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Study Design Systematic review. Objectives Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. Results An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. Conclusion The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.

Acromial and scapular spine fractures are common complications after reverse total shoulder arthroplasty (RTSA). There is limited information on the treatment outcome of these fractures. Therefore, the purpose of this study was to compare the clinical outcome of operative and conservative treatment of patients with acromial or scapular spine fractures.A total of 1146 RTSAs were performed in our institution between 1999 and 2016. In 23 patients (2%), we identified an acromial fracture, and in 7 cases (0.6%), a scapular spine fracture in the postoperative course. Of those patients, 7 patients (23%) were treated with open reduction and internal fixation and 23 (77%) were treated conservatively. We compared the outcome of operative vs. conservative treatment assessing the Constant score (CS), range of motion, and subjective shoulder value (SSV). Fractures were classified by the system of Crosby. Radiographic assessment consisted of measuring the healing rate, time to heal, and the displacement of the acromion before and immediately after the fracture as well as after treatment.There were no statistically significant differences between operative and conservative treatment. The mean preoperative CS in the operative group was 32 points and improved to 45 points after surgery, whereas it was 35 points in the conservative group and improved to 61 points at the final follow-up. The mean SSV improved from 20 to 50 points in the operative group and from 22 to 58 points in the conservative group. Mean active flexion changed from 59° to 75°, mean abduction from 68° to 67°, and external rotation from 25° to 13° in the operative group and from 75° to 91°, 67° to 92°, and 28° to 24° in the conservative group.In our study, operative treatment was not superior to conservative treatment, neither for CS, SSV, or range of motion. Both treatment forms, however, resulted in inferior results to those previously reported for RTSA without postoperative acromion fractures. Before better surgical methods have been developed, conservative treatment of acromial fractures may be the better treatment option for acromial fractures after RTSA.

We report on outcomes of surgically versus (vs) non-surgically treated patients with moderate adolescent idiopathic scoliosis (AIS) after minimum of 29 years. AIS patients with a follow-up of ≥ 41 years in the surgical group and ≥ 29 years in the non-surgical group were included. Patients were treated surgically for primary curves ≥ 45° vs non-surgically for curves

Anterior knee pain (AKP) is common following total knee arthroplasty. The tibial tuberosity trochlear groove distance (TTTG) influences patellofemoral joint loading in the native knee. Increased TTTG may lead to maltracking of the patella and anterior knee pain. The purpose of this study was to investigate potential changes in TTTG following total knee arthroplasty (TKA).TTTG was measured on preoperative CT data on a consecutive series of patients scheduled to receive TKA with patient-specific instrumentation, and compared to a computer simulation of the postoperative TTTG. Preoperative TTTG was measured with a 3D planning software in 250 knees. The postoperative result was simulated and TTTG measured within the software. Three different groups were analysed: neutral (180° ± 3) (n = 50), valgus ( 190°) (n = 100), and varus ( 170°) (n = 100).Median preoperative to simulated postoperative TTTG decreased from 15.0 [interquartile range (IQR) 6.0] mm to 6.5 (IQR 5.0) mm for all axes combined. A significant postoperative reduction of TTTG was found in each group (p 0.001). The mean change in TTTG did not differ significantly between the groups [- 8.8 (IQR 5.5) mm neutral, - 8.3 (IQR 7.0) mm valgus, - 7.5 (IQR 5.8) mm varus, p = 0.223].This computer-based study suggests that mechanically aligned TKA significantly decreases TTTG distance in neutral, valgus and varus knees, assuming that the postoperative result coincides with the preoperative planning. Further study is warranted to evaluate the clinical relevance of this finding.

The objective was to report radiological and clinical outcomes after reversed L-shaped osteotomy (ReveL) for hallux valgus (HV). A retrospective cohort study was performed between January 2004 and December 2013. The primary outcome was radiological recurrence of HV (HV angle [HVA] >15°). There were various exposure and secondary outcome variables. The results showed a median follow-up of 12.0 months (N = 827). Radiological recurrence, limited patient satisfaction, complication, revision surgery, and elective hardware removal were found in 25.0%, 15.3%, 4.6%, 2.5%, and 26.7%. Median pre- to postoperative changes were highest for HVA (delta = –16.7°). Recurrence was more likely in cases with preoperative HVA ≥40° (adjusted odds ratio [ORadjusted]) 3.63, p

Background Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN. Methods A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development. Results Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2–11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations. Conclusions With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking. Level of Evidence III, long-term retrospective cohort study

Purpose The purpose of this study was to outline an indirect sign of advanced Achilles tendinopathy on magnetic resonance imaging (MRI), based on the hypothesis that these patients would present with secondary hypertrophy of the flexor hallucis longus muscle (FHL). Methods MRI scans of Achilles tendon were analyzed retrospectively in two cohorts. The study group consisted of consecutive patients presenting with clinical signs of Achilles tendinopathy and no previous surgeries, while the control group were patients that had an MRI due to other reasons and no signs of tendinopathy. Two parameters from two muscle bellies were measured and compared on axial MRI scans 4–5 cm above the ankle joint line at the level of greatest thickness: area and diameter of the triceps surae (TS) and of the FHL muscle. Ratios (FHL/TS) were calculated for area (Ar) and diameter (Dm) measurements. Interobserver agreement was analyzed. A receiver operating characteristic (ROC) curve was created for both ratios to assess potential cutoff points to differentiate between the groups. Results A total of 60 patients for each study group were included. Both ratios Ar(FHL/TS) and Dm(FHL/TS) showed significant higher values in the tendinopathy group (p Conclusion In our patient cohort, FHL hypertrophy was observed in patients with Achilles tendinopathy as a possible compensatory mechanism. Measuring a diameter ratio Dm(FHL/TS) of 2.0 or higher on an axial MRI, may be indicative as an indirect sign of functional deterioration of the Achilles tendon.

Patients with adult spinal deformity suffer from disease related disability as measured by the Oswestry Disability Index (ODI) for which surgery can result in significant improvements.The purpose of this study was to show the change in overall and individual components of the ODI in patients aged 60 years or older following multi-level spinal deformity surgery.Prospective, multicenter, multi-continental, observational longitudinal cohort study PATIENT SAMPLE: Patients ≥60 years undergoing primary spinal fusion surgery of ≥5 levels for coronal, sagittal or combined deformity.Oswestry Disability Index (ODI) METHODS: : Patients completed the ODI pre-operatively for baseline, then at 10 weeks, 12 months and 24 months post-operatively. ODI scores were grouped into deciles, and change was calculated with numerical score and improvement or worsening was further categorized from baseline as substantial (≥20%), marginal (≥10-20%) or no change (within 10%).Two-hundred nineteen patients met inclusion criteria for the study. The median number of spinal levels fused was 9 [Q1=5.0, Q3=12.0]. Two-year mean (95% CI) ODI improvement was 19.3% (16.7%; 21.9%; p.001) for all age groups, with mean scores improved from a baseline of 46.3% (44.1%; 48.4%) to 41.1% (38.5%; 43.6%) at 10 weeks (p.001), 28.1% (25.6%; 30.6%) at 12 months (p.001), and 27.0% (24.4%; 29.5%) at 24 months (p.001). At 2 years, 45.5% of patients showed 20% or greater improvement in ODI, 23.7% improved between 10% and 20%, 26.3% reported no change (defined as±10% from baseline), 4.5% of patients reported a worsening between 10% to 20%, and none reported worsening greater than 20%. 59.0% of patients were severely disabled (ODI40%) pre-operatively, which decreased to 20.2% at 2 years. Significant improvement was observed across all 10 ODI items at 12 and 24 months. The largest improvements were seen in pain, walking, standing, sex life, social life and traveling.In this prospective, multicenter, multi-continental study of patients 60 years or older undergoing multi-level spinal deformity surgery, almost 70% of patients reported significant improvements in ODI without taking into account surgical indications, techniques or complications. Clear data is presented demonstrating the particular change from baseline for each decile of pre-operative ODI score, for each sub-score, and for each age group.

Purpose To report and analyse factors affecting the outcome of streptococcal periprosthetic joint infections (PJIs). Methods A retrospective analysis of consecutive streptococcal PJIs was performed. Musculoskeletal Infection Society 2013 criteria were used. Outcome was compared with a prospective PJI cohort from the same institution. Results The most common isolated streptococcal species was Streptococcus dysgalactiae (9/22, 41%) among 22 patients included. Surgical treatment consisted of DAIR (debridement, antibiotics, irrigation and retention) in 12 (55%), one-stage revision arthroplasty in one (4%), two-stage revision arthroplasty in eight (37%) and implant removal in one (4%) patient. An infection free-outcome was achieved in 15 cases (68%), whilst seven (32%) patients failed initial revision and relapsed with the same pathogen, from which six were treated with DAIR and one with one-stage revision arthroplasty. No failures were observed in patients who received a two-stage revision. Failure rates did not differ in the cases treated with rifampin (1/5) from those without 6/17 (p = 0.55). There was no correlation between the length of antibiotic treatment and relapse (p = 0.723). In all failures, a persistent distant infection focus was identified at the time of relapse. Compared with our prospective PJI cohort, relapse rates were significantly higher 32% vs 12% (p Conclusion No correlation with the use of rifampin or length of antibiotic treatment was found. No failures were observed in patients who received a two-stage revision, which may be the surgical treatment of choice. A distant persisting infection focus could be the reason for PJI relapse with recurrent hematogenous seeding in the joint.

Background context Spinal sarcomas are a rare, heterogeneous group of mesenchymal tumors. Current literature reporting demographic variables and survival information is limited to small case series, and a single registry with variable treatment modalities and time periods. Purpose We report on population-level data regarding all spinal sarcomas diagnosed over a 23-year period in Ontario, Canada, for the purposes of calculating incidence and prevalence of these tumors. Secondarily, survival is assessed by tumor type as well as adjuvant therapies during this time period. Study design Retrospective Cohort Study Patient sample Population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015. Outcome measures Outcome measures include incidence and prevalence of spinal osteosarcoma, Ewing's sarcoma, and chondrosarcoma of the spine, as well as 2-, 5-, 10- and 15-year survival and prevalence of adjuvant therapies. Methods Utilizing population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015, ICD codes were searched and available data extracted for the purposes of reporting basic demographic information and calculation of Kaplan Meyer survival curves. Databases include the Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan, National Ambulatory Care Reporting System, Registered Persons DataBase (death) were analyzed. Results One hundred and seven spinal sarcomas were identified, with a mean incidence was 0.38 sarcomas per million population per year, that was stable over time. The mean prevalence was 8.1 sarcomas per million population. The most common diagnosis was Ewing's sarcoma (48 [44.9%] patients), followed by chondrosarcoma (33 [30.8%] patients), and osteosarcoma (26 [24.3%] patients). Chondrosarcoma had the highest survival rates with 77.2% and 64.2% 5- and 10-year survival rates, respectively, followed by Ewing's sarcoma with 48.1% and 44.9% 5 and 10-year survival and osteosarcoma with 36.0% and 30.9% 5- and 10-year survival. Conclusions Spinal sarcoma is a rare disease with variable survival depending on the histologic diagnosis. This population-level study involves a heterogeneous group of patients with variable stages of disease at presentation and variable treatments. Our data fit with the published literature for survival for those treated conservatively and surgically. Our data show considerable improvement in 5- and 10-year mortality when compared with previous population level studies on earlier patient cohorts, likely reflecting improvements in systemic and surgical treatments.

The mechanical conflict in symptomatic femoroacetabular impingement can lead to early osteoarthritis. However, radiographic impingement morphology is often seen in asymptomatic individuals. Long-term observation regarding the risk of developing osteoarthritis in these individuals is lacking. Our study addressed the following questions: Does femoroacetabular impingement morphology increase the risk for development of osteoarthritis after at least 25 years? If yes, which radiographic parameter is the most predictive? Does the level of activity influence the risk for development of osteoarthritis? Are PROM influenced by the grade of osteoarthritis in this population? We investigated 51 (32 male, 19 female) patients for whom AP pelvis and Dunn view radiographs were available with a minimum follow-up of 25 years. Alpha angle in AP pelvis and Dunn view radiographs, femoral torsion in Dunn view, lateral center edge angle, cross-over sign, posterior wall sign and prominence of ischial spine sign in AP pelvis radiographs were determined. On the follow-up radiographs, osteoarthritis was graded. Tegner Score for the time of the index radiograph was evaluated. Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index were assessed at latest follow-up. The mean follow-up was 43 years (range 25–58). Cam impingement morphology showed to increase the risk for development of osteoarthritis: Alpha angles of ≥ 55° on AP pelvis and Dunn view radiographs were associated risk factors and showed an OR of 1.05 (p = 0.002) and 1.10 (p = 0.001), respectively. Abnormal femoral torsion and acetabular retroversion were not risk factors for osteoarthritis. Tegner Score at index presentation, HHS and WOMAC Score did not correlate with the grade of osteoarthritis. This study showed that cam impingement morphology in young patients raises the risk for development of hip osteoarthritis by 5–10% in a long-term follow-up with a minimum of 25 years, thus its contribution was small.

The aim of this work is to evaluate the effectiveness of training with the low-fidelity ArthroBox® regarding performance of different basic arthroscopy tasks using a validated high-fidelity virtual reality simulator of the knee. Nineteen volunteers (14 females and 5 males) without any previous experience in arthroscopy were randomly assigned either to the ArthroBox® training group (n =10) or the non-training group (n =9). The training group underwent a supervised ArthroBox ® training consisting of a daily 60-min session for three consecutive days. Both groups completed the basic and the final assessment using a validated virtual reality-based passive haptic knee arthroscopy simulator (ArthroS, VirtaMed™). The following three factors were measured in different exercises (explained in “Materials and methods”): amount of time to finish the task, length of camera and scope path within the joint. Furthermore, the volunteers’ demographics (age, sex, dexterity, video game experience, sport activities and profession) was assessed but showed no differences between the groups. There were no significant differences between the training and non-training group regarding the above-mentioned demographic factors. However, the training group showed significant improvement from baseline to follow-up in most activities (e.g. task performance time in seconds, intra-articular camera and grasp distance in centimetres; see Table 1) in comparison to the non-training group. The results from this study demonstrate that training for three consecutive days using a portable and versatile low-fidelity simulator significantly improves arthroscopy performance when using a validated high-fidelity virtual knee simulator. Arthroscopic triangulation training outside the operating theatre with a portable, low-cost simulator has proven to be a valuable educational tool to improve the arthroscopic skills of trainee surgeons. Diagnostic study, Level II.

Background Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length. Hypothesis LLD after THA is associated with lower back pain. Materials and methods Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA. Results Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD > 5 mm was present in 44 (56%) (median 8.0 (IQR −3.0 to 12.0; range −22 to 22) mm) and > 10 mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range −22 to 22) mm) patients. iLLD changed > 5 mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range −8 to 18) mm) and > 10 mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p = 0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of > 10 mm (p = 0.01). Conclusions Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10 mm. Level of evidence IV.

Background Portal placement is a key factor for the success of arthroscopic procedures, particularly in rotator cuff repair. We hypothesize that the acromial anatomy may strongly determine the position of the shoulder bony landmarks and limit the surgeon’s freedom to position the arthroscopic approaches in direction towards the acromion. The purpose of this study was to analyze the relation between different acromial shapes and the freedom of movement of arthroscopic instruments relative to the rotator cuff from standardized arthroscopic portals in a laboratory study on 3D shoulder models. Methods 3D models of shoulders with a broad range of different acromial shapes were printed using CT and MRI scans. Angles from the portals to defined points on the rotator cuff and the supraglenoid tubercle were measured. In conventional radiographs, the critical shoulder angle, the scapular body acromial angle, and the glenoid acromial angle were measured and compared with the measured angles to the rotator cuff. Results There was a large variation of angles of approach of instruments to the rotator cuff between the seven shoulders for each portal. From the joint line portal and the posterior edge portal, the biggest angles were measured to the posterior cuff. From the intermediate portal, the angles were largest to the intermediate rotator cuff and from the anterior portals to the anterior cuff. To the supraglenoid tubercle, best access was from anterior. For all portals, there was a big correlation between the glenoid acromial angle and the scapular body acromial angle with the angles of approach to the tendon and especially to the supraglenoid tubercle. Conclusion The access to the rotator cuff from almost every portal is influenced by the acromial shape. As hypothesized, a small (small GAA) and flat (big SBAA) acromion provide an easier approach to the rotator cuff from almost every portal. Therefore, it may severely influence the instruments maneuverability.

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

BACKGROUND A fascial dehiscence after spinal instrumentation is usually located at the mechanically stressed interscapular thoracic spine and often causes cosmetic impairment and pain. However, therapy options remain barely discussed. Synthetic meshes have been successfully used in the treatment of abdominal hernias. OBJECTIVE It was hypothesized that synthetic meshes are a successful treatment option for spinal fascial dehiscence. METHODS This retrospective study of a prospective database investigated all consecutive patients who received a synthetic mesh for a fascial dehiscence of the spine between 2010 and 2014 after prior spinal instrumentation. Primary outcomes were healing of the fascial dehiscence, recurrence, infection, revision, subjective satisfaction on a visual analog scale (VAS), and the Oswestry Disability Index (ODI). Among others, secondary outcomes consisted of seroma formation and return to work. The evaluated risk factors consisted of the body mass index (BMI), outer abdominal fat (OAF), back tissue, smoking, immunomodulatory therapy, preoperative radiation dose, and instrumented levels. RESULTS Sixteen patients with a mean follow up of 24 months were included. Every fascial dehiscence successfully healed with the synthetic mesh and there were no recurrences, infections or revisions. The mean subjective satisfaction level was VAS 7.3 and the mean ODI was 26%. Five (31%) patients had a seroma postoperatively, but did not show any differences in the outcome (e.g. ODI of 28%). In the patient group < 65 years (n = 12), all but two patients, who had work restrictions due to other diseases, regained at least some capacity to work. Worse ODI scores were found for patients with increased BMI, OAF, back tissue, cortisone therapy, instrumented levels, preoperative radiation dose, and for smokers. CONCLUSION Synthetic meshes are a successful treatment option for spinal fascial dehiscence, even seemingly in patients with a higher risk profile such as obese and immunocompromised patients as well as in revision procedures. They are associated with respectable cosmetic results, pain relief and clinical outcome. Postoperatively, it is recommended to leave drains for more than five to seven days in order to avoid seroma formation and to avoid weight training for six weeks. Further prospective, comparative studies are recommended.

Introduction Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling. Materials and methods An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague–Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest). Results The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0–1]) compared to controls (median = 2 [IQR = 1–3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups. Conclusions In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

BACKGROUND Anatomic factors associated with static posterior translation of the humeral head with or without glenohumeral osteoarthritis are unknown. We tested the hypothesis that there is an association between glenoid wear, glenoid version, and/or anteroposterior acromial tilt. METHODS Ninety-nine patients with glenohumeral joint degeneration involving advanced glenoid cartilage wear and/or rotator cuff disease scheduled for anatomic or reverse total shoulder replacement underwent standardized conventional radiographic and computed tomographic shoulder imaging. Measurements included glenoid version, humeral torsion, posterior acromial slope, and critical shoulder angle. The glenoid shape was classified according to Walch et al, and the integrity of the rotator cuff was assessed. RESULTS Patients with glenoid type B2 or C had a median of 4° more glenoid retroversion (P = .022), a 5° less steep acromion (posterior acromial slope, 61° vs 56°; P = .004), and a higher combined score (glenoid version minus slope; odds ratio, 0.93 [95% confidence interval, 0.89-0.97]; P

Background Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length. Hypothesis LLD after THA is associated with lower back pain. Materials and methods Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA. Results Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD > 5 mm was present in 44 (56%) (median 8.0 (IQR -3.0 to 12.0; range -22 to 22) mm) and > 10 mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range -22 to 22) mm) patients. iLLD changed > 5 mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range -8 to 18) mm) and > 10 mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p = 0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of > 10 mm (p = 0.01). Conclusions Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10 mm. Level of evidence IV.

Wearing high heels is associated with chronic pain of the neck, lower back and knees. The mechanisms behind this have not been fully understood. The purpose of this study was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels. Lateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups. Standing in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p

The prevalence of cardiac implantable electronic devices (CIEDs), pacemakers and implantable cardioverter defibrillators (ICDs) is increasing. However, postmortem analysis of CIEDs is not performed routinely. Fourteen consecutive CIEDs were analyzed. The indication for and date of implantation, technical data, CIED reprogramming, heart rhythm disturbances, patient demographics and medical consultations were investigated. Death during the first year after implantation was seen in 54%, whereof 71% consulted a physician within 10 days before death. The time of death was attributed to a particular day in 29%. There was a relationship between CIEDs and cause/manner of death in 50%. Although limited by a small sample size, this study advocates the routine postmortem CIED analysis for forensic and clinical purposes in selected cases. Patients with CIEDs seem to show an increased risk of death during the first year after implantation. The analysis of CIEDs can be helpful in evaluating the time/cause/manner of death.

Background Surgical treatment of hallux valgus (HV) is one of the major flagships of orthopedic surgeons. Due to relatively unsatisfactory radiological and clinical outcomes, the search for the best surgical technique and causes for unsatisfactory outcomes continues. The objective was to investigate associations of the number of screws and additional surgical techniques for HV with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL). Methods A retrospective cohort study of adults from a single University Hospital between 2004 and 2013 was performed. The primary exposure was the number of screws (one vs two) used for osseous fixation after ReveL. The secondary exposure was an additional surgical technique for HV (e.g., Akin osteotomy). The primary outcome was a radiological recurrence of HV (HV angle (HVA) > 15°) at last follow-up. The secondary outcomes were limited patient satisfaction, complication, revision surgery, and elective hardware removal. Odds ratio (OR) and 95% confidence interval (CI) were estimated by logistic regression adjusting for confounders. Results The recurrence was 45% less likely with the use of one screw, independent of age, sex, additional technique, and preoperative HVA (odds ratio (ORadjusted) = 0.55 [95% CI 0.30–0.98], p = 0.043). The recurrence was 162% more likely with an additional surgical technique for HV (ORadjusted = 2.62 [1.24–5.52], p = 0.011). Conclusion In ReveL for HV, a single screw (instead of two screws) may be sufficient enough for a similar or even better outcome, which may also reduce costs. Additional surgical procedures for HV may be refrained from if possible. Due to limitations of a retrospective study, results may need validation with clinical trials.

Surgical knots are particularly challenged by high-strength suture material. It was hypothesized that sutures in a double-stranded looped configuration present mechanical advantages.This in vitro biomechanical study repeatedly tested 12 different knots with a static distraction material testing machine with a constant tensile speed. The cow hitch, its altered version, and conventional half hitches were also tested on bovine tendon. Suture material was braided polyblend non-bioresorbable polyester. Primary outcome was knot security (stiffness) at clinical failure (≥3mm displacement). Secondary outcomes were knot size and loop security.Double-stranded looped knots were up to three times stronger than one and a half- and single-stranded knots. The cow hitch was stiffest (mean 185 [95% CI 172-197]Newton per millimeter [N/mm]) (p0.001), followed by the Nice knot (169 [154-183]N/mm). It was stiffer than half hitches (65 [53-78]N/mm). These findings remained in tendons (82 [77-86] and 40 [32-49]N/mm, p0.001). The cow hitch (7.6mmDouble-stranded knot configurations with a loop on one side are mechanically stronger and stiffer, less bulky, and preserve applied tension during tying better than conventional knots. The best performing and technically most simple knots best suited to exploit enormous mechanical capabilities of modern high-strength suture material are the cow hitch and Nice knot.Not applicable due to the biomechanical nature of the study.

Objectives The use of new anticoagulants potentially carries the risk of increased intracranial bleeding, but there is a lack of evidence. The aim of this study was to investigate whether the morbidity and mortality differs in head trauma patients depending on the type of anticoagulation. Patients and methods A retrospective cohort study was conducted in 2009–2014. Based on sex, age, and Glasgow-Coma Scale (GCS), patients that received rivaroxaban were matched to two control groups, one that received no anticoagulant and another one that received phenprocoumon. The primary outcome was mortality. Among others, secondary outcome variables were the length of stay (LOS) at the hospital and presence of an intracranial injury. Results Sixty-nine patients (23 patients per group) were analyzed. The characteristics of patients did not differ significantly across groups. There were no significant differences between groups for the primary and secondary outcomes. Two patients died in the rivaroxaban group (one of them likely due to head trauma), while one patient died in the phenprocoumon group (likely not due to head trauma), and no patient died in the no anticoagulatoin group (p = 0.36). The LOS at the hospital was similar (5.0, 4.0, and 5.0 days; p = 0.94). An intracranial injury was observed in a similar number of patients in all groups (n = 11, n = 10, and n = 8; p = 0.75). Conclusion Although limited in size, this study did not observe significant outcome differences in patients with traumatic head injuries, who received rivaroxaban, no anticoagulant or phenprocoumon. Although not significant, the only death likely due to head trauma in the study occurred in the rivaroxaban group. Larger studies are needed before clinical application of these findings.

While spinal instrumentations are becoming more common, the advantages of elective spinal implant removal remain ambiguous. We hypothesized that elective implant removal of the posterior spine is beneficial. A retrospective study evaluated 137 consecutive trauma patients with elective implant removal of the posterior spine. If additional cages were present, they were not removed. Primary outcomes were the change in pre- and post-operative pain, fingertip-floor distance (FFD), and Cobb angles. Some secondary outcomes consisted of complications, work disability, and pelvic incidence (PI). Different stabilization approaches and cage sizes were compared. The presence and amount of pain as well as the FFD showed significant improvement. There was no loss of reduction. Delayed wound healing was observed in 9 %, but only 3 % needed revision. Thoracic fascial dehiscences were seen only in patients (9 %) that had stand-alone posterior surgery. Larger cages were associated with increased work disability. An increased PI was associated with less post-operative pain and decreased FFD. In this study, trauma patients benefited from elective implant removal of the posterior spine due to lower presence and level of pain, improved function and low revision rates; irrespective of an initial combined or stand-alone posterior approach or varying cage sizes. However, stand-alone posterior instrumentation may be accompanied by increased rates of fascial dehiscence surgeries and larger cages may lead to increased work disability. Increased PI may be associated with less pain after spinal implant removal.

There is a lack of studies on obesity measured by outer abdominal fat (OAF), which describes abdominal subcutaneous adipose tissue thickness with regard to spino-pelvic parameters. We investigated OAF and its physiologic values on computed tomography (CT) scans with regard to age, gender, facet joint (FJ) arthritis, FJ orientation, lumbar lordosis (LL) and pelvic incidence (PI).OAF, lumbar FJs, LL and PI were evaluated on CT scans.CT scans of 620 individuals with a mean age of 42.5 years were reviewed. OAF showed a mean value of 19.7 millimeters (mm). It significantly increased with age until 70 years and decreased thereafter (p 0.0001). There was no significant gender difference. OAF was significantly increased with FJ arthritis (p = 0.01), but not with FJ orientation, LL or PI.OAF on CT scans seems to have a mean value of 19.7 mm. It is higher in the older age groups until 70 years and declines again afterward. As a novelty finding, OAF significantly increases with higher degrees of FJ arthritis, but is not related to gender or other spino-pelvic parameters such as FJ orientation, LL or PI. Differences in fat distribution may be found at other anatomic sites, such as visceral fat. Obese patients may benefit from weight loss by decreasing their FJ arthritis, which may potentially decrease associated back pain, which may be worth further investigations.

Objectives: Rib fractures are commonly found in trauma patients and have a relevant mortality rate. Obesity is usually measured with the body mass index (BMI). Although it can predict all-cause mortality, there is only sparse literature whether it can predict rib fracture-mortality. This may be in part[for full text, please go to the a.m. URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2017)

Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n = 10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10 µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n = 10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10 µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10 weeks after surgery. The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1–S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. A single local application of zoledronic acid with DBM putty during posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our results justify further investigations to potentially use local application of zoledronic acid in future clinical studies.

Category: Ankle, Hindfoot, Trauma Introduction/Purpose: Lateral talar process fractures (LTPF) constitute 15% of ankle injuries in snowboarders. They are often misdiagnosed on conventional radiographs, which are also susceptible to rotational malpositioning due to pain. A positive V sign is an interruption of the contour of the lateral talar process. It has been suggested to be pathognomonic for LTPF. However, there are very few studies about this topic. The objectives were to study whether the V sign is useful in diagnosing LTPF. Methods: In an experimental study, two investigators evaluated lateral radiographs (n=108) of high resolution, solid foam, radiopaque distal foot and ankle models. Two other investigators, who obtained the radiographs, defined the gold standard. Four different models (no fracture, type A, B, or C fractures according to Hawkins) and three varying ankle joint positions (0°, 20°, and 40° of inversion, plantar flexion, and internal rotation) were the independent variables. The correct detection of a V sign on lateral radiographs (Figure 2 showing a positive V sign on a lateral radiograph in a type B LTPF) was the primary dependent variable and the detection of the fracture type and uncertainty in making this decision were the secondary dependent variables. The chosen study size surpassed the sample size calculation. The chi-squared test was used for categorical data. Results: There were fair interobserver agreements on the V sign and fracture types (kappa coefficient [k]=0.35, 95% confidence interval [CI] 0.18-0.53, pConclusion: It is not recommended to exclusively use the V sign for the evaluation of LTPF. If negative, LTPF cannot be excluded. However, if positive, it may be a helpful surrogate parameter for the presence of LTPF, especially type B fractures. Inversion may lead to better visualization of the V sign. This knowledge about the V sign is a valuable asset for the diagnostic skillset of an orthopaedic surgeon. Future clinical studies may focus on validating these experimental findings. [Notes: Level of evidence is not applicable to this study. This abstract has also been submitted to the swiss orthopaedics congress 2017.]

STUDY DESIGN A retrospective study. OBJECTIVE Our study opted to clarify the remaining issues of lumbar lordosis (LL) with regard to (1) its physiological values, (2) age, (3) sex, and (4) facet joint (FJ) arthritis and orientation using computed tomography (CT) scans. SUMMARY OF BACKGROUND DATA Recent studies have questioned whether LL really decreases with age, but study sample sizes have been rather small and mostly been based on x-rays. As hyperlordosis increases the load transferred through the FJs, it seems plausible that hyperlordosis may lead to FJ arthritis at the lower lumbar spine. METHODS We retrospectively analyzed the CT scans of 620 individuals, with a mean age of 42.5 (range, 14-94) years, who presented to our traumatology department and underwent a whole-body CT scan, between 2008 and 2010. LL was evaluated between the superior endplates of L1 and S1. FJs of the lumbar spine were evaluated for arthritis and orientation between L2 and S1. RESULTS (1) The mean LL was 49.0 degrees (SD 11.1 degrees; range, 11.4-80.1 degrees). (2) LL increased with age and there was a significant difference in LL in our age groups (30 y and below, 31-50, 51-70, and ≥71 y and above) (P=0.02). (3) There was no significant difference in LL between females and males (50 and 49 degrees) (P=0.17). (4) LL showed a significant linear association with FJ arthritis [P=0.0026, OR=1.022 (1.008-1.036)] and sagittal FJ orientation at L5/S1 (P=0.001). In a logistic regression analysis, the cutoff point for LL was 49.4 degrees. CONCLUSIONS This is the largest CT-based study on LL and FJs. LL significantly increases with age. As a novelty finding, hyperlordosis is significantly associated with FJ arthritis and sagittal FJ orientation at the lower lumbar spine. Thus, hyperlordosis may present with back pain and patients may benefit from surgical correction, for example, in the setting of trauma.

Surgical debridement, negative-pressure wound therapy (NPWT) and antibiotics are used for the treatment of open wounds. However, it remains unclear whether this treatment regimen is successful in the reduction and shift of the bacterial load. After debridement in the operating room, NPWT, and antibiotic treatment, primary and secondary consecutive microbiological samples of 115 patients with 120 open wounds with bacterial or yeast growth in ≥1 swab or tissue microbiological sample(s) were compared for bacterial growth, Gram staining and oxygen use at a level one trauma center in 2011. Secondary samples had significantly less bacterial growth (32 vs. 89%, p

Resume Les nœuds chirurgicaux sont particulierement sollicites par les sutures a haute resistance. Notre hypothese est que les sutures dans une configuration en boucle a double brin diminuent le nombre d’extremites de sutures libres a nouer et presentent des avantages mecaniques. Methodologie Cette etude biomecanique in vitro a teste 12 nœuds differents sur machine avec une vitesse de traction constante. Le nœud « cow hitch », sa version modifiee et les demi-cles conventionnelles ont egalement ete testes sur des tendons de bovin. Le materiau de suture est un polyester non resorbable tresse. L’interet principal est la securite du nœud (raideur) a la rupture (deplacement ≥ 3 mm). Les interets secondaires sont la taille du nœud et la securite de la boucle. Resultat Les nœuds en boucle a double brin sont jusqu’a trois fois plus resistants que les nœuds a un et demi et a simple brin. Le « cow hitch » est le plus rigide (moyenne 185 [IC a 95 % : 172–197] N/mm) (p Conclusion Les configurations de nœuds en boucle a double brin sont mecaniquement plus resistantes et plus rigides, moins volumineuses et conservent mieux la tension appliquee durant le nouage que les nœuds conventionnels. Les nœuds les plus performants et techniquement les plus simples qui conviennent le mieux pour exploiter les enormes capacites mecaniques des sutures a haute resistance sont le « cow hitch » et le nœud Nice. Niveau de preuve Non applicable du a la nature biomecanique de l’etude.

Background Sarcomas are associated with a relatively high local recurrence rate of around 30 % in the pelvis. Inadequate surgical margins are the most important reason. However, obtaining adequate margins is particularly difficult in this anatomically demanding region. Recently, three-dimensional (3-D) planning, printed models, and patient-specific instruments (PSI) with cutting blocks have been introduced to improve the precision during surgical tumor resection. This case series illustrates these modern 3-D tools in pelvic tumor surgery. Methods The first consecutive patients with 3-D-planned tumor resection around the pelvis were included in this retrospective study at a University Hospital in 2015. Detailed information about the clinical presentation, imaging techniques, preoperative planning, intraoperative surgical procedures, and postoperative evaluation is provided for each case. The primary outcome was tumor-free resection margins as assessed by a postoperative computed tomography (CT) scan of the specimen. The secondary outcomes were precision of preoperative planning and complications. Results Four patients with pelvic sarcomas were included in this study. The mean follow-up was 7.8 (range, 6.0–9.0) months. The combined use of preoperative planning with 3-D techniques, 3-D-printed models, and PSI for osteotomies led to higher precision (maximal (max) error of 0.4 centimeters (cm)) than conventional 3-D planning and freehand osteotomies (max error of 2.8 cm). Tumor-free margins were obtained where measurable (n = 3; margins were not assessable in a patient with curettage). Two insufficiency fractures were noted postoperatively. Conclusions Three-dimensional planning as well as the intraoperative use of 3-D-printed models and PSI are valuable for complex sarcoma resection at the pelvis. Three-dimensionally printed models of the patient anatomy may help visualization and precision. PSI with cutting blocks help perform very precise osteotomies for adequate resection margins.

Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets. One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions. Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p

Background Heterotopic ossification (HO) is a frequent complication following orthopedic and trauma surgery. It often leads to substantial morbidity as many affected patients suffer from pain and joint contractures. Current prophylactic measures include nonsteroidal anti-inflammatory drugs (NSAID) and local radiation. However, several disadvantages such as delayed fracture healing and impaired ossification have been reported. For this reason, a novel approach for prevention of HO was searched for. We hypothesized that systemic administration of hydroxyethyl starch (HES), a substance known to influence microcirculation, would reduce formation of HO in a murine model. Methods A pre-established murine model was used where HO has been shown to develop following Achilles tendon tenotomy. Twenty CD1 mice were randomly assigned to a control (n = 10) or treatment group (n = 10). The treatment group received two intravenous HES injections perioperatively, while the control group underwent tenotomy only. After ten weeks, the mice were euthanized and micro CT scans of the hind limbs were performed. HO was manually identified and quantitatively assessed. A Wilcoxon rank sum test was used for comparison of both groups. Results The mean heterotopic bone volume in the control group was significantly larger compared to the HES group (2.276 mm3 vs. 0.271 mm3, p = 0.005). A reduction of mean ectopic bone volume of 88 % was found following administration of HES. Conclusion A substantial reduction of HO formation was found following perioperative short-term administration of HES. This work represents a preliminary study, necessitating further studies before drawing ultimate conclusions. However, this simple addition to current prophylactic measures might lead to a more effective prevention of HO in the future.

Background There is a need for effective drugs in the prevention and treatment of heterotopic ossifications (HO) after fractures. Echinomycin has been shown to prevent formation of HO in an animal model. However, before it may be considered as an option against HO, it needs to be studied whether it prevents fracture healing similar to non-steroidal anti-inflammatory drugs (NSAIDS). Therefore, the hypothesis was that echinomycin prevents fracture healing and callus formation. Methods In an experimental murine pilot study, standard blunt femur fractures were induced and retrograde intramedullary compression fixation of the femur was performed. The treatment group (n = 8) received echinomycin (0.3 mg/kg body weight) and the control group (n = 8) did not receive echinomycin. The fractures and implant positions were verified by conventional X-rays immediately postoperatively. As the primary outcome variable, fracture healing (osseous consolidation) was evaluated by conventional X-rays and micro-computed tomography (CT) scans after ten weeks and graded as healed, partial or complete pseudarthrosis. The secondary outcome, callus formation, was graded semi-quantitatively from 0 (mostly absent) to 3 (maximum). Results Fracture healing was present in all living cases after ten weeks concerning the treatment group. Partial pseudarthrosis was seen in two cases, one in the treatment and another one in the control group. Complete pseudarthrosis was seen in one case of the control group after an open fracture. Callus formation was similar in both groups with a mean grade of 1.5 within each group. Two cases of the treatment group died. Conclusion As a novel finding, echinomycin did not inhibit fracture healing or callus formation in this in vivo murine standard femur fracture model pilot study. Further studies involving a larger number of cases, quantitative assessment with CT scans and histopathological analysis are needed before generalizing the results of this pilot study.

Minimal invasive screw fixation is common for treating posterior pelvic ring pathologies, but lack of bone quality may cause anchorage problems. The aim of this study was to report in detail a new technique combining iliosacral screw fixation with in-screw cement augmentation (ISFICA). The patient was put under general anesthesia and placed in the supine position. A K-wire was inserted under inlet–outlet view to guide the fully threaded screw. The screw placement followed in adequate position. Cement was applied through a bone filler device, inserted at the screwdriver. The immediate control of cement distribution, accurate screw placement and potential leakage were obtained via intraoperative CT scan. Twenty consecutive patients treated with ISFICA were included in this study. The mean age was 74.4 years (range 48–98). Screw placement, possible cement leakage and screw positioning were evaluated via intraoperative CT scan. Postoperative neurologic deficits, pain reduction and immediate postoperative mobilization were clinically evaluated. Twenty-six screws were implanted. All patients were postoperatively, instantly mobilized with reduced pain. No neurologic deficits were apparent postoperatively. No cement leakage occurred. One breach of the iliac cortical bone was noted due to severe osteoporosis. One screw migration was seen after 1 year and two patients showed iliosacral joint arthropathy, which led to screw removal. ISFICA is a very promising technique in terms of safety, precision and initial postoperative outcome. Long-term outcomes such as lasting mechanical stability or pain reduction and screw loosening despite cement augmentation should be investigated in further studies with larger patient numbers.

Introduction: Radiation protection is becoming more important with an ongoing increase in radiation exposure due to the use of X-rays in minimally invasive procedures in orthopaedic and trauma surgeries. However, sufficient education in medical physics and radiation protection can often be improved. Materials and methods: A questionnaire consisting of four questions about personal data and ten questions about radiation protection was distributed to lead consultants, consultants, residents, medical students, and medical technical assistants at two institutions, a level 1 trauma center and a children's hospital. Results: This study consisted of 83 participants. The compliance with radiation protection, i.e., usage of a dosimetry, an apron, and a thyroid shieldon a regular basis was only seen in 54%. Participants from the trauma center wore a dosimeter and thyroid shield significantly more often. The regular use of a thyroid shield differed significantly between job positions. It was observed in 80 % of students, but only 15 % of technical assistants. Only 65% of all knowledge questions were answered correctly. There was a discrepancy between incorrectly answered knowledge questions (35%) and those marked as uncertain (20%). Different job positions did not have an impact on theanswers to the questions in most instances. Conclusions: The compliance with and the knowledge about radiation protection seems to be unnecessarily low in trauma physicians and technical assistants. The discrepancy in falsely answered questions and those marked as uncertain may suggest that participants may overestimate their knowledge about radiation protection, which is potentially harmful due to the increased radiation exposure. Therefore, we advocate a quick and valuable training of trauma surgeons and medical staff addressing the important preventive measures, some of which are illustrated in the present study. These consist of wearing dosimetry and protection devices, reduction inX-ray duration, preferably antero-posterior C-arm positioning with the image intensifier close to the patient and the surgeon, maximal distance, collimation, and increased voltage. Furthermore, the use of visual feedback on complex and potentially hazardous radiation facts may beuseful for training purposes. Study design: Cross-sectional study with a questionnaire.

Surgical site infections (SSIs) increase morbidity and mortality rates and generate additional cost for the healthcare system. Pre-operative blood transfusion and the subcutaneous fat thickness (SFT) have been described as risk factors for SSI in other surgical areas. The purpose of this study was to assess the impact of pre-operative blood transfusion and the SFT on the occurrence of SSI in posterior thoracic spine surgery.In total, 244 patients (median age 55 y; 97 female) who underwent posterior thoracic spine fusions from 2008 to 2012 were reviewed retrospectively. Patient-specific characteristics, pre-operative hemoglobin concentration/hematocrit values, the amount of blood transfused, and the occurrence of a post-operative SSI were documented. The SFT was measured on pre-operative computed tomography scans.Surgical site infection was observed in 26 patients (11%). The SFT was 13 mm in patients without SSI and 14 mm in those with infection (p=0.195). The odds ratio for patients with pre-operative blood transfusion to present with SSI was 3.1 (confidence interval [CI] 1.4-7.2) and 2.7 (CI 1.1-6.4) when adjusted for age. There was no difference between the groups with regard to pre-operative hemoglobin concentration (p=0.519) or hematocrit (p=0.908). The SFT did not differ in the two groups.Allogeneic red blood cell transfusion within 48 h prior to surgery was an independent risk factor for SSI after posterior fusion for the fixation of thoracic spine instabilities. Pre-operative blood transfusion tripled the risk, whereas SFT had no influence on the occurrence of SSI.

We present a detailed description of the surgical technique and the preliminary results of an endoscopic denervation for patients with chronic low back pain (CLBP) originating from the facet joints (FJ). Endoscopic denervation of the medial branches of the dorsal rami supplying the FJ has recently been appraised as providing excellent intraoperative visualization and long term pain relief for these patients. Conventional endoscopic rhizotomy has been expanded to include a the precise localization of 3D navigation. A surgical description and the results of our first four patients treated with 3D navigated endoscopic rhizotomy (3DNER) are presented. Four patients with a mean age of 59years and a follow-up time of 2months were included. All patients reported pain reduction in the immediate postoperative period, while three patients (75%) had long lasting relief. The patient without persisting relief had previously sustained a lumbar disc prolapse and only achieved minor pain relief with preoperative FJ infiltration, compared to the significant relief that was seen in the other patients. In contrast to conventional rhizotomy, 3DNER enables the surgeon to ablate more precisely and extensively, which is especially useful if scar tissue is present from previous injuries or surgeries. When successful, this technique may provide long lasting pain relief, especially if the preoperative FJ infiltrations are followed by a substantial pain reduction.

Background The socioeconomic status has been associated with disparities in the incidence and mortality of traumatic injuries. However, there is a lack of studies on the level of health insurance with regard to various epidemiologic data of traumatic injuries, which this study opted to clarify. Materials and methods All consecutive 6595 patients admitted to a level one trauma center in 2012 and 2013 were included in this retrospective cohort study. Patients were grouped according to their health insurance status (public versus private extended health care insurance) and compared with regard to several epidemiologic variables, that is, the type of injuries, inhospital outcome, and surgical procedures. Results Public insurance coverage was significantly more common than private insurance (75% versus 25%). Public insurance was associated with younger age, male sex, transfers to another hospital or mental institution, head concussions, head fractures, and increased mortality. Contrarily, patients with private insurance were more often associated with longer hospital stay, discharge to a rehabilitation clinic, fractures of the proximal humerus, and shoulder dislocations. However, there were no significant differences for the remaining majority of studied variables. Conclusions In a trauma setting, the level of insurance does not seem to play a crucial role in most types of injuries and surgical procedures in a country with a high level of obligatory health care coverage. Nonetheless, it appears that publicly insured patients are more commonly younger, males, transferred to another hospital more often, more prone to head trauma, and subject to increased mortality, whereas privately insured patients show longer hospital stays, increased transfers to rehabilitation clinics, and more fractures of the proximal humerus.

Reconstruction of the extensor mechanism after resection of the proximal tibia is challenging, and several methods are available. A medial gastrocnemius flap commonly is used, although it may be associated with an extensor lag. This problem also is encountered, although perhaps to a lesser extent, with other techniques for reconstruction of the extensor apparatus. It is not known how such lag develops with time and how it correlates with functional outcome.We therefore (1) assessed patellar height with time, (2) correlated patellar height with function using the Musculoskeletal Tumor Society (MSTS) score, and (3) correlated patellar height with range of motion (ROM) after medial gastrocnemius flap reconstruction.Sixteen patients underwent tumor endoprosthesis implantation and extensor apparatus reconstruction between 1997 and 2009 using a medial gastrocnemius flap after sarcoma resection of the proximal tibia. These patients represented 100% of the population for whom we performed extensor mechanism reconstructions during that time. The minimum followup was 2 years (mean, 5 years; range, 2-11 years). Fourteen patients were alive at the time of this study. We used the Blackburne-Peel Index to follow patellar height radiographically with time. Functional outcomes were assessed retrospectively using the MSTS, and ROM was evaluated through active extensor lag and flexion.Eleven patients had patella alta develop, whereby the maximal patellar height was reached after a mean of 2 years and then stabilized. More normal patellar height was associated with better functional scores, a smaller extensor lag, but less flexion; the mean extensor lag (and flexion) of patients with patella alta was 17° (and 94°) compared with only 4° (and 77°) without.In our patients patella alta evolved during the first 2 postoperative years. Patella alta is associated with extensor lag, greater flexion, and worse MSTS scores. Surgical fixation of the patellar tendon more distally to its anatomic position or strict postoperative bracing may be advisable.Level IV, clinical cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

We retrospectively analyzed CT scans of 620 individuals, who presented to our traumatology department between 2008 and 2010. Facet joint (FJ) arthritis was present in 308 (49.7%) individuals with a mean grade of 1. It was seen in 27% of individuals ≤40 years and in 75% of individuals ≥41 years (P < 0.0001) as well as in 52% of females and 49% of males (P = 0.61). Mean FJ orientation was 30.4° at L2/3, 38.7° at L3/4, 47° at L4/5, and 47.3° at L5/S1. FJ arthritis was significantly associated with more coronal (increased degree) FJ orientation at L2/3 (P = 0.03) with a cutoff point at ≥32°. FJs were more coronally oriented (48.8°) in individuals ≤40 years and more sagittally oriented (45.6°) in individuals ≥41 years at L5/S1 (P = 0.01). Mean FJ asymmetry was 4.89° at L2/3, 6.01° at L3/4, 6.67° at L4/5, and 7.27° at L5/S1, without a significant difference for FJ arthritis. FJ arthritis is common, increases with age, and affects both genders equally. More coronally oriented FJs (≥32°) in the upper lumbar spine may be an individual risk factor for development of FJ arthritis.

Introduction Spontaneous bleeding resulting in compartment syndrome at the lower adult leg due to acquired hemophilia A is rare. There are no reports on operative management of this entity. Case presentation We present a case of atraumatic compartment syndrome of the lower leg due to acquired factor VIII deficiency, in an 83-year-old Caucasian man of European descent. He was treated surgically with a long and complicated postoperative course after presenting to a community hospital with a 2-day history of increasing pain and swelling in his left lower leg without a previous history of trauma. Conclusions Awareness, prompt diagnosis and effective treatment of compartment syndrome caused by a rare bleeding disorder, which is usually acquired by the elderly, is essential and may spare a patient from surgery or even limb loss, if early administration of recombinant factor VIIa is effective. The course of disease in a patient with operative management of spontaneous bleeding, compartment syndrome and acquired hemophilia A may be prolonged. However, an interdisciplinary approach with meticulous surgical treatment and bleeding management with recombinant factor VIIa as well as inhibitor eradication by immunosuppressive treatment can be successful and expensive.

Background Glenohumeral instability is a rare indication for primary reverse total shoulder arthroplasty (RTSA), accounting for fewer than 1% of the indications in the literature. The aim of this study was to analyze the clinical and radiographic outcomes of RTSA for recurrent instability after failed operative repair or instability associated with major bone loss in elderly patients. Methods A retrospective matched case-control study was performed. We compared 11 shoulders treated with RTSA for instability (cases) with 22 matched shoulders treated with RTSA for rotator cuff insufficiency (controls). Clinical and radiographic outcomes were compared. Results The median follow-up period was 74 months (interquartile range [IQR], 18 months; range, 22-171 months) in cases and 70 months (IQR, 13 months; range, 23-172 months) in controls. The median age was 74 years (IQR, 18 years) in the case group and 70 years (IQR, 13 years) in the control group. No significant differences were found between the 2 groups in satisfaction scores, preoperative and postoperative absolute and relative Constant scores, and complication rates. Active range of motion tended to be superior in the controls for mean flexion (130° vs. 110°, P = .15), abduction (143° vs. 100°, P = .16), and external rotation (28° vs. 20°, P = .86) without the differences reaching statistical significance, possibly because of the small sample size. Postoperative dislocation was not recorded in cases or controls, but subjective insecurity regarding stability was reported once in each group. Conclusion RTSA seems to represent a valuable treatment option for glenohumeral instability in an elderly population with large bone loss or as a salvage procedure after failed operative glenohumeral stabilization. Postoperative instability was not observed in the case and control groups.

Background Displaced femoral neck fractures are common in the elderly patient. The surgical treatment options consist of a hemiarthroplasty (HA) or total hip arthroplasty (THA). However, the best surgical choice is still under debate. Bipolar HAs do not address preexisting arthritic changes of the acetabulum, which may lead to an unfavorable clinical outcome. The purpose of the present study was to conduct a long term follow-up analysis of the bipolar hemiarthroplasty with particular focus on the influence of preoperative acetabular osteoarthritis on the functional outcome. Methods In a retrospective observational study, the medical charts of consecutive patients treated with a bipolar hemiarthroplasty at a level one trauma center between 2004 and 2008 were reviewed before a final radiographic and clinical follow-up was performed. The outcome variables consisted of arthritic findings on the pre- and postoperative x-rays with particular focus on double fond osteophyte (DFO) and posterior wall sign (PWS) as well as the revision rate and functional scores. Results This study included 102 patients with a mean age of 77.2 years. Most patients (75 %) had a Kellgren-Lawrence grading scale (KLGS) of 2 or 3. While only 30 % of patients had a DFO, most patients (73 %) had a PWS. The DFO correlated significantly with the KLGS, but no correlation was seen with the clinical outcome. Most patients showed a decreased offset by a mean of −7.8 mm. The mean modified Harris Hip Score (HHS) of 90.3 and the mean Merle d'Aubigné score of 10.8 correlated significantly. Despite a significant correlation of the HSS subcategory of pain and the preoperative KLGS, there was no statistical relationship between the arthritic x-ray measurements and the clinical outcome. Conclusions In the presented study population, the presence of radiographic acetabular osteoarthritis did not influence the clinical outcome after bipolar hemiarthroplasty for displaced femoral neck fractures.