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Background Existing patient-reported outcome measures (PROMs) that assess knee pain and symptoms show insufficient quality regarding their psychometric properties. We developed and validated a new PROM assessing knee pain and especially patellofemoral pathologies, the COMPrehensive AaChen Knee Score (COMPACK). Methods We followed a three-phase process of development and validation. (1) Scale development: we conducted a systematic literature research to collect and analyse the most commonly used PROMs for knee and patellofemoral pathologies to identify appropriate items. (2) Pilot testing: we assessed the content validity of the COMPACK based on interviews with patients and health experts regarding relevance, comprehensibility and comprehensiveness of the used items. (3) Field testing: we used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines to evaluate the structural validity, internal consistency and test–retest reliability of the COMPACK. Results The COMPACK scale showed good structural validity, with two subscales measuring pain intensity and frequency. Further, scores of the COMPACK correlated positively with those obtained from the International Knee Documentation Committee Subjective Knee Form (IKDC) (r = 0.64) and the 12-item Short Form Health Survey subscale of physical function: (r = 0.43). Both the total scale and the two subscales showed good internal consistency (Cronbach’s α > 0.82) and good to excellent test–retest reliability (Cronbach’s α > 0.82). Conclusions The final COMPACK score was shown to be a valid and reliable instrument and thus meets the most important psychometric quality criteria. In its development, we specifically focused on its content validity, structural validity and applicability.

Fisheries bycatch threatens the viability of some seabird populations and reduces fishing efficiency. Albatross bycatch in a US North Pacific tuna longline fishery has increased over the past decade and now exceeds 1000 annual captures. Seabirds interacting with this fishery reach hooks at depths up to 1 m. A branchline weight’s mass and distance from the hook affect seabird catch rates. We conducted experimental fishing to compare the commercial viability of a weighted hook relative to conventional gear with weights attached 0.75 m from the hook. We used a Bayesian random effects meta-analytic regression modelling approach to estimate pooled expected species-specific log relative risk of capture on conventional versus experimental gear. There was a significant 53% (95% HDI: − 75 to − 25%) decrease in retained species’ catch rates on experimental hooks, indicating an unacceptable economic cost, and no significant effect for discarded species. Using a Bayesian general linear mixed regression modelling approach, experimental hooks sank to 85 cm ca. 1.4 times (95% HDI: 1.37–1.48) faster than control hooks. Given their potential to reduce seabird catch rates, eliminate safety risks from bite-offs and facilitate robust compliance monitoring, it is a priority to find a weighted hook design with acceptable catch rates.

To perform a systematic review and compare the functional and objective outcomes after single-bundle (SB) vs. double-bundle (DB) posterior cruciate ligament reconstruction (PCLR). Where possible to pool outcomes and arrive at summary estimates of treatment effect for DB PCLR vs. SB PCLR via an embedded meta-analysis.A comprehensive PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) literature search identified 13 eligible studies evaluating clinical outcomes of both techniques for PCLR. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm Score, Tegner Activity Scale) and objective measurements of posterior laxity of the operated knee (arthrometer and stress radiographs).The meta-analysis included 603 patients. Three hundred and fifteen patients were treated with SB and two hundred and eighty-eight patients with DB PCLR. There were no significant differences between SB and DB PCLR in postoperative functional Lysholm Scores (CI [- 0.18, 0.17]), Tegner Activity Scales (CI [- 0.32, 0.12]) and IKDC objective grades (CI [- 0.13, 1.17]). Regarding posterior stability using KT-1000 and Kneelax III arthrometer measurements, there were no differences between the SB and DB group. However, double-bundle reconstruction provided better objective outcome of measurement of posterior laxity (CI [0.02, 0.46]) when measured with Telos stress radiography.A systematic review was conducted to identify current best evidence pertaining to DB and SB PCLR. An embedded meta-analysis arrived at similar summary estimates of treatment effect for motion, stability and overall function for both techniques. There is no demonstrable clinically relevant difference between techniques based on the currently available evidence.III.

Background Smartphones have become increasingly more popular and complicated tasks can be performed with these devices. However, the increasing use is associated with shoulder and neck pain, as well as with psychological addiction. Research question Do different smartphone tasks lead to changes in spinal posture and pelvic position? Is there a relationship between smartphone addiction and changes in posture? Methods A cross-sectional study including 50 participants was performed. Test subjects completed the Smartphone Addiction Scale and the SF-36 health questionnaire. Subjects spinal posture and pelvic position during different smartphone tasks were measured through a surface topography system. The different tasks were: standing in an upright position, simulating a phone call, texting with one or two hands during standing or while walking on a treadmill. Paired T-tests and ANOVA tests were performed to evaluate differences. The Kendall rank test was used to investigate the association between clinical scores and changes in spinal posture. Results All smartphone tasks lead to a significant increase in thoracic kyphosis and trunk inclination during standing and while walking. A significant increased lumbar lordosis was also found. Texting with one or two hands correlated with increased surface rotation. No associations between smartphone addiction and changes of the spinal posture were reported. Significance This represents the first surface topography study that investigated the influence of different smartphone tasks on the spinal posture and pelvic position during standing and while walking. With the results of this study we demonstrated that smartphone use leads to significant changes of sagittal and frontal spine parameters. Further research should focus on the evaluation of possible detrimental effects of long-term smartphone use on the spinal posture and on the development of preventive measures.

Leg length inequalities (LLI) are a common problem in medicine. So far, the diagnosis and treatment are performed under static conditions. Surface Topography (ST) is an optical, non-invasive technique that uses the principle of triangulation to measure spinal posture and pelvic position. This technique offers the opportunity to detect and treat LLIs and their effects under dynamic conditions.question The aim of the study is to show that ST can detect simulated LLIs under dynamic conditions and to prove if there are differences between the effects on the human body under static and dynamic conditions.In the clinical study a total of 30 test subjects were examined with a ST measuring device. LLIs (1 to 4 cm) were simulated using a custom- built sandal and insoles of various thickness. The pelvic obliquity, the surface rotation and lateral deviation of the spine were detected on a treadmill under static and dynamic conditions (3 km/h).Under static and dynamic conditions LLIs lead to a significant increase of all measured parameters. The pelvic obliquity reaches a significant level of p 0.0001 under static and p = 0.0001-0.0421 under dynamic conditions. However, for all examined parameters the magnitudes of the parameters under dynamic conditions were smaller than under static conditions.The study showed that simulated LLIs also have a significant effect on the human pelvis and spine under dynamic conditions, but with a smaller magnitude than under static conditions. The human individuum is a dynamic one. Because of that, for the future it should be of great interest to use dynamic measurements to detect and treat LLIs to provide an over correction of LLIs.

Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason’s classification type III after primary arthroplasty using a cemented bipolar design. In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively. DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases. Primary cemented bipolar arthroplasty for type III fractures according to Mason’s classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

AimsThe aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome.Patients and MethodsA total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws.ResultsGood results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis.ConclusionMonteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18.

We provide a meta-analysis for clinicians and researchers regarding reliability and validity of rasterstereographic measurement of the spinal posture.A comprehensive PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) literature search identified 19 eligible studies evaluating reliability and validity of static rasterstereographic measurements in healthy subjects and patients with different spinal pathologies.Our meta-analysis suggests that rasterstereography is a reliable and valid instrument to assess spinal posture parameters, especially thoracic kyphosis, lumbar lordosis, and scoliosis, reliability overall effect sizes rs .91, ps .001, validity overall effect sizes rs 70, ps .001, when compared to traditional radiological imaging techniques. Validity is higher in scoliosis patients compared with healthy controls. Limitations are a lack of reported statistics of the included studies and small sample sizes.The first meta-analysis on reliability and validity of rasterstereography shows satisfactory results. Rasterstereography thus presents a reliable and valid alternative to classic radiological imaging technique to assess and evaluate spinal posture in patients with spinal pathologies. Further studies are needed, focusing on the measurement properties of both static and dynamic rasterstereographic measurements.

Introduction Anterior tension wiring using Kirschner wires (K-wires) is still considered the standard treatment for patella fractures, despite its high complication rate. The objective of this prospective clinical study was to evaluate intra- and perioperative complications as well as the clinical outcome of patients with patella fracture treated with a new developed bilateral, polyaxial, fixed-angle 2.7 mm patella plate. Patients and methods Between 2011 and 2014 all patients with a patella fracture were included in this prospective study and treated with a fixed-angle patella plate. Avulsion fractures of the inferior or superior pole of the patella were excluded. All fractures were classified according to the AO/OTA fracture classification. During a twelve-month follow up period all intra- and postoperative complications were recorded as well as the time until fracture healing. One year postoperatively the Lysholm Score, the pre- and postoperative Tegner Score, the Hospital for Special Surgery Knee Score (HSS), the Turba Score, the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the Bostman Score and the Iowa Knee Score were surveyed. Altogether, 20 patella fractures in 19 patients were included in this prospective study. The most frequent type of fracture, n = 10, was a simple transverse patella fracture (C1), followed by 7 comminuted patella fractures (C3) and 3 T-shaped patella fractures (C2). Results During the 12-month follow up period two patients treated with the patella plate had a complication. In one patient a superficial wound infection occurred, which was treated successfully with hardware removal and in one patient a fracture dislocation due to an implant failure occurred. X-rays demonstrated complete bony healing in all fractures on average 3.2 months postoperatively. All knee scores showed good to excellent clinical results one year postoperatively. Conclusion The results of this first clinical study indicate that the fixed-angle patella plate is an effective and safe treatment option for patella fractures with a short operative learning curve. The treatment of communited patella fractures (C3) with a fixed-angle patella plate should be well-considered to avoid distending the indication and biomechanical properties.

Total knee arthroplasty (TKA) is a very successful procedure. The alignment in TKA has been identified as being of importance to prevent early implant failure and patient dissatisfaction. Our hypothesis was that patients with a preoperative varus deformation remaining in a slight varus alignment as their natural alignment after TKA will have superior clinical results compared with patients who are restored in neutral alignment. A total of 115 patients were corrected from varus to neutral (varus–neutral) and in 33 patients a preoperative varus alignment was kept in varus (varus). Standardized preoperative and postoperative full-length hip–knee–ankle radiographs under full weight-bearing conditions were performed in all patients. The patients' knees were categorized preoperatively and postoperatively based on the angle between mechanical femoral axis and mechanical tibial axis. Knees with alignment between ± 3 degrees were categorized as neutrally aligned, whereas alignment within ≤ –3 degrees was categorized as varus. The Knee Injury Osteoarthritis Outcome Score (KOOS) and Oxford Knee Score were determined retrospectively. The varus group scored significantly better in total KOOS (p 0.05). This trend was even more evident in varus knees which were slightly undercorrected. The results support the assumption that leaving a residual varus alignment after TKA leads to better functional outcomes in TKA for patients with preoperative varus osteoarthritis.

The purpose of this study was to examine the spinal posture in young athletes depending on training intensity. The spinal curvature of 245 children, age 8 to 12 years, was evaluated using rasterstereography. According to their weekly training time group 1 (mean age: 9.54 ± 1.18) did 2-6, group 2 (mean age: 9.49 ± 0.87) did 6-15 and group 3 (mean age: 9.68 ± 0.87) did over 15 hours of training. Group 1 had a significantly higher weight (p = 0.028) (33.86 ± 7. kg) than those of the more active groups (30.67 ± 6.49 kg and 29.46 ± 4.33 kg). The mean kyphotic angle decreased significantly (p < 0.001) with the amount of training per week from 46.86 ± 8.2° in group 1 to 40.08 ± 8° in group 3. We also found a significant decrease (p = 0.047) in lateral deviation with training from group 1 with 5.3 ± 3 mm to group 2 with 4.1 ± 1.6 mm. The results of our study suggest that higher training time can be associated with lower weight and decreases in thoracic kyphosis and lateral deviation of the spine.

Despite the high prevalence of low back pain during pregnancy there is still a lack in the understanding of its aetiology. Changes of the spinal posture due to the anatomical changes of the pregnant body seem to be in part responsible for the back pain. In this pilot study we assessed the potential to accurately measure the spinal posture and pelvic position during pregnancy without any harmful radiation using a spine and surface topography system. Thirteen pregnant women were examined during the second and third trimester of their pregnancy, and postpartum. Twenty female, non-pregnant volunteers comprised the control group. The spinal posture and pelvic position were measured with a radiation-free spine and surface topography system. We found a significant increase in thoracic kyphosis during the course of pregnancy, but no increased lumbar lordosis. The lateral deviation of the spine also decreased significantly. However, we did not measure significant changes of the pelvic position during or after pregnancy. The results of our study show that pregnancy has an effect on the spinal posture, and that spine and surface topography can be used to measure these changes three-dimensionally and without any harmful radiation. In future studies this technique could allow to further evaluate the relationship between posture and low back pain during pregnancy, helping to understand the aetiology of low back pain in pregnancy as well as to identify methods for its prevention and treatment.

PLOS ONE 14(8), e0221695 (2019). doi:10.1371/journal.pone.0221695, Published by PLOS, San Francisco, California, US

BACKGROUND Arthroscopic suture fixation of tibial eminence fractures using FiberWire is a favorable therapeutic option. The application of biodegradable material may be of advantage especially during childhood. The aim of this study was to evaluate the biomechanical properties using the biodegradable suture materials PDS II and Vicryl compared with FiberWire. METHODS Bone mineral density was evaluated by pqCT in 18 human knee specimens and 3 similar groups were formed. A standardized anterior tibial eminence fracture was created and suture fixation was performed using each suture material (PDS II, Vicryl, FiberWire) in 6 specimens. Cyclic testing and destructive loading to failure was conducted. RESULTS Both testing modalities showed PDS II to be inferior to the other evaluated suture materials. Although significantly higher failure loads were seen with FiberWire sutures, Vicryl yielded comparable stiffness in load-to-failure testing. No significant differences between Vicryl and FiberWire could be observed under nondestructive cyclic conditions. CONCLUSIONS Even though FiberWire yields a superior ultimate failure load, Vicryl presented comparable results under cyclic conditions. CLINICAL RELEVANCE For tibial eminence fractures in children, Vicryl should be considered as an alternative biodegradable suture material. The use of PDS II cannot be advocated.

The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty.Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated.Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age.Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected.

Displaced tibial eminence fractures require surgical fixation in order to obtain a stable knee joint. Suture fixation with FiberWire(®) seems to be the most favorable therapeutic option. Biomechanical studies show failure of this technique most commonly due to a suture cutout with subsequent fracture of the tibial eminence fragment. The goal of this study is to compare the biomechanical properties of three different techniques of suture fixation using FiberWire(®).Bone mineral density was evaluated in 18 human knee specimens by pqCT, and three similar groups were formed. A standardized anterior tibial eminence fracture was created, and suture fixation was performed using one of three different techniques in 6 specimens each. Cyclic and destructive testing was conducted.Significant differences between the three techniques could be shown neither in the cycles needed to achieve a steady state nor in a failure load or initial stiffness. Almost all specimens failed by suture cutout.The presented modification of the existing technique for suture fixation of tibial eminence fractures did not lead to an increased initial stability nor did it lower the rate of suture cutout. All tested suture techniques showed comparable initial stiffness and failure load.

Objective The management of knee osteoarthritis includes the use of wedged shoe insoles to unload the affected knee compartment. Although the biomechanical effects of shoe insoles on the knee joint are known and described, only little is known about their influence on the pelvis and spine. Therefore, the purpose of this study was to evaluate the effects of different foot positions, such as how they could be achieved by shoe insoles, on pelvic position and spinal posture. Methods A total of 51 test subjects were measured for this study. The different foot positions (inner and outer margin increase, positive and negative heel height) were simulated with a specially designed stand platform. A rasterstereographic device was used to measure the immediate effects of the simulated foot positions on the pelvic position and spinal posture. Results Positive and negative heel heights as well as an increase of the outer margin of the platform led to significant changes of the pelvic tilt. The pelvic torsion also changed significantly during positive heel height changes of 10 and 15 mm and increases of the outer margin of the foot. No significant changes were found between foot position and spinal parameters. Conclusion The results of our study support the existence of a kinematic chain, where changes of foot position also led to significant alterations of the pelvic position. Whether these changes could lead to long-term pathologic alterations still needs to be evaluated. However, in our setting, no correlation between foot position and spinal posture changes was found.

Surgical treatment of femoral neck fractures is associated with a significant impact on quality of life. The aim of this study was to determine the long-term influence of displaced femoral neck fractures treated by bipolar hemiarthroplasty on the activities of daily living, quality of life and social dependency.We studied 487 geriatric patients treated in the years 1989 to 2003. At the beginning of follow-up in 2004, 166 patients were alive and evaluation was carried out on 145 patients (87.3%) at 91.3 (14 - 244) months postoperatively by a standardized questionnaire. All enrolled patients had been treated with cemented bipolar hemiarthroplasty for a displaced femoral neck fracture. Patients were evaluated concerning their average pre- and postoperative ability to walk, the need for assisting devices, type of residency and the SF-12® Score.Femoral neck fracture and hemiarthroplasty had a significant influence on all recorded aspects of quality of life. Even though almost two thirds of the patients needed assisting devices to walk after surgery, about two thirds returned to their original type of accommodation and the majority reached their original degree of mobility. Compared to a normal population no significant impact was observed on the quality of life measured by the SF-12® score.We consider bipolar hemiarthroplasty an effective treatment option for displaced femoral neck fractures in geriatric patients. Most patients returned to their original type of accommodation and level of mobility, even though the majority required a number of assisting devices to do so.

A tibial nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular proximal tibial fractures. The goal of this study is to analyze if the angle stable tibial nail (ASN) is biomechanically more stable than an established conventional standard nail (CN). Two types of nails were compared on a series of ten matched pairs of human tibiae. After setting a proximal tibial defect fracture, the intramedullary stabilized tibiae were axially loaded starting from 100 N increasing in steps of 100 N after every 200 cycles until failure was reached. Failure was defined as deformation of the fracture gap, fracturing of the bone or the implant. The two types of nails showed no significant difference in terms of maximum tolerated load, maximum cycles repeated or axial deformation of the bone–implant construct. The mean load at failure was 1,365 N for the CN and 1,195 N for the ASN. The mean axial deformation for conventional (19 mm) and angle stable nail (21 mm) did not differ significantly. Slightly less nail or screw loosening was noticed with the fixed-angle nail. No significant difference in stability between the two compared implants could be demonstrated. A trend could be shown indicating that the rate of nail loosening in the proximal osteotomized part of the bone was lower for the angle stable nail. This trend, however, could not be substantiated statistically.

Leg length inequalities (LLI) are a common finding. Rasterstereography offers a non-invasive, contact-free and reliable method to detect the effects of LLIs on spinal posture and pelvic position. A total of 115 subjects were rasterstereographically examined during different artificially created leg length inequalities (5–15 mm) using a platform. The pelvic obliquity and torsion and the lateral and frontal deviation of the spine, as well as the surface rotation, were measured. Changes in platform height led to an increase of the pelvic tilt and torsion. Only minor changes in the spinal posture were found by different simulated leg length inequalities. Our study showed that there was a correlation between an artificial leg length inequality up to 15 mm and pelvic tilt or torsion, but only minor changes in the spinal posture were measured. Further studies should investigate the effects of greater leg length inequalities on spine and pelvis.

Purpose of this study was to evaluate the reliability and validity of 4D rasterstereography under dynamic conditions. Therefore simulated anatomical fixed points on a wooden plate were measured during different movements. Seven different motion patterns in all three angles of space were evaluated. The simulated parameter trunk length was measured with an accuracy of 3.58 mm (SD±3.29 mm) and the dimple distance was detected with an accuracy of 0.88 mm (SD±1.04 mm). With this rasterstereographic prototype it is possible to examine dynamically the spinal posture with adequate accuracy.

Objective Modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring are currently the fixation of choice for patellar fractures. Failure of fixation, migration of the wires, postoperative pain and resulting revision surgery, however, are not uncommon. After preliminary biomechanical testing of a new fixed-angle plate system especially designed for fixation of patella fractures the aim of this study was to evaluate the surgical and anatomical feasibility of implanting such a plate-device at the human patella. Methods In six fresh unfixed female cadavers without history of previous fractures around the knee (average age 88.8 years) a bilateral fixed-angle plate fixation of the patella was carried out after previous placement of a transverse central osteotomy. Operative time, intra-operative problems, degree of retropatellar arthritis (following Outerbridge), quality of reduction and existence of any intraarticular screw placement have been raised. In addition, lateral and anteroposterior radiographs of all specimens were made. Results Due to the high average age of 88.8 years no patella showed an unimpaired retropatellar articular surface and all were severely osteoporotic, which made a secure fixation of the reduction forceps during surgery difficult. The operation time averaged 49 minutes (range: 36-65). Although in postoperative X-rays the fracture gap between the fragments was still visible, the analysis of the retropatellar surface showed no residual articular step or dehiscence > 0.5 mm. Also in a total of 24 inserted screws not one intraarticular malposition was found. No intraoperative complications were noticed. Conclusions Osteosynthesis of a medial third patella fracture with a bilateral fixed-angle plate-device is surgically and anatomically feasible without difficulties. Further studies have to depict whether the bilateral fixed-angle plate-osteosynthesis of the patella displays advantages over the established operative procedures.

Purpose: To prospectively determine the negative predictive value of normal adenosine stress cardiac MR (CMR) in routine patients referred for evaluation of coronary artery disease (CAD), predominantly with intermediate to high pretest risk. Materials and Methods: Consecutive patients referred for coronary angiography were examined in a 1.5 Tesla whole-body scanner before catheterization. A total of 158 patients with normal CMR on qualitative assessment were included, and semiquantitative perfusion analysis was performed. Significant CAD was regarded as luminal narrowing of ≥70% in coronary angiography. Results: In the 158 study patients, negative predictive value of normal adenosine-stress CMR for significant CAD was 96.2% (for stenosis ≥90%: 98.1%). True-negative and false-negative patients were comparable regarding clinical presentation, risk factors, and CMR findings. Semiquantitative perfusion analysis gave significantly prolonged arrival time index and peak time index in the false-negative group. Using cutoff values >1.8 for arrival time index or >1.2 for peak time index, the CMR negative predictive value increased to 98.7% (for stenosis ≥90%: to 100%). Conclusion: The very high negative predictive value for CAD supports CMR-based decision making for the indication to coronary angiography. Semiquantitative perfusion analysis seems promising to identify the small group of CAD patients not detectable by qualitative CMR assessment. J. Magn. Reson. Imaging 2010;32:615–621. © 2010 Wiley-Liss, Inc.

This retrospective study investigates the radiological and the functional results as well as complications following locking palmar plating on the distal radius. Eighty-nine adult patients with a dorsally displaced distal radius fracture were treated using a locking palmar plate at our clinic over a period of 25 months. The radiological and functional results as well as the DASH score were recorded for 77 out of 89 patients in the routine final examinations conducted on average 12 months later. The radiological examinations showed a relevant shortening of the radius among five patients. A dorsal angulation of more than 20° as well as a radial inclination of less than 10° was observed in 11 patients. Most of the patients showed good to excellent functional and radiological results as well as good results on the DASH score. A3 fractures in elderly patients and the majority of C1 and C2 fractures can be safely treated with locking palmar plating.

Today the most frequently used operative procedures in advanced arthritis of the hindfoot joints are isolated talonavicular arthrodesis and double arthrodesis (involving the talonavicular and calcaneocuboid joints, i.e. the Chopart joint). This in vitro study investigates whether the fusion of the talonavicular joint alone can provide the hindfoot, as well as a midfoot, with comparable biomechanical stability as the double arthrodesis does. Hence with the less-invasive intervention the same benefit in terms of pain reduction and better functionality could be achieved. In a series of ten fresh cadaver feet without any radiological pathologies, we measured the range of motion of different tarsal bones in three planes under axial stress. Every foot was loaded without arthrodesis, after talonavicular and after double arthrodesis, by charging tibia and fibula with a force of 350 N using a calibrated Instron® load frame. Each tarsal bone was marked with a K-wire and its motion was measured by registering the movement of the wire’s shade that was projected onto the surrounding walls of the trial box. Both operative procedures led to a considerable reduction of the motion of every marked bone to a mean of 18% of the preoperative value. In direct comparison of the two simulated arthrodeses we found for every bone and in every plane only minimal differences of the mean excursions of 1.0 mm on average. Both fusions lead to equal residual tarsal bone motion postoperatively, and provide the midtarsal joint as well as the subtalar joint with comparable biomechanical stability. Isolated talonavicular arthrodesis is a useful and effective alternative to double arthrodesis. It is the less complicated, less-invasive and functionally equivalent operative option for arthritic alterations of the hindfoot and transverse tarsal joint.

It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization.Twenty-one consecutive non-randomized patients with thoracolumbar vertebral body fractures, which had been stabilized posteriorly without any intervertebral body fusion between 1996 and 1997, and without any neurological symptoms, were examined retrospectively more than 5 years after trauma. Eleven patients had been treated conventionally open and 10 patients minimally invasive. As methods of evaluation, the intra- and postoperative amount of blood loss, the X-ray time, the Hannover-Spine-Score, the SF-36 Health Questionnaire and radiological assessment of the bisegmental wedge and vertebral body angle were made use of.The blood loss was significantly lower among those patients who had been operated in a minimally invasive way. The operating time, the time of X-ray exposure and the loss of correction were identical in both groups. The first year after implant removal, the loss of correction was the highest with 2.1 degrees for the body angle and 6.86 degrees for the bisegmental wedge angle. Neither in the Hannover-Spine-Score nor in the SF-36 Health Questionnaire did both groups show a difference. A correlation between the loss of correction and the clinical results could not be demonstrated.The minimally invasive posterior stabilization leads to lower blood loss in comparison to the conventionally open method and can be carried out without any special effort limited to A-fractures without any neurological symptoms.

It is generally accepted that severely displaced or malrotated neck fractures of the fifth metacarpal should be treated by closed reduction and pinning. As antegrade intramedullary splinting avoids adhesions of the extensor hood and provides intramedullary stability this technique seems to be advantageous in comparison with traditional retrograde percutaneous crossed pinning. We raised the question whether the antegrade technique would give clinical and radiological results superior to the retrograde technique and investigated this within a comparative clinical study.Thirty patients with displaced neck fractures of the fifth metacarpal who received operative treatment were included in a retrospective cohort study. Data was analysed from medical records and a clinical and radiological outcome evaluation was performed. Fifteen patients had antegrade intramedullary splinting and fifteen patients retrograde percutaneous pinning. Median time for follow-up was 17 and 18 months, respectively.A significantly better outcome was found after antegrade splinting for ROM restriction of the metacarpophalangeal joint (0 degrees vs. -15 degrees ; P = 0.016), shortening (P = 0.029), pain (0 vs. 5; VAS 0-100; P = 0.026), and overall assessment by the Steel score (400 vs. 357; P = 0.001). There was no statistical difference in grip strength and functional assessment by the DASH score.From our clinical and radiological data we conclude that antegrade intramedullary splinting is superior to retrograde percutaneous crossed pinning and thus should be preferentially considered for displaced neck fractures of the fifth metacarpal.

Real world cardiology is faced with a low diagnostic yield of coronary angiography (CXA) in patients presenting with ACC/AHA class II CXA indication. Our aim was to analyze the clinical implication of a Cardiac MR (CMR) protocol including adenosine stress perfusion in this patient population. We examined whether CMR could enhance appropriate CXA indication and thus reduce the rate of pure diagnostic CXA. In addition, we compared the relative impact of CMR exam components (perfusion, function and viability assessment) in achieving this target.176 patients were referred for CXA with class II indication. 171 underwent complete additional CMR exam in a 1.5-T whole body CMR-scanner for myocardial function, ischemia and viability prior to CXA. The routine protocol for assessment of CAD consisted of functional imaging (long and short axes), adenosine stress- and rest-perfusion in short axis orientation and "late enhancement" imaging in long and short axes. Images were analyzed by two independent and blinded investigators. Interobserver differences were resolved by a third reader.There was a high association between CMR results and subsequent invasive findings (chi square for CMR perfusion deficit and stenosis70% in CXA: 113.7, p0.0001). 109 (63.7%) of our patients had relevant perfusion deficits as seen by CMR and matching coronary artery stenosis70%. Four (2.3%) patients had false negative CMR findings. In 58 patients (33.9%) no relevant coronary artery stenosis could be observed, correctly predicted by CMR in 48 cases; in 10 (5.8%) patients CMR provided false positive results. Sensitivity of CMR to detect relevant CAD (70% luminal narrowing) was 0.96, specificity 0.83, positive predictive value 0.92 and negative predictive value 0.92. Of the CMR components, perfusion deficit was the strongest independent predictor (odds ratio 132.3, p0.0001).In a great number of patients being referred to cath lab with ACC/AHA class II indication for CXA, CMR provides a high accuracy for decision making regarding appropriateness of the invasive exam. CMR prior to CXA could substantially reduce pure diagnostic coronary angiographies in patients with intermediate probability for CAD, in our patient-cohort from approximately 34% to 6%. Further studies are warranted to identify rare false negative CMR results.

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome.The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results.From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction.All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome.In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.Cite this article: Bone Joint J 2014;96-B:1385–91.

This biomechanical study is the first to compare 3 fixation methods—bilateral fixed-angle plate, modified anterior tension wiring, and cannulated lag screws with anterior tension wiring—in multifragmentary distal patella fractures. A T-shaped 3-part fracture simulating a multifragmentary articular distal patella fracture (AO/OTA 34-C2.2) was created in 18 human cadaver knee specimens. Three groups were created using homogenous ages and bone mineral densities based on the fixation method received. Repetitive testing over 100 cycles was performed by moving the knee against gravity from 90° flexion to full extension. Failure was defined as fracture displacement greater than 2 mm. In all patellae using fixed-angle plates, an anatomical fracture reduction could be maintained throughout cyclic testing, whereas anterior tension wiring and lag screws with tension wiring showed significant fracture displacement after 100 cycles, with mean fracture gaps of 2.0±1.3 and 1.9±1.6 mm, respectively. The differences in fracture gaps between the fixed-angle plate group and the other 2 groups were statistically significant. In both groups using tension wiring, half of the constructs (3 of 6 in each group) failed due to a fracture displacement greater than 2 mm. The bilateral fixed-angle plate was the only fixation method that sustainably stabilized a multifragmentary articular distal patella fracture during cyclic loading when compared with modified anterior tension wiring and cannulated lag screws with anterior tension wiring.

The purpose of this study was to investigate age differences in the response of the spine and pelvis to simulated leg length inequalities (LLIs).A total of 107 subjects, separated into three age groups (group 1: 20-39 years, group 2: 40-59 years, group 3:60 years), were used to evaluate for any age effects in the response to LLIs. LLIs of +10, +20, and +30 mm were simulated with a simulation platform on both sides, and the respective changes of pelvic position (pelvic obliquity, pelvic torsion) and spinal posture (lateral deviation, surface rotation, kyphotic, and lordotic angles) were measured with a rasterstereographic system.In all three age groups an increase in LLI led to significant changes in the pelvic position as measured by the parameters of pelvic obliquity and torsion. No significant differences in the response of the pelvis to the LLIs were found between the age groups. In all age groups an increase in surface rotation and lateral deviation of the spine with increasing LLIs was found. However, none of these parameters responded significantly different between the three age groups.Under static conditions, LLIs lead to significant changes of the pelvic position and spinal posture. Despite all known age-related changes, no significant differences of the measured pelvic and spinal parameters in elderly patients as a response to the simulated LLIs occurred.

Introduction The assessment of spinal deformities with rasterstereography can enhance the understanding, as well as can reduce the number of x-rays needed. However, to date this technique only allows measurements under static conditions. Since it would be of great value to be able to also analyze the spine in dynamic conditions, the present study evaluated a novel rasterstereographic system. Materials and Methods A new rasterstereographic device was evaluated in a comparison with the gold standard in motion analysis, the VICON system. After initial testing using 12 flat infrared markers adhered to a solid plate, the two systems were evaluated with the markers adhered onto the backs of 8 test subjects. Four triangles were defined using the markers, and the sides of each triangle were measured under static and dynamic conditions. Results On the solid plate, the sides of the 4 triangles were measured with a measuring tape and then by the two optical systems. Rasterstereography showed a high accuracy in marker detection on the solid plate. Under dynamic conditions, with the subjects walking on a treadmill, the rasterstereographically-measured side lengths were compared with the lengths measured by the VICON system as an assessment of marker detection. No significant differences (p>0.05) were found between the systems, differing only 0.07–1.1% for all sides of the four triangles with both systems. Discussion A novel rasterstereographic measurement device that allows surface and spine topography under dynamic conditions was assessed. The accuracy of this system was with one millimeter on a solid plate and during dynamic measurements, to the gold standard for motion detection. The advantage of rasterstereography is that it can be used to determine a three-dimensional surface map and also allows the analysis of the underlying spine.

Leg length inequalities (LLIs) can result in an increased energy consumption, abnormal gait or osteoarthritis of the hip. In a previous study we simulated different LLIs of up to 15 mm and evaluated their effects on the pelvic position and spinal posture. We found a correlation between LLIs and resulting changes of the pelvic position. Despite suggestions in the literature we were not able to detect significant changes of the spinal posture. Therefore, the purpose of this study was to determine the amount of LLI that would in fact alter the spinal posture.The subjects were placed on a simulation platform, whose height could be precisely controlled by the measuring device, to simulate different LLIs of up to 20 mm. For LLIs20 mm, additional precision-cut wooden blocks were used under one foot. After an adaptation period the resulting changes of the pelvis and spine were measured with a rasterstereographic device.We found a significant correlation between platform height changes and changes of the pelvic position. The frontal spinal parameters surface rotation and lateral deviation changed significantly when simulating differences greater than 20 mm. No changes of the sagittal spinal curvature were measured, however, a trend to decreasing kyphotic angles was noted.Our study has shown for the first time that LLIs20 mm will lead to significant changes in the spinal posture of healthy test subjects. However, these changes were only found in frontal (surface rotation and lateral flexion) spinal parameters, but not in sagittal parameters. Here for the kyphotic angle only a tendency to decreasing angles was noted. We have also found a significant correlation between different leg lengths and changes of the pelvic position. Further, females and males seem to react in the same way to LLIs.

Introduction Operative treatment of patella fractures is frequently associated with implant failure and secondary dislocation which can be attributed to the employed hardware. Therefore, a 2.7 mm fixed-angle plate designed for the treatment of patella fractures was tested biomechanically against the currently preferred methods of fixation. It was hypothesized that under simulated cyclic loading fixed-angle plating would be superior to modified anterior tension wiring or cannulated lag screws with anterior tension wiring. Materials and methods Eighteen human cadaver knees, matched by bone mineral density and age, were divided into three groups of six. After setting a transverse patella fracture each group received one of the osteosyntheses mentioned above. Repetitive testing over 100 cycles was performed at non-destructive loads by simulating knee motion from 90° flexion to full extension. Results Anterior tension wiring as well as lag screws with tension wiring showed significant fracture displacement after the initial cycle already. Both constructs, lag screws plus wiring (3.7 ± 2.7 mm) as well as tension wiring alone (7.1 ± 2.2 mm) displayed fracture displacement of >2 mm which is clinically regarded as failure. Those patellae stabilized with fixed-angle plates showed no significant fracture gap widening after completion of 100 cycles (0.7 ± 0.5 mm). The differences between the fixed-angle plate group and the other two groups were statistically significant (p Conclusion In contrast to modified anterior tension wiring and cannulated lag screws with anterior tension wiring the bilateral fixed-angle plate was the only fixation device to stabilize transverse patella fractures securely and sustainably.

A bilateral fixed-angle plate was biomechanically compared to the two currently preferred methods of osteosynthesis for transverse patella fractures. It was hypothesized that the new angle-stable implant would provide a secure and sustainable fracture fixation, superior to the established standard techniques.Twenty-one identical patellae made of polyurethane foam (Sawbones(®)), osteotomized to create a transverse two-part fracture, were fixed with modified anterior tension wiring, cannulated lag screws with anterior tension wiring or bilateral polyaxial 2.7-mm fixed-angle plates. The testing protocol consisted of 10,000 repetitive cycles using a non-destructive physiological load between 100 and 300 N at a simulated knee flexion of 60°.All 21 Sawbone(®)-patellae sustained repetitive loading up to 10,000 cycles without failing. The anterior tension wire group displayed significant displacement of the fracture gap (0.7 ± 0.2 mm) during cyclic loading, while both lag screws with tension wiring and bilateral fixed-angle plates showed no fracture gap widening at all (p 0.01).The bilateral fixed-angle plate and cannulated lag screws with anterior tension wiring preserved a constantly reduced fracture gap over 10,000 tensile cycles in contrast to modified anterior tension wiring, which exhibited significant widening of the gap after initial loading. Results of in vitro testing indicate that bilateral fixed-angle plates provide sustainable fixation stability offering a promising new option in the treatment for transverse patella fractures.

BACKGROUND A distal femur nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular distal femur fractures. The goal of this study was to analyze whether the locked compression distal femur nail (LCN) was biomechanically more stable than a conventional standard distal femur nail (CN). METHODS Both nails were compared on a series of 10 matched pairs of human femora. After setting a distal femur defect fracture, the intramedullary stabilized femur was axially loaded starting from 100 N, increasing in steps of 100 N after every 200 cycles with a triangular frequency of 1 Hz, until a predefined point of failure was reached. RESULTS The two types of nails showed no significant difference in terms of maximum tolerated load, maximum number of cycles repeated, or axial deformation of the bone-implant construct. The mean load at failure was 2,954 N for the CN and 2,483 N for the LCN. The mean axial deformation for the conventional (14.8 mm) and locked compression nail (15.3 mm) did not differ significantly. Mode of failure was a bony fracture in all specimens predominantly involving the proximal femur. CONCLUSIONS No significant difference in stability between the two compared implants could be demonstrated. The LCN showed comparable characteristics under cyclic axial loading as the conventional distal femur nail. No migration into the articular space or implant failure was observed.

Background and Purpose— Dynamic cerebral autoregulation is impaired in subjects who develop acute mountain sickness (AMS), a neurological disorder characterized by headache. The present study examined if the normoxic sea-level measurement of dynamic cerebral autoregulation would predict subsequent susceptibility to AMS during rapid ascent to terrestrial high altitude. Methods— A dynamic cerebral autoregulation index was determined in 18 subjects at sea level from continuous recordings of middle cerebral artery blood flow velocity (Doppler ultrasonography) and arterial blood pressure (finger photoplethysmography) after recovery from transiently induced hypotension. Six hours after passive ascent to 3800 m (Mt Elbrus, Russia), the Lake Louise and Environmental Symptoms Cerebral Symptoms questionnaires were used to assess AMS. Results— AMS scores increased markedly at high-altitude (Lake Louise: +3±2 points, P =0.001 and Environmental Symptoms Cerebral Symptoms: +0.6±0.9 points, P =0.0003 versus sea level). Inverse relationships were observed between the sea-level autoregulation index score and the high-altitude-induced increases in the Lake Louise ( r =−0.62, P =0.007) and Environmental Symptoms Cerebral Symptoms ( r =−0.78, P =0.01) scores. One subject with a history of high-altitude pulmonary and cerebral edema presented with the lowest sea-level autoregulation index score (3.7 versus group: 6.2±1.0 points) and later developed high-altitude cerebral edema at 4800 m during the summit bid. Conclusions— These findings suggest that a lower baseline autoregulation index may be considered a potential risk factor for AMS. This laboratory measurement may prove a useful screening tool for the expedition doctor when considering targeted pharmacological prophylaxis in individuals deemed “AMS-susceptible.”

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance ( P >.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).

The objective of this study comparing the proximal femoral nails Targon PF (Aesculap, Tuttlingen, Germany) and Proximal Femoral Nail Antirotation (PFNA; Synthes. Oberdorf, Switzerland) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation, with special attention devoted to the dynamic properties of both implants under physiological load in vivo. The survey was designed as a randomized, prospective study of 80 patients who had sustained a pertrochanteric femoral fracture (AO type 31.A2). Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail. Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group, which was significantly lower than in the Targon PF group (84.7 minutes and 164.5 seconds, respectively). No significant difference was found between the 2 groups in terms of range of motion ( P =.26) or Harris Hip Score ( P =.83). The femoral neck components of the Targon PF showed a significantly higher sliding ability (14.5 mm; P =.04) than the PFNA (11.1 mm). Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results. The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo. A disadvantage of the Targon PF, however, is the more complicated surgical technique and the longer operative time.

The Matthiass posture test is a clinical test to detect posture changes in children and adolescents. Aim of this study was to objectify this test using a dynamic rasterstereographic measuring device. We examined 31 healthy athletes during a modified Matthiass test with a dynamic rasterstereographic measuring system. Hereby the trunk inclination, kyphosis and lordosis angle were measured. The trunk inclination decreased by about 50% of the basic value just by raising the arms. Additional weight loads of only 5% body weight (bw) resulted in significant changes of the posture (lordosis and kyphosis angle) during this test. With this rasterstereographic measuring device it seems to be possible to determine spinal posture changes under dynamic conditions. The results suggest that additional weights of 5% bw during the Matthias-test are enough to create significant deviations in posture parameters, even in healthy subjects.

Little attention has been devoted to subtalar dislocations without an associated bone injury in the literature to date. The aim of this study was to assess the functional and subjective results of a cohort of patients with this injury.A total of ninety-seven patients with a subtalar dislocation were treated at two major university trauma centers from January 1994 to March 2007. Computed tomographic scans indicated a subtalar dislocation without associated bone injury in twenty-three of these patients. Clinical and radiographic examinations were performed on all twenty-three patients at an average of 58.3 months after the completion of treatment. The postoperative clinical examination was supplemented by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and the degree of arthritis was assessed radiographically.The average score on the AOFAS ankle-hindfoot scale score was 82.3 points. Twenty-one patients achieved a good result, and two patients had a satisfactory result. The range of motion of the subtalar joint was an average of 41.3 degrees. No difference between the results of the medial and lateral subtalar dislocations was observed. Only six patients had minor radiographic changes.The intermediate-term results for a subtalar dislocation without an associated osseous injury are good, and the direction of the dislocation does not appear to make a difference with regard to clinical or radiographic outcome.

Background The goal of this study is carry out a biomechanical evaluation of the stability of a bilateral, polyaxial, fixed-angle 2.7 mm plate system specifically designed for use on the patella. The results of this approach are then compared to the two currently most commonly used surgical techniques for patella fractures: modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring. Methods A transient biomechanical analysis determining material failure points of all osteosyntheses were conducted on 21 identical left polyurethane foam patellae, which were osteotomized horizontally. Evaluated were load (N), displacement (mm) and run-time (s) as well as elastic modulus (MPa), tensile strength (MPa) and strain at failure (%). Findings With a maximum load capacity of 2396 (SD 492) N, the fixed-angle plate proved to be significantly stronger than the cannulated lag screws with anterior tension wiring (1015 (SD 246) N) and the modified anterior tension wiring (625 (SD 84.9) N). The fixed-angle plate displayed significantly greater stiffness and lower fracture gap dehiscence than the other osteosyntheses. Additionally, osteosynthesis deformation was found to be lower for the fixed-angle plate. Interpretation A bilateral fixed-angle plate was the most rigid and stable osteosynthesis for horizontal patella fractures with the least amount of fracture gap dehiscence. Further biomechanical trials performed under cycling loading with fresh cadaver specimen should be done to figure out if a fixed-angle plate may be an alternative in the surgical treatment of patella fractures.

The Internet is an inexpensive platform for the investigation of medical questions in case of low prevalence. By accessing www.ao-nailregister.org, every interested participant may participate in the English-language survey of the complications specific to the femoral nail. The address data of the participant, the anonymised key data of the patients and the medical parameters are entered. In real time, these data are checked for plausibility, evaluated and published on the Internet where they are freely accessible immediately. Because of national differences, data acquisition caused considerable difficulties at the beginning. In addition, wrong data were entered because of linguistic or contextual misunderstandings. After having reworked the questionnaire completely, facilitating data input and implementing an automated plausibility check, these difficulties could be cleared. In a next step, the automatic evaluation of the data was implemented. Only very few data still have to be checked for plausibility manually to exclude wrong entries, which cannot be verified by the computer. The effort required for data acquisition and evaluation of the Internet-based femoral nail register was reduced distinctly. The possibility of free international participation as well as the freely accessible representation of the results offers transparency.

Kynurenine, the major degradation product of tryptophan has been shown to directly damage tissues, but its possible contribution to posttraumatic morbidity is unknown. Here, we studied the kinetics of kynurenine in patients after major trauma and whether this correlates with the development of posttraumatic sepsis. Kynurenine and tryptophan levels of 60 multiple-injured patients with Injury Severity Score of more than 16 were quantified prospectively by high-performance liquid chromatography. Blood samples were obtained daily from admission until day 10 after admission. Significantly increased kynurenine values were detectable already at day 1 after admission in blood from patients who later developed sepsis, regardless of injury pattern (P < 0.01). In contrast, kynurenine values of nonsepsis patients remained low throughout the observation period. However, all patients exhibited significantly decreased tryptophan values versus healthy controls (P < 0.01). Moreover, significantly increased kynurenine-tryptophan ratios rapidly predicted subsequent sepsis, multiple organ failure, and death (P < 0.01). Both increased kynurenine values and kynurenine-tryptophan ratios predicted posttraumatic development of sepsis and organ failure. This ought to be validated in subsequent studies.

Posterior dislocations of the glenohumeral joint are extremely rare (2–4% of all shoulder dislocations) and often associated with bone or ligamentary injuries. Though the reverse Hill-Sachs lesion is a common injury associated with posterior shoulder dislocation, there have been only few articles describing specific treatments for this type of humeral head defect. This article describes the successful operative treatment of an acute locked posterior shoulder dislocation by reconstructing the articular surface of the humeral head with the use of autologous bone graft taken from the iliac crest. The patient was doing quite well with no complaints, good range of shoulder motion and no recurrence of posterior shoulder dislocation despite several epileptic seizures, 1.5 years after surgical reconstruction of the anatomy of the humeral head. His right shoulder function revealed to be “excellent” or “good”, assessed with an absolute Constant Score of 76 points and a relative Score of 88% when compared with an age- and sex-matched normal population.

We report two cases of leuprolide acetate-treated leiomyomas with striking vascular changes and histologic features of vasculitis and atherosclerosis. These changes may cause ischemic damage if they occur in other organs. We describe the histologic findings and discuss their clinical implications.