfixation des Grafts.Teilbelastung 20 kg für 6 Wochen. HKB-Orthese mit tibialer Unterstützung 12 Wochen postoperativ. Flexionslimitierung auf 30° für die ersten 2 Wochen, dann 60° für 2 Wochen, dann 90° für weitere 2 Wochen. Passive Flexion in Bauchlage wird durchgeführt. Training der aktiv-dynamischen Kniegelenkstabilisatoren startet ab der 7. postoperativen Woche. Empfohlen wird, Freizeit- und Wettkampfsport erst wiederaufzunehmen, wenn Kraft und Koordination vollständig wiederhergestellt sind, frühestens 9–12 Monate postoperativ.Zwei isolierte und 19 kombinierte HKB-Verletzungen wurden behandelt. Das durchschnittliche Patientenalter betrug 27,4 Jahre und das minimale Follow-up 12 Monate. Nach HKB-Ersatzplastik fanden wir durchschnittlich gute klinische Ergebnisse mit geringer hinterer Kniegelenklaxizität (4,1 mm) im Vergleich zur gesunden Gegenseite. Bei der Nachuntersuchung zeigte klinisch kein Patient einen Gelenkerguss. Die Beweglichkeit des operierten Kniegelenks war in 19 von 21 Fällen vollständig wieder hergestellt. Ein Patient erlitt ein Graftversagen, was sich anhand einer fortgesetzten posterioren Instabilität und anhaltenden Symptomen bemerkbar machte.

PURPOSE Primary repair of the anterior cruciate ligament (ACL) is regaining popularity. Long-term results are lacking. The purpose of the current study was to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization. METHODS Between 2011 and 2013, 57 patients with acute proximal ACL ruptures underwent DIS repair within 3 weeks from injury and were available for final follow-up at least 5 years postoperatively. Failure as an end point was defined as conversion to ACL reconstruction, failure to restore stability with persisting laxity side-to-side laxity of > 5 mm or a late-traumatic re-rupture or loss of stability. Kaplan-Meier survival analysis was performed. RESULTS Kaplan-Meier survival analysis demonstrated an overall survival of 70.0% (standard error SE 6.6%) at 74 months follow-up. Patients performing competitive sports prior to injury demonstrated an inferior long-term ACL survival of 56.4% (SE 11.6%). Patients performing recreational sport activities demonstrated a survival rate of 79.2% (SE 7.7%). The one factor demonstrating a direct influence on failure after adjustment was a high-pre-injury level of physical (odds ratio 4.0 confidence interval 1.0-15.8, p = 0.04). CONCLUSION The minimum 5 years survival rate after primary ACL repair using this technique was 70%. This value dropped to 56% in highly active patients performing competitive sports. Patients not suffering failure of repair demonstrated adequate restoration of knee laxity and high satisfaction. This study not only underlines the potential of ACL repair, but also highlights the danger of the procedure if strict patient selection is not appreciated. LEVEL OF EVIDENCE Level IV.

The most widely spread and frequently performed osteotomy around the knee joint is the medial opening wedge high tibial osteotomy (mwHTO), a procedure that has managed to occupy a spotlight position as a powerful modality for the treatment of medial compartment gonalgia and degeneration [1–3]. The art is surely not in the technicality aspect of the procedure, but in correct patient selection. Therefore, the procedure would provide an elegant modality for the symptomatic patient with a constitutional metaphyseal varus of the proximal tibia. A few aspects are provided in the following chapter.

Background Post-traumatic elbow stiffness is a frequent and disabling complication after elbow trauma. Surgical release is needed if conservative treatment fails. In contrast to open surgical release, arthroscopic arthrolysis is a good and least invasive option to restore joint mobility. The aim of this study was to evaluate the clinical outcomes, range of motion (ROM), and function of post-traumatic elbow contracture after arthroscopic arthrolysis and to assess health-related quality of life (HRQL). Methods Between 2007 and 2013, 44 patients with post-traumatic elbow stiffness were treated by arthroscopic arthrolysis and followed up in a consecutive series. Clinical (ROM) and functional analyses (Disabilities of the Arm, Shoulder, and Hand Questionnaire [DASH], Mayo Elbow Performance Index [MEPI]) were performed at final follow-up 3 (1-7) years postoperatively. Furthermore, HRQL was evaluated (EQ-5D, 36-Item Short Form Health Survey [SF-36]). Discussion The average arc of elbow motion increased from 84° ± 28° preoperatively to 120° ± 18° postoperatively. All applied scores significantly improved pre- to postoperatively: the MEPI (59.8 ± 17.3 / 84.3 ± 14.0), DASH (43.5 ± 23.1 / 16.8 ± 15.6), EQ-5D (72.8 ± 16.6 / 84.0 ± 13.6), and SF-36 showed improved results in all categories. Univariate logistic regression revealed that preoperative pain level predicts a poorer postoperative outcome measured with the MEPI score. Revision arthroscopy was needed in 1 case because of persistent pain. Conclusions Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life. The complication rate as well as the revision rate is very low.

Der Erhalt des vorderen Kreuzbandes (VKB) mittels dynamischer intraligamentarer Stabilisierung (DIS; Ligamys ®; Mathys AG Bettlach, Schweiz) ist eine neue Therapiemoglichkeit von akuten, femoral lokalisierten VKB-Rupturen bei aktiven Patienten. Bei diesem Verfahren wird das originare VKB mithilfe von PDS-Faden femoral adaptiert und die Heilungszone durch einen Polyethylenfaden mit Federsystem mechanisch geschutzt. Somit stellt die DIS einen temporaren dynamischen alloplastischen VKB-Ersatz dar, wobei in jeder Position eine definierte Federkraft den Tibiakopf nach dorsal zieht. Erste klinische Studien mit dieser Technik zeigten in den ersten Jahren nach DIS zufriedenstellende subjektive und objektive Resultate. Multivarianzanalysen wurden zur Prufung von negativen Einflussen auf die Heilungsprognose durchgefuhrt, um die ideale Indikation besser zu validieren. Dabei wurde als „ideale“ Indikation der aktive Patient, jedoch nicht der Hochleistungs- bzw. Kontaktsportler identifiziert mit einer frischen VKB-Ruptur des proximalen bzw. des femoralen Drittels. Zusatzlich sollte die Riss-Morphologie eine gute VKB-Substanz zeigen, ohne dass eine vollig zerfaserte oder gar Defektruptur vorliegt. Daher sollte die Entscheidung intraoperativ erfolgen. Postoperativ sollte die Sportwiederaufnahme, insbesondere bei Wettkampfsport, unter identischen funktionellen Aspekten wie nach einem VKB-Ersatz erfolgen.

PURPOSE The aim of this study was to perform a comprehensive biomechanical examination of frequently applied femoral cortical suspension devices, comparing the properties of both fixed and adjustable fixation mechanisms. It was hypothesized that adjustable loop devices demonstrate less consistent fixation properties with increased variability compared to fixed loop devices. METHODS Nine frequently applied fixation button types were tested, six adjustable and three rigid loop devices. Six samples of each device type were purchased. Each device was installed in a servo-hydraulic mechanical testing machine, running a 2000 cycle loading protocol at force increments between 50 and 500 N. Irreversible displacement in mm was measured for all of the tested samples of each implant. Ultimately, maximum load to failure was applied and measured in Nm. An irreversible displacement of 3 mm was considered failure of the implant. RESULTS Three of the six adjustable devices (GraftMax™, TightRope® ToggleLoc™) demonstrated a median displacement above the threshold of clinical failure before completion of the cycles. All adjustable loop devices showed a wide intragroup variation in terms of irreversible displacement, compared to fixed-loop devices. Fixed-loop devices provided consistent reproducible results with narrow ranges and significantly lower irreversible displacement (p

A growing burden of gunshot injuries demands evidence-based ballistic trauma management. No comprehensive systematic overview of the current knowledge is available to date. This study aims to identify and analyze the most influential publications in the field of orthopedic ballistic trauma research. All databases available in the Thomson Reuters Web of Knowledge were searched to conduct this bibliometrical study. The most cited orthopedic ballistic trauma articles published between 1950 and 2015 were identified by use of a multi-step approach. Publications with ten citations and more were analyzed for citations, journal, authorship, geographic origin, area of research, anatomical site, study type, study category, and level of evidence. Citations of the 128 included studies ranged from 113 to 10. These were published in fifty different journals between 1953 and 2011. Most publications ( n = 106; 83%) originated from the USA, were retrospective ( n = 85; 66.4%), level IV studies ( n = 90; 70.3%), reported on spinal gunshot injuries ( n = 49; 38.33%) and were published between 1980 and 2000 ( n = 111; 86.7%). This bibliometric study provides the first comprehensive overview of influential publications in the field of orthopedic ballistic trauma research. More prospective studies and high-quality systematic reviews are needed. Centres with a high burden of gunshot injuries from the developing world need to share their experience in form of international publications, to provide a more comprehensive picture of the global gun-related orthopedic injury burden. Type of study: bibliometric analysis: level III.

BACKGROUND Large acetabular defects and pelvic discontinuity represent complex problems in revision total hip arthroplasty. This study aimed to investigate whether reconstruction with the Ganz reinforcement ring would provide durable function in large acetabular defects. PATIENTS AND METHODS 46 hips (45 patients, 19 male, 26 female, mean age 68 years) with AAOS type III and IV defects undergoing acetabular revision with the Ganz reinforcement ring were evaluated at a mean follow-up of 74 months (24-161 months). Fourteen patients died during follow-up. All surviving patients were available for clinical assessment and radiographic studies. Radiographs were evaluated for bone healing and component loosening. A Cox-regression model was performed to identify factors influencing survival of the Ganz-ring. RESULTS In the group of AAOS III defects, 3 of 26 acetabular reconstructions failed, all due to aseptic loosening. In pelvic discontinuity (AAOS IV), 9 of 20 hips failed due to aseptic loosening (n = 4), deep infection (n = 3), and non-union of the pelvic ring (n = 2). With acetabular revision for any reason as an endpoint, the estimated Kaplan-Meier 5-year survival was 86% in type III defects and 57% in type IV defects, respectively. The presence of pelvic discontinuity was identified as the only independent predictive factor for failure of the Ganz ring acetabular reconstruction (AAOS III vs. IV, Hazard ratio: 0.217, 95%, Confidence interval: 0.054-0.880, p = 0.032). CONCLUSION The Ganz reinforcement ring remains a favorable implant for combined segmental and cavitary defects. However, defects with pelvic discontinuity demonstrate high failure rates. The indications should therefore be narrowed to acetabular defects not associated with pelvic discontinuity.

Study Design Bibliometric review of the literature. Objective This bibliometric analysis aims to give an overview of the most influential academic literature written on spinal tuberculosis. Methods All databases included in the Thomson Reuters Web of Knowledge were searched for the most influential publications in spinal tuberculosis. The most cited articles published between 1950 and 2015, with the main focus on orthopedic surgery, were identified using a multistep approach, and a total of 100 articles were included. The publications were then analyzed in this bibliometric analysis. Results The number of citations ranged from 243 to 36, with an average of 77.11. The articles were published in 34 different journals, and the studies were conducted in 20 different countries. The top 3 countries, India, the United States, and China, published a total of 51% (n = 51) of all articles. Low-burden countries produced 60% (n = 60) of all articles in our list. African centers produced only 4% (n = 4) of all included articles. Conclusions Indian and Chinese researchers dominate evidence in spinal tuberculosis. Other areas with high disease burden, such as Africa, do not feature. Most publications are retrospective studies with a low level of evidence.

Study Design: Retrospective case series. Objective: Short posterior stabilization with vertebroplasty is one treatment option for thoracolumbar burst fractures (AO A3). Whether it avoids progression in segmental kyphosis, especially after implant removal, is unclear. In a retrospective case-control study, its stability and the effect on intervertebral discs with and without implant removal was studied. Methods: Fifty-nine consecutive patients were treated with bisegmental short posterior instrumentation and additional vertebroplasty of the fractured vertebra. Twenty-nine patients (male/female 17/12; age: 41.7 ± 15.4 years) underwent implant removal. Changes of segmental kyphosis and disc heights between both groups (with and without implant removal) were compared on lateral X-rays preoperative, postoperative, after 1 year and after implant removal. Risk factors for loss of reduction were analyzed. Results: Kyphosis increased up to 12 months after implant removal. The loss of bisegmental correction was 6.0 ± 4.2 (range 0° to 16°) 12 months after implant removal. Risk factors for loss of reduction are younger patient age, fractures of the thoracolumbar junction (Th12), and degree of traumatic kyphosis. Intervertebral discs traversed by the stabilization lose height and don’t recover within 1 year after implant removal. Without implant removal, disc height of the lower adjacent level is reduced after 24 months. Conclusions: Short posterior stabilization in combination with vertebroplasty is a treatment alternative for thoracic and lumbar AO A3 fractures. After implant removal kyphosis increases, predominantly in the segment above the augmented vertebra. Risk factors for loss of reduction include younger age, fractures of the thoracolumbar junction (T12), and higher fracture kyphosis.

Background With the development of hip arthroscopy (HA), a shift away from surgical hip dislocation (SHD) is becoming a noticeable reality. It was the aim of this study to examine whether SHD provides a benefit over HA regarding its corrective power in the treatment of femoroacetabular impingement (FAI). Hypothesis It was hypothesized that SHD provides the more powerful tool for acetabular correction in FAI surgery compared to HA. Method The examined cohort consisted of 85 hips of which 31 (36%) underwent a high degree of acetabular correction which was defined as a correction of > 2 standard deviations from the population mean. A lateral center edge angle (LCE) correction > 12° or an acetabular index (AI) correction > 8° were therefore considered to high correction. A logistic regression model was applied to determine factors influencing high correction in FAI surgery. Subsequent adjustment was performed using a multivariate model. Results After adjusting for pre-operative acetabular orientation, SHD showed a pronounced influence on the likelihood of achieving the adequate degree of high acetabular correction (odds ratio (OR) 10.0 confidence interval (C.I) 2.3 to 44.0, p = 0.002). On the other hand, SHD showed no influence on femoral correction (p = n.s). Conclusion Surgical hip dislocation is a powerful modality for achieving high degrees of acetabular correction in the situation of a femoroactabular conflict, being defined as an LCE correction of > 12° or AI correction of > 8°. The reason for these results may be seen in the excellent exposure and the improved possibility of performing dynamic intra-operative examination to verify the results. The benefits are only limited to large acetabular correction. These findings should provide a helpful tool for decision making in clinical practise. Level of evidence Level III retrospective cohort study.

PURPOSE Most biomechanical investigations of tendon repairs were based on output measures from hydraulic loading machines, therefore, accounting for construct failure rather than true gapping within the rupture zone. It was hypothesized that the elastic capacity of a tendon-repair construct influences the force necessary to induce gapping. METHODS A tendon-repair model was created in 48 porcine lower hind limbs, which were allocated to three fixation techniques: (1) Krackow, (2) transosseous and (3) anchor fixation. Loading was performed based on a standardized phased load-to-failure protocol using a servohydraulic mechanical testing system MTS (Zwick Roell, Ulm, Germany). Rupture-zone dehiscence was measured with an external motion capture device. Factors influencing dehiscence formation was determined using a linear regression model and adjustment performed as necessary. A 3-mm gap was considered clinically relevant. Analysis of variance (ANOVA) was used for comparison between groups. RESULTS The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping of 3 mm (F3mm) [β = 0.6, confidence interval (CI) 0.4-1.0, p

PURPOSE (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE III.

PURPOSE Due to the juvenility of research in the field of periprosthetic joint infection (PJI), approaches employed for diagnosis of PJI vary amongst surgeons in different geographic regions. The aim of this study was to determine common diagnostic approaches utilized by European knee arthroplasty surgeons for the diagnosis of PJI. METHODS A task force was established for questionnaire development, consisting of surgeons and clinical researchers who each had a record of publishing in the field of PJI. A pool of items was initially generated from a Medline literature search. These were organized into a file and independently sent to each task force member for evaluation and additional supplementation. After reaching a consensus, a final online version was generated and administered to all 4865 members of the "European Society of Sports Traumatology Knee Surgery & Arthroscopy". RESULTS There were 262 respondents between August 2015 and March 2016. Most European surgeons (41.1 %) diagnose between 2 and 5 PJIs yearly, and only 5.8 % diagnose >30 PJIs per year. Serum tests to rule out infection were commonly CRP (97.7 %), leucocyte count (73.6 %) and microbiology cultures (45.3 %), while serum interleukins were least common (5. Most biopsies (98.8 %) are sent for culture exams and 72.5 % for histology, and 36.4 % of surgeons send the implants for sonication. CONCLUSION Microbiology and cell count remain the most commonly applied synovial fluid tests in Europe, while α-defensin and leucocyte esterase are currently less common. Serum interleukins have not gained widespread use. Implant sonication, despite evidence of diagnostic effectiveness, was only applied by one-third of survey respondents, highlighting the problematic issues of cost and accessibility of some tools. The results highlight the current state of European diagnostic practice, emphasizing the areas of divergence from state of evidence and demonstrating the need for development of standard diagnostic algorithms. LEVEL OF EVIDENCE Cross-sectional survey, Level IV.

Background With the development of hip arthroscopy (HA), a shift away from surgical hip dislocation(SHD) is becoming a noticeable reality. It was the aim of this study to examine whether SHD provides a benefit over HA regarding its corrective power in the treatment of femoroacetabular impingement (FAI). Hypothesis It was hypothesized that SHD provides the more powerful tool for acetabular correction in FAI surgery compared to HA. Method The examined cohort consisted of 85 hips of which 31 (36%) underwent a high degree of acetab-ular correction which was defined as a correction of > 2 standard deviations from the population mean. A lateral center edge angle (LCE) correction > 12∘or an acetabular index (AI) correction > 8 were therefore considered to high correction. A logistic regression model was applied to determine factors influencing high correction in FAI surgery. Subsequent adjustment was performed using a multivariate model. Results After adjusting for pre-operative acetabular orientation, SHD showed a pronounced influence on the likelihood of achieving the adequate degree of high acetabular correction (odds ratio (OR) 10.0confidence interval (C.I) 2.3 to 44.0, p = 0.002). On the other hand, SHD showed no influence on femoral correction (p = n.s). Conclusion Surgical hip dislocation is a powerful modality for achieving high degrees of acetabular correction in the situation of a femoroactabular conflict, being defined as an LCE correction of > 12 or AI correction of > 8. The reason for these results may be seen in the excellent exposure and the improved possibility of performing dynamic intra-operative examination to verify the results. The benefits are only limited to large acetabular correction. These findings should provide a helpful tool for decision making in clinical practise. Level of evidence Level III retrospective cohort study.

Civilian gunshot violence is common and concentrated in specific geographic regions of the world, consuming a significant proportion of trauma practice in those particular regions. Unfortunately, the state of clinical evidence is scarce, and it is fair to emphasize that the field is scientifically under-represented. In the current review, the authors point out key aspects and principles requiring attention when treating low energy gunshot wounds to the lower extremity. These treatment principles include the following management concepts: 1) Conservative management of soft tissue injuries if the projectile causes no discomfort. 2) Conservative management of non-complete fractures of the tibia or femoral shaft. 3) Prophylactic fixation of non-complete peri-trochanteric fractures. 4) Fixation of allcomplete fractures. 5) Removal of all intra-articular projectiles. 6) Treating as septic arthritis if the missile passes through large bowel (not small bowel) prior to penetrating a joint capsule. The proposed concepts are based on available evidence from the literature and expert opinion. The authors also highlight challenges with conducting clinical studies in the field, given the high rate of 'loss to follow-up' and compliance issues in this particular group of patients.

The knee is the most frequent site of musculoskeletal injury in the pediatric athlete. Recent literature data support that children and adolescents account for 0.5–3% of all ACL injuries. Management of such lesions is mandatory to avoid future chondral or meniscal injury which can lead to early osteoarthritis. However, treatment in children is challenging and subjects such as operative time, surgical technique, graft selection and residual complications are still controversial.

Redirective, periacetabular osteotomies (PAO) represent a group of surgical procedures for treatment of developmental dysplasia of the hip (DDH) in skeletally mature and immature patients. The ultimate goal of all procedures is to reduce symptoms, improve function and delay or prevent progression of osteoarthritis. During the last two decades, the understanding of the underlying pathomechanisms has continuously evolved. This is mainly attributable to the development of the femoroacetabular impingement concept that has increased the awareness of the underlying three-dimensional complexity associated with DDH. With increasing knowledge about the pathobiomechanics of dysplastic hips, diagnostic tools have improved allowing for sophisticated preoperative analyses of the morphological and pathobiomechanical features, and early recognition of degenerative changes, which may alter the long-term outcome. As redirective, PAO are technically demanding procedures, preoperative planning is crucial to avoid intraoperative obstacles and to sufficiently address the patient-specific deformity. Although conventional radiography has been used for decades, it has not lost its primary role in the diagnostic work-up of patients with DDH. Furthermore, an increasing number of modern imaging techniques exists allowing for assessment of early cartilage degeneration (biochemical magnetic resonance imaging) as well as 3D planning and computer-based virtual treatment simulation of PAO. This article reviews the literature with regard to the current concepts of imaging of DDH, preoperative planning and treatment recommendations for redirective, PAO.

BACKGROUND Patients with electrolyte imbalances or disorders have a high risk of mortality. It is unknown if this finding from sodium or potassium disorders extends to alterations of magnesium levels. METHODS AND PATIENTS In this cross-sectional analysis, all emergency room patients between 2010 and 2011 at the Inselspital Bern, Switzerland, were included. A multivariable logistic regression model was performed to assess the association between magnesium levels and in-hospital mortality up to 28days. RESULTS A total of 22,239 subjects were screened for the study. A total of 5339 patients had plasma magnesium concentrations measured at hospital admission and were included into the analysis. A total of 6.3% of the 352 patients with hypomagnesemia and 36.9% of the 151 patients with hypermagnesemia died. In a multivariate Cox regression model hypermagnesemia (HR 11.6, p0.05). Age was an independent risk factor for mortality (both p

Background Traumatic knee dislocation represents a rare but devastating injury. Several controversies persist regarding type of treatment, surgical timing, graft selection, repair versus reconstruction of the medial and lateral structures, surgical techniques and postoperative rehabilitation. A new technique for primary ACL stabilization, dynamic intaligamentary stabilization (DIS) was developed at the authors’ institution. The purpose of this study was to analyze the clinical and radiological outcomes of surgically treated traumatic knee dislocations by means of the DIS technique for the ACL, primary suturing for PCL, MCL and LCL. Methods Between 2009 and 2012, 35 patients treated surgically for traumatic knee dislocation with primary anterior cruciate ligament (ACL) reconstruction with DIS, suturing of the posterior cruciate ligament (PCL) and primary complete repair of collaterals, were evaluated clinically (IKDC score, SF12 health survey, Lysholm score, Tegner score) and radiologically with a mean follow up of 2.2 years (range 1.00–3.50 years) years. Instrumented anterior–posterior translation was measured (KT-2000). Results Anterior/posterior translation (KT-2000) for the healthy and injured limb was 4.8 mm (range 3–8 mm) and 7.3 mm (range 5–10) (89 N) respectively. Valgus and varus stress testing in 30° flexion was normal in 26 (75%) and 29 (83%) patients, respectively. The IKDC score was B in 29 (83%) and C in 6 (17%) patients, while the mean Tegner score was 6 (range 4–8). The mean Lysholm score was 90.83 (range 81–95) and mean SF-12 physical and mental scores were 54.1 (range 45–60) and 51.0 (range 39–62) respectively. In 2 patients, a secondary operation was performed. Conclusions Early, one stage reconstruction with DIS can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity without graft requirements.

PURPOSE Clinical research in the area of anterior cruciate ligament (ACL) injury has shown substantial growth during the last decade. This was accompanied by the establishment of a wide range of outcome measures used to address the demands of clinical studies. The aim of this study was to evaluate outcome measures reported by highly cited level I trials in ACL research and identify factors influencing citation metrics. METHODS The database of the Institute for Scientific Information (ISI) was utilized to screen journals under the subject categories "Orthopaedics", "Sports Sciences", "Radiology" and "General medicine" for the 50 most cited level I ACL trials based on predefined inclusion criteria. Metadata, citation metrics and outcome measures were extracted for each article. Frequencies of reported outcome measures were calculated, and a multiple linear regression model applied to identify factors influencing citation metrics. RESULTS Two independent outcome measures demonstrated an influence on acquisition of citations including: 1-report of the pivot-shift test and 2-inclusion of the Knee Injury and Osteoarthritis Outcome (KOOS) score. Furthermore, highly cited ACL trials frequently reported KT-1000 measures of anterior translation, range of motion (ROM), graft failure, Lysholm, Tegner and subjective International Knee Documentation (IKDC) scores. CONCLUSION This analysis reflects on the outcome measures utilized in highly cited level I trials impacting the field of ACL research. It also identifies factors likely to influence acquisition of citations. This is of both clinical and academic relevance when choosing appropriate measures for post-operative outcome evaluation after ACL surgery. LEVEL OF EVIDENCE I.

Background: In patients with return of spontaneous circulation (ROSC) after resuscitation, the current gold standard for assessing acute cardiac function is cardiac echocardiography. However, its use may be limited in acute critically ill patients by delays, interobserver discrepancies or the varying priorities of radiographic examinations. We now report that standardised acute cardiac function in these patients can be assessed with triple rule out thoracic (TRO) computed tomography. Methods and patients: We retrospectively analysed cardiac function in all patients with ROSC after resuscitation and who underwent acute computed tomography between 01/2013 and 01/2015 with a new post processing software client after TRO- computed tomography angiography (n=15). The syngo-CT-cardiac-function-client (syngo.via VA 20, Siemens, Erlangen, Germany) was used to measure ejection fraction, myocardial mass, stroke volume, end systolic and end-diastolic volumes, as well as coronary morphology. Multivariate regression modelling and ROC analysis were used to control the independent associations between these parameters. Results: ROC curve analysis showed that right cardiac end systolic volume and left cardiac end systolic volume were associated with ROSC (AUC: 0.74 and AUC: 0.74, respectively). In these patients, we defined thresholds for right cardiac end systolic volume of 119 ml and for left cardiac end systolic volume of 48 ml. Conclusion: In combination with TRO computed tomography, the syngo-CT-cardiac-function-client provides a valuable, standardised tool to assess acute cardiac function in patients with ROSC after resuscitation.

Background Prosthetic joint infection(PJI) is deemed to be the most serious complication following total hip arthroplasty. Obesity and smoking are known risk factors for PJI. However, the influence of these variables on infection free survival, of septic revision hip arthroplasty, is yet to be explored. The aim of this study was to determine the effect of obesity and smoking on the outcome of two-stage prosthetic exchange surgery. Patients and methods A consecutive series of 97 hips in 94 patients (69 male, 25 female, mean age 66 ± 12 years), undergoing two-stage revision surgery for hip PJI, were investigated retrospectively, after a mean follow-up of 60 (24–170) months. Survival was estimated using Kaplan-Meyer curves. A multivariate cox-regression model was applied to test for the influence of smoking or obesity (BMI ≥ 30) after adjusting 16 potential patient-dependant variables. Hypothesis The study hypothesis was that smoking and high BMI are predictors for the failure of septic revision hip arthroplasty. Failure of septic revision hip arthroplasty was defined as failure to eradicate the infection or eradication of the infection but failure to preserve the arthroplasty. Results Kaplan-Meier showed a cumulative survival proportion of 80.4% (standard error S.E 4%), of the definitive implant, at 5 years. Obese patients(BMI ≥ 30) and smokers had a significantly lower 5-year survival of 60.9% (S.E 1%) and 50.6% (S.E 1.4%), respectively (p = 0.001). Discussion Obesity and smoking are both factors determining infection free survival in two-stage revision hip arthroplasty. Clinicians should be aware of potential complications and anticipate a higher likelihood of conversion to a Girdlestone resection or even amputation in this group of patients. Level of evidence III, retrospective cohort study.

PURPOSE Primary repair of the anterior cruciate ligament (ACL) has regained interest of clinicians with recent development of novel repair techniques. Dynamic intraligamentary stabilisation was introduced in an attempt to promote healing by shielding cyclic loads acting upon the ACL during the healing phase. The aim of this study was to identify negative factors likely to influence success of this procedure. METHODS Between 2009 and 2014, 264 patients with an acute ACL rupture undergoing dynamic intraligamentary stabilisation were included in this study. Patients were evaluated for anterior/posterior laxity; range of motion and patient reported outcome measures. Adverse events and re-operations were noted. Failure was defined as AP Translation >3 mm, re-rupture or conversion to ACL reconstruction. Minimum follow-up was 24 months. Univariate and multivariate regression models were utilized to determine predictors of failure. RESULTS An overall complication rate of 15.1% was noted comprising 9.5% (n = 25) re-ruptures, 4.1% (n = 11) persistent instability, and 1.5% (n = 4) > 10° fixed flexion deformity. Two factors were identified as negative predictors of failure: (1) pursuit of competitive sport activities with a Tegner pre-injury score >7 (Odds Ratio (OR) 4.4, CI 1.2-15.9, p = 0.02) and (2) mid-substance ACL rupture location (OR 2.5, 1.1-5.7, p = 0.02). When neither of those risk factors occurred the failure rate was limited to 3.9%. CONCLUSIONS Correct patient selection and narrowing of indications are necessary to maintain high success rates of the procedure. Mid-substance ACL ruptures and a high pre-injury sports activity level are two predictors of inferior outcome. LEVEL OF EVIDENCE II.

BACKGROUND Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants. METHODS This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 (n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared - those with and those without intracranial haemorrhage. RESULTS There was no significant difference in age between the patient groups with (n = 86) and without (n = 114) intracranial haemorrhage (p = 0.078). In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively). CONCLUSION Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.

PURPOSE There are few evidence-based recommendations on the most effective methods for diagnosing prosthetic joint infections (PJIs), and the potency of tests in relation to each other also remains vague. This systematic review aimed to (1) identify systematic reviews reporting accuracies of available approaches for diagnosing PJI, (2) critically appraise their quality and bias, and (3) compare the available approaches in terms of accuracy for diagnosing PJI. METHODS PubMed and EMBASE databases were searched for meta-analyses reporting accuracies of different diagnostic modalities for PJIs. Thirteen systematic reviews met the inclusion and exclusion criteria, and their data were extracted and tabulated by two reviewers in duplicate and independent manners. RESULTS The 13 articles reported diagnostic accuracy from 278 clinical studies comprising 27,754 patients and evaluating 13 diagnostic tests grouped into 7 broad categories. Implant sonication had the highest positive likelihood ratio (17.2), followed by bacteriology (15.3) and synovial fluid differentiated cytology (13.3). The highest negative likelihood ratio was for interleukin (IL)-6 serum marker (0.03) followed by synovial fluid cytology and differentiation (0.12 and 0.13, respectively). CONCLUSION The diagnostic tests that are most likely to rule out PJI include serum IL-6, serum C-reactive protein, and synovial fluid cytology. On the other hand, the diagnostic test that is most likely to confirm PJI is implant sonication. Nuclear imaging showed low overall accuracy as diagnostic tests for PJI. The findings of this study could enable clinicians to confirm or rule out PJIs using the most accurate, rapid, least invasive, and cost-effective tools available, thereby enabling fast treatment before formation of resistant biofilms and degradation of patient conditions. LEVEL OF EVIDENCE Systematic review, Level IV.

Mandibular fracture is a common occurrence in emergency medicine and belongs to the most frequent facial fractures. Historically road traffic injuries (RTIs) have played a prominent role as a cause for mandibular fractures. We extracted data from all patients between August 2012 and February 2015 with “lower jaw fracture” or “mandibular fracture” from the routine database from the emergency department. We conducted a descriptive analysis at a Swiss level one trauma centre. 144 patients were admitted with suspected mandibular fractures. The majority underwent CT diagnostic (83%). In 7% suspected mandibular fracture was not confirmed. More than half of all patients suffered two or more fractures. The fractures were median or paramedian in 77/144 patients (53%) and in other parts (corpus, mandibular angle, ramus mandibularis, collum, and temporomandibular joint) in 100/144 (69%). Male to female ratio was 3 : 1 up to 59 years of age; 69% were younger than 40 years. 72% of all patients presented during daytime, 69% had to be hospitalized, and 31% could be discharged from the ED after treatment. Most fractures were due to fall (44%), followed by interpersonal violence (25%) and sport activities (12%). Falls were a dominant cause of fracture in all age groups while violence and sport activities were common only in younger patients. Comparisons to other studies were difficult due to lack of standardization of causes contributing to the injuries. In the observed time period and setting RTIs have played a minor role compared to falls, interpersonal violence, and sports. In the future, standardized documentation as well as categorization of causes for analytic purposes is urgently needed to facilitate international comparison of studies.

PURPOSE Dynamic intraligamentary stabilization was recently proposed as an option for the treatment of acute ACL ruptures. The aim of this study was to investigate the feasibility of the procedure in mid-substance ACL ruptures and examine whether the additional application of a bilayer collagen I/III membrane would provide for a superior outcome. METHODS The study group consisted of patients presenting with a mid-substance ACL rupture undergoing dynamic intraligamentary stabilization using the Ligamys™ device along with application of a collagen I/III membrane to the surface of the ACL (group A, n = 23). The control group comprised a matched series of patients presenting with a mid-substance ACL rupture also treated by dynamic intraligamentary stabilization Ligamys™ repair, however, without additional collagen application (group B, n = 33). Patients were evaluated preoperatively and at 24-month follow-up for stability as well as Tegner and Lysholm scores. Knee laxity was measured as a difference in anterior translation (ΔAP) and pivot shift. Any events occurring during the follow-up period of 24 months were documented. Logistic regression of complications was performed, and adjustment undertaken where necessary. RESULTS A high total complication rate of 78.8 % was noted in group B, compared to group A (8.7 %) (p = 0.002). The addition of a collagen membrane was the only independent prognostic factor associated with reduced complications (OR 8.0, CI 2.0-32.2, p = 0.003, for collagen-free treatment). In group B, 6 patients suffered a re-rupture with subsequent instability requiring secondary hamstring reconstruction surgery, and 11 developed extension loss requiring arthroscopic debridement, whilst in group A, 2 patients required arthroscopic debridement for loss of exension, with no further encountered complication. Median Lysholm score was significantly higher in group A compared to group B (median 100 range 93-100 vs median 95 range 60-100, p = 0.03) at final follow-up. CONCLUSIONS A high complication rate following ACL Ligamys™ repair of mid-substance ruptures was noted. Application of a collagen membrane to the surface of the ACL resulted in a reduced incidence of extension deficit and re-ruptures. The results indicate that solitary ACL Ligamys™ repair does not present an appropriate treatment modality for mid-substance ACL ruptures. Collage application proved to provide healing benefits with superior clinical outcome after ACL repair. LEVEL OF EVIDENCE Case control study, Level III.

Background The aim of this study was to identify the 100 most cited classics in the field of hip research analysing their qualities and characteristics. Methods Hip joint related articles were identified and the hundred most cited selected for subsequent analysis of citation count, current citation rate, citation density (citations/article age), authorship, geographic origin institution, and level of evidence (LOE). Results In a total of 121 journals, 1,311,851 articles were published between 1945 and 2013, of which 1,287 (0.1%) possessed 250 citations or more. Total citations per article for the 100 most-cited ranged from 290 to 3,144 citations. The most common areas of research were degenerative disease and arthroplasty, followed by hip preserving surgery for which the leading authors were William H. Harris and Reinhold Ganz respectively. All articles were published in 8 journals and originated from 9 countries. 10 institutes published 48/100 of the articles. There was a significant negative correlation between both citation rate, citation density and article age. Total citation count was highest for articles published in the decade of 1970. Although 5% (2,103 articles) of hip literature comprised randomised trials (RCTs), only 1 (1%) of the citation classics was an RCT. Conclusions The study provides intellectual milestones in hip research, reflecting on the qualities and characteristics of the research. Degenerative hip disease and arthroplasty research take up the greatest proportion of citations, followed by hip preserving research. LOE was low and there was only one RCT amongst the classics, emphasising that high LOE is not a prerequisite for a high citation count.

Background Recently, a new technique, dynamic intraligamentary stabilization (DIS) was introduced for the acute repair of ACL ruptures. The purpose of this study was to report the functional recovery for patients undergoing acute anterior cruciate ligament (ACL) repair alongside DIS. Methods Forty five patients sustaining acute ACL rupture and treated with DIS repair were retrospectively evaluated. Limb symmetry index of the hop test as well as knee function by means of range of motion, knee swelling, pain and maximum strength were evaluated. Following completion of the rehabilitation program, the difference in anterior–posterior translation (Δ-AP Translation), IKDC, Tegner score (TAS) was additionally analyzed. Results Forty five (13 females, 32 males) patients were included in the study. Mean age was 26 years (range 18 to 54 years). Median time to successfully complete hop test was 22.0 weeks (range 11 to 32 weeks) postoperatively. Median limb symmetry index 91.6% ± 8.3%. Median delta anterior-posterior translation compared to the healthy side was plus 0.0 mm ± 1.6 mm. Median IKDC was 89.5 ± 6.5. Mean Tegner score (TAS) at 12 months of follow-up was seven (range four to nine). Three patients suffered a rerupture during the first 12 postoperative months. Conclusions DIS technique with proper rehabilitation following acute ACL rupture provides successful functional recovery and low rerupture rate at one-year follow-up.

BACKGROUND Arthroscopy is considered as "the gold standard" for the diagnosis of traumatic intraarticular knee lesions. However, recent developments in magnetic resonance imaging (MRI) now offer good opportunities for the indirect assessment of the integrity and structural changes of the knee articular cartilage. The study was to investigate whether cartilage-specific sequences on a 3-Tesla MRI provide accurate assessment for the detection of cartilage defects. METHODS A 3-Tesla (3-T) MRI combined with three-dimensional double-echo steady-state (3D-DESS) cartilage specific sequences was performed on 210 patients with knee pain prior to knee arthroscopy. Sensitivity, specificity, and positive and negative predictive values of magnetic resonance imaging were calculated and correlated to the arthroscopic findings of cartilaginous lesions. Lesions were classified using the modified Outerbridge classification. RESULTS For the 210 patients (1260 cartilage surfaces: patella, trochlea, medial femoral condyle, medial tibia, lateral femoral condyle, lateral tibia) evaluated, the sensitivities, specificities, positive predictive values, and negative predictive values of 3-T MRI were 83.3, 99.8, 84.4, and 99.8 %, respectively, for the detection of grade IV lesions; 74.1, 99.6, 85.2, and 99.3 %, respectively, for grade III lesions; 67.9, 99.2, 76.6, and 98.2 %, respectively, for grade II lesions; and 8.8, 99.5, 80, and 92 %, respectively, for grade I lesions. CONCLUSIONS For grade III and IV lesions, 3-T MRI combined with 3D-DESS cartilage-specific sequences represents an accurate diagnostic tool. For grade II lesions, the technique demonstrates moderate sensitivity, while for grade I lesions, the sensitivity is limited to provide reliable diagnosis compared to knee arthroscopy.

BACKGROUND Many studies quantitatively analyzing scientific papers have appeared in the last 2 years. Citation analysis is a commonly used bibliometric method. In spite of some limitations, it remains a good measure of the impact an article has on a specific field, specialty, or a journal. The aim of this study was to analyze the qualities and characteristics of the 100 most cited articles in the field of bariatric surgery. METHODS The Thomson Reuters Web of Knowledge was used to list all bariatric surgery-related articles (BSRA) published from 1945 to 2014. The top 100 most cited BSRA in 354 surgical and high impact general journals were selected for further analysis. RESULTS Most of the articles were published in the 2000s (60%). The top 100 most cited were published in 17 of the 354 journals. Leading countries were USA followed by Canada and Australia. Most of the articles published (76%) were clinical experience articles. The most common level of evidence was IV (42%). CONCLUSIONS Many of the milestone papers in bariatric surgery have been included in this bibliometric study. A huge increase in research activity during the last decade is clearly visible in the field. It is apparent that the number of citations of an article is not related to its level of evidence; a fact that is increasingly being emphasized in surgical research.