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Background Additional lateral extra-articular procedures can reduce the risk of failure of primary anterior cruciate ligament reconstruction (ACLR). There is limited evidence on the effect of lateral extra-articular procedures in revision ACL surgery. The purpose of this study was to evaluate the clinical outcome of patients with lateral extra-articular tenodesis (LET) in combination with revision ACLR for combined ACL graft failure and high-grade anterior knee instability. Methods Between 2016 and 2018, 75 patients with graft failure after primary ACLR and high-grade anterior knee instability who received revision ACLR were included in the retrospective study. High-grade anterior knee instability was defined as high-grade pivot-shift or side-to-side difference of more than six millimeters in Rolimeter®-testing. An additional modified Lemaire tenodesis was performed in 59 patients during revision ACLR. Seventy-three patients were clinically examined with a minimum of two years after revision surgery. Results Failure of the revision ACLR occurred in 8.2% (n = 6) of the cases. LET lead to significant decreased failure rates (five percent vs. 21%, p = .045) and decreased incidence of a positive pivot-shift in patients with revision ACLR and high-grade anterior knee instability in comparison to patients without LET. Also, postoperative functional scores were significantly increased in the group of additional LET. Conclusions Additional LET in patients with revision ACLR and high-grade anterior instability significantly reduces the risk of failure of revision ACLR, the incidence of pivot-shift and increases postoperative functional outcome.

Zur operativen Rekonstruktion lateraler und posterolateraler (Rotations‑)Instabilitaten bei Verletzungen der posterolateralen Ecke, Popliteussehne (PLT), popliteofibulares Ligament (PFL), laterales Kollateralband (LCL), sind nichtanatomische und anatomische Techniken in offener und arthroskopischer Form etabliert. Exemplarisch erfolgt die Demonstration der anatomischen Rekonstruktion nach LaPrade. Insgesamt werden vier Bohrkanale benotigt (fibular, tibial, zwei femorale Kanale). Nach offener Praparation und Darstellung des N. peroneus wird zunachst der fibulare Bohrkanal, ausgehend vom Ursprungsbereich des LCL in Richtung auf den Ursprungsbereich des PFL angelegt. Anschliesend wird ein tibialer Kanal von ventral zwischen dem Tuberculum Gerdi und der Tuberositas tibiae nach dorsal in Richtung des muskulotendinosen Ubergangs des M. popliteus gebohrt. Die Bohrrichtung der femoralen Kanale verlauft von den femoralen Ansatzpunkten des LCL und PLT aus parallel nach proximal und ventral. Die Transplantate werden zunachst femoral befestigt, wovon der popliteale Schenkel im Verlauf der Popliteussehne nach dorsal ausgeleitet wird. Der LCL-Schenkel wird dagegen unterhalb des Tractus zum ventralen Eingang des fibularen Bohrkanals ausgeleitet und durch diesen hindurch eingezogen. Die fibulare Fixation des LCL-Schenkels erfolgt in strecknaher Position und unter Valgusstress. Schlieslich werden beide Transplantate gemeinsam von dorsal nach ventral durch den tibialen Bohrkanal gefuhrt und unter Zugspannung in beugenaher Position (60° Flexion) mit einer Interferenzschraube befestigt. Die fruhfunktionelle Nachbehandlung mittels Orthese und sukzessiver Steigerung des Bewegungsausmases unter Teilbelastung erfolgt in verschiedenen Phasen. Die Ruckkehr zum Sport erfolgt nach individueller Freigabe.

Introduction Injuries of the posterolateral corner (PLC) of the knee lead to chronic lateral and external rotational instability and are often associated with PCL injuries. Numerous surgical techniques for repair and reconstruction of the PLC are established. Recently, several arthroscopic techniques have been published in order to address different degrees of PLC injuries through reconstruction of one or more functional structures. The purpose of this systematic review is to give an overview about arthroscopic techniques of posterolateral corner reconstructions and to evaluate their safeness. Materials and methods A systematic review of the literature on arthroscopic reconstructions of the posterolateral corner of the knee according to the PRISMA guidelines was performed using PubMed MEDLINE and Web of Science Databases on June 15th, 2020. Inclusion criteria were descriptions of surgical techniques to reconstruct different aspects of the posterolateral corner either strictly arthroscopically or minimally-invasive with an arthroscopic assistance. Results Arthroscopic techniques differ with regard to the extent of reconstructed units (popliteus tendon, popliteofibular ligament, lateral collateral ligament), surgical approach (transseptal, lateral) and biomechanical results (anatomic vs. non-anatomic reconstruction, restoration of rotational instability and/or lateral instability). Conclusion Different approaches to arthroscopic PLC reconstruction are presented, yet clinical results are scarce. Up to now good and excellent clinical results are reported. No major complications are reported in the literature so far.

Purpose Surgical treatment of tibial plateau fracture (TPF) is common. Surgical site infections (SSI) are among the most serious complications of TPF. This multicentre study aimed to evaluate the effect of fracturoscopy on the incidence of surgical site infections in patients with TPF. Methods We performed a retrospective multicentre study. All patients with an AO/OTA 41 B and C TPF from January 2005 to December 2014 were included. Patients were divided into three groups: those who underwent arthroscopic reduction and internal fixation (ARIF), and those who underwent open reduction and internal fixation (ORIF) with fracturoscopy, and those treated with ORIF without fracturoscopy. The groups were compared to assess the effect of fracturoscopy. We characterised our cohort and the subgroups using descriptive statistics. Furthermore, we fitted a logistic regression model which was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios and inclusive 95% confidence intervals were calculated. Results Overall, 52 patients who underwent fracturoscopy, 48 patients who underwent ARIF, and 2000 patients treated with ORIF were identified. The rate of SSI was 0% (0/48) in the ARIF group and 1.9% (1/52) in the fracturoscopy group compared to 4.7% (93/2000) in the ORIF group (OR = 0.40, p = 0.37). Regression analyses indicated a potential positive effect of fracturoscopy (OR, 0.65; 95% CI, 0.07–5.68; p = 0.69). Conclusion Our study shows that fracturoscopy is associated with reduced rates of SSI. Further studies with larger cohorts are needed to investigate this. Level of evidence Level III.

Verletzungen des thorakolumbalen Ubergangs stellen aufgrund ihrer anatomischen Position und der Belastung die haufigsten Frakturen der Wirbelsaule dar. Die Einteilung in gangige Klassifikationssysteme differenziert zwischen stabilen und instabilen Verletzungen und somit auch zwischen einer operativen und einer konservativen Therapie. Ein Grosteil der Verletzungen kann konservativ behandelt werden, instabile Frakturen bedurfen aus vielerlei Grunden einer operativen Versorgung. Im Graubereich zwischen stabil und instabil ist eine klinische Entscheidung notwendig, um hier mit Erfahrung die richtige Therapie durchzufuhren. Hier mussen verschiedenste Parameter einbezogen werden, es kann auch zu einem Strategiewechsel von konservativ zu operativ kommen. Die dorsale Instrumentierung ist das haufigste Verfahren, eine rein ventrale Stabilisierung ist selten. Die Lange der Instrumentation/Spondylodese ist u. a. von der Knochenqualitat, dem Alter des Patienten und dem Frakturalter abhangig zu machen. Die Entscheidung, ob eine ventrale operative Versorgung mit einer zusatzlichen Stabilisierung erfolgt, ist abhangig von der Frakturmorphologie, der erfolgreichen Reposition und der sich hieraus ergebenden Stabilitat. Das offene operative Vorgehen wird wie bei der dorsalen Versorgung auch bei den ventralen Techniken zunehmend von minimal-invasiven Verfahren ersetzt, kann jedoch bei komplexen Verletzungen (B- und C‑Verletzungen nach AO [Arbeitsgemeinschaft fur Osteosynthesefragen]) von Vorteil sein. Ebenso sind auch Hybridversorgungen moglich. Dieses gilt auch fur die Versorgung von osteoporotischen Frakturen, da eine klare Zuordnung zwischen traumatischer und osteoporotischer Ursache nicht immer einfach und moglich ist. Der vorliegende Artikel beschreibt das Prinzip, die moglichen Indikationen und Limitationen der minimal-invasiven dorsalen und ventralen Stabilisierung.

Background The reoperation rate after primary meniscal repair is about 20%. Thus far, it has remained unclear whether there are distinct individual preconditions that may be associated with a better or worse outcome of this procedure. We therefore analysed typical biochemical mediators in the synovial fluid (SF) of patients with meniscus tear before arthroscopic meniscal refixation and correlated their concentrations to the occurrence of re-rupture after meniscus repair. Methods In this study, 48 patients with meniscus ruptures were included. SF samples were taken intraoperatively prior to arthroscopy. Multiplex enzyme-linked immunosorbent assay (ELISA)-based methods were used to measure hepatocyte growth factor (HGF), interleukin-18 (IL-18), matrix metalloproteinases (MMP) MMP-1, MMP-2, MMP-9 and MMP-13 in the SF. At follow-up, the patients were classified into two groups: surgical success and surgical failure. Results Ten out of 48 patients (20.8%) had to undergo revision surgery after meniscal repair (surgical failure). The median HGF in the surgical failure group was 2.4-times higher than in the surgical success group (P = .006), and the median MMP-2 was 1.8 times higher (P = .017). Concentration levels of the other tested proteins were not correlated with the success or failure of the meniscus surgery. There was weak evidence that both markers are indicators of an unsatisfactory healing process for meniscal refixation. Conclusion These results suggest that HGF and MMP-2 could serve as molecular markers to estimate the chances of healing success of meniscus repair and possibly to individualise therapy in meniscal surgery.

Bei Verletzungen des hinteren Kreuzbandes kommt es haufig zu einer begleitenden Verletzung der posterolateralen Ecke mit Beteiligung des Ligamentum popliteofibulare sowie des Ligamentum collaterale laterale. Die Gefahr, diese Verletzung zu ubersehen, ist hoch, eine ausbleibende Therapie der Instabilitat birgt das Risiko fur das Scheitern einer hinteren Kreuzbandplastik. Posterolaterale Verletzungen unterscheiden sich deutlich hinsichtlich der verletzten Strukturen und der resultierenden Instabilitat. Eine eindeutige Klassifizierung und stadiengerechte Therapie ist daher entscheidend. Die geringe Evidenz in der Literatur macht klare Empfehlungen zur Versorgung bisher schwierig. Die extraanatomische Rekonstruktion nach Larson ist in Deutschland noch immer eine der am haufigsten angewandten OP-Techniken zur Adressierung lateraler und posterolateraler Verletzungen. Anatomische Rekonstruktionstechniken wie nach LaPrade oder Arciero zeigen jedoch uberlegene Ergebnisse. Entscheidend ist, sich die biomechanische Funktion der verletzten Struktur zu vergegenwartigen und eine Technik zu wahlen, mit der diese sicher und so anatomisch wie moglich, rekonstruiert werden kann. Jungst konnten differenzierte arthroskopische Techniken mit guten Ergebnissen etabliert werden.

Purpose Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis. Methods Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs. Results Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p p p p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p n = 4, p = 0.035). Conclusion Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.

Multiligamentäre Kniegelenkverletzungen sind glücklicherweise sehr selten. Doch wenn es dazu kommt, stellen sie für den behandelnden Arzt wegen der geringen Inzidenz, der möglichen Begleitverletzungen und der unterschiedlichen Unfallmechanismen eine erhebliche diagnostische Herausforderung dar.

Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.

Chronic acromioclavicular (AC) joint instability may result after failed surgical or non-operative treatment of acute AC joint dislocation. Data on clinical outcomes of chronic AC joint instability are limited; thus, no gold standard surgical technique exists. This study aimed to evaluate clinical and radiological results after arthroscopically assisted or hook plate stabilization of chronic type III–V AC joint instability. We hypothesized that (1) operative treatment would improve outcomes in short-term follow-up (2) without a difference between the groups. Five level I trauma centers prospectively included patients in this non-randomized multicenter study. Patients had undergone reconstruction of the coracoclavicular (CC) and AC ligaments with an anatomic hamstring autograft. Graft healing was supported by arthroscopically assisted AC joint stabilization using a flip button or by a hook plate. Inclusion criteria were chronic high-grade (Rockwood III–V) AC joint instability and failed surgical or non-operative treatment after a trial of conservative management measures ≥12 weeks. Functional outcome measures (Subjective Shoulder Value, Constant Score, Taft Score, Acromioclavicular Joint Instability Score) were recorded preoperatively and at follow-up. Radiographs were performed pre- and postoperatively, and at follow-up. A total of 43 patients were included (mean age 44 ± 12 years, range 18–64; 17, 40%, Rockwood III and 26, 60%, Rockwood V; 32, 74%, arthroscopic and 11, 26%, hook plate; 35 available for follow-up; mean follow-up 12 ± 3 months, range 6–20). All clinical outcome measures improved significantly (p

Die sichere Diagnostik und Klassifikation proximaler Femur- und Tibiafrakturen ist zur Festlegung des therapeutischen Vorgehens essenziell. In diesem Beitrag werden die aktuellen Standards bezuglich der Bildgebung im Bereich des proximalen Femurs und der Tibia dargestellt sowie die Wertigkeit verschiedener Klassifikationssysteme eingeordnet. Das konventionelle Rontgenbild in 2 Ebenen bleibt die Grundlage zur Frakturdiagnostik in beiden Lokalisationen. Wahrend am proximalen Femur eine weiterfuhrende Diagnostik oft nicht notwendig ist, muss diese im Bereich der proximalen Tibia regelhaft erfolgen.

Eine Fehlstellung nach Tibiaplateaufraktur tritt meist aufgrund einer unzureichenden Visualisierung der intraartikularen Oberflache auf. In 85 % aller Typ-„C“-Tibiaplateaufrakturen konnte eine Beteiligung des posterolateral-zentralen Segments beobachtet werden, dieses stellt gleichzeitig die Region mit den meisten postoperativen Fehlpositionen dar. Die Wahl des Zuganges wird durch die frakturierten Segmente des Tibiaplateaus und die gewunschte Position des Osteosynthesematerials bestimmt. Bei einfachen lateralen Frakturen des Tibiaplateaus ohne Beteiligung des posterolateral-zentralen Segments ist in den meisten Fallen ein anterolateraler Standardzugang in Ruckenlage mit einer lateralen Plattenosteosynthese die Behandlung der Wahl. Bei komplexeren Frakturen muss der Chirurg berucksichtigen, dass die Gelenkflache des lateralen Plateaus erst durch Erweiterung der Zugange in Rucken‑, Seiten- oder Bauchlage vollstandig dargestellt werden kann. Die anterolaterale und laterale Plattenosteosynthese kann in Rucken‑, Seiten- oder Bauchlage durchgefuhrt werden. Eine direkte Fixierung des posterolateral-zentralen Segments mit einer Platte oder Schraube von posterior sollte jedoch nur in Bauch- oder Seitenlage, nicht aber in Ruckenlage erfolgen. Der posterolaterale Zugang beinhaltet die Verwendung von zwei chirurgischen Fenstern zur direkten Visualisierung der Fraktur. Bei unzureichender Darstellung sollte der Zugang durch eine laterale Epikondylenosteotomie erweitert werden, wodurch die Moglichkeit besteht, mindestens 83 % der lateralen Gelenkflache einzusehen. Wenn zusatzlich ein dorsales, kapsulares Release des lateralen Meniskus durchgefuhrt wird, kann der laterale Meniskus zentral subluxiert und so fast 100 % der lateralen Gelenkflache eingesehen werden.

ZusammenfassungTibiaplateaufrakturen stellen im klinischen Alltag eine vergleichsweise seltene Verletzung dar. Aufgrund des heterogenen Patientenkollektivs, des divergierenden Traumamechanismus und der Vielzahl an möglichen weichteiligen Begleitverletzungen ist die adäquate Diagnostik und bedarfsgerechte Behandlung weiterhin eine große Herausforderung im klinischen Alltag. Neben der konventionellen Röntgenaufnahme in zwei Ebenen hat sich die Computertomographie (CT) mit zusätzlicher 3‑D-Rekonstruktion als probates und reliables diagnostisches Werkzeug im Alltag vieler Kliniken etabliert. Die so angefertigten Befunde zeigen dem Chirurgen mit hoher Genauigkeit die Frakturmorphologie und lassen Rückschlüsse auf Begleitverletzungen zu. Die Diagnostik der weichteiligen Begleitverletzungen erfolgt aktuell u. a. im Rahmen der klinischen Untersuchung, dem chirurgischen Befund sowie der intraoperativen Arthroskopie. Mit der Magnetresonanztomographie (MRT) steht eine Technik zur Verfügung, welche die diagnostische Lücke zwischen der CT-Bildgebung und dem intraoperativen Befund schließen kann. Mit hoher Sensitivität kann eine adäquate präoperative Diagnostik der weichteiligen Begleitverletzungen erfolgen und so entscheidenden Einfluss nicht nur auf die Frakturklassifikation, sondern vor allem auf das operative Vorgehen nehmen. Neben der klinischen Verfügbarkeit und (noch) hohen Kosten im Vergleich zur CT stellt vor allem die fehlende Erfahrung mit präoperativ angefertigten MRT-Befunden eine große Herausforderung in der umfassenden Anwendung dieses diagnostischen Tools bei der Behandlung von Tibiaplateaufrakturen dar.

IntroductionChildhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.MethodsProspective cohort study in 109 institutions in 41 countries. Inclusion criteria: children ResultsAll-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3–11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); pConclusionsChildren with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.

Hypothesis and background The possibility of implanting a conventional anchor at the pullout site following all-suture anchor failure was evaluated in a biomechanical cadaveric model. The hypothesis of the study was that anchor revision would yield equal biomechanical properties. Methods Ten human humeri were obtained, and bone density was determined via computed tomography. After all-suture anchor (n = 5) and conventional 4.5-mm anchor (n = 5) insertion, biomechanical testing was conducted. Following all-suture anchor pullout, a conventional 5.5-mm anchor was inserted at the exact site of pullout (n = 5) and biomechanical testing was reinitiated. Testing was conducted using an initial preload of 20 N, followed by an unlimited cyclic protocol, with a stepwise increasing force of 0.05 N for each cycle at a rate of 1 Hz until system failure. The number of cycles, maximum load to failure, stiffness, displacement, and failure mode, as well as macroscopic observation at the failure site including diameter, shape, and cortical destruction, were registered. Results The defect following all-suture pullout showed a mean diameter of 4 mm, and conventional revision was possible in each sample. There was no significant difference between the initial all-suture anchor implantation and the conventional anchor implantation or the conventional revision following all-suture failure regarding mean pullout strength, stiffness, displacement, or total number of cycles until failure. Conclusion Conventional anchor revision at the exact same site where all-suture anchor pullout occurred is possible and exhibits similar biomechanical properties.

ZusammenfassungDie Fraktur der proximalen Tibia mit und ohne Gelenkbeteiligung ist eine schwere und komplikationsträchtige Verletzung. Sie stellt Patienten und Behandler aufgrund der operativen Anforderungen und individuellen Behandlung vor eine herausfordernde Aufgabe. Im folgenden Artikel werden Risiken und Komplikationen dargestellt sowie mögliche Behandlungspfade aufgezeigt.

Introduction Arthroscopic reconstruction techniques of the posterolateral corner (PLC) of the knee have been developed in recent years. Reconstruction techniques for higher-grade PLC injuries have not yet been validated in clinical studies. This study aimed to compare clinical outcomes of two different techniques and to present results of the first prospective randomized clinical trial of patients to undergo these novel procedures. Materials and methods 19 patients with Fanelli Type B posterolateral corner injuries and additional posterior cruciate ligament ruptures were included in this prospective study. They were randomly assigned to one of two novel arthroscopic reconstruction techniques, based on open surgeries developed by Arciero (group A) and LaPrade (group B). Follow-up was conducted at 6 and 12 months postoperatively and included clinical examinations for lateral, rotational and posterior stability, range of motion and subjective clinical outcome scores (IKDC Subjective Score, Lysholm Score, Tegner Activity Scale and Numeric Rating Scale for pain). Results At 6 and 12 months postoperative, all patients in both groups presented stable to varus, external rotational and posterior forces, there were no significant differences between the two groups. At 12-month follow-up, group A patients showed significantly higher maximum flexion angles (134.17° ± 3.76° vs. 126.60° ± 4.22°; p = 0.021) compared to patients of group B. Duration of surgery was significantly longer in Group B patients than in group A (121.88 ± 11.63 vs. 165.00 ± 35.65 min; p = 0.003). Posterior drawer (side-to-side difference) remained more reduced in group A (2.50 ± 0.69 mm vs. 3.27 ± 0.92 mm; p = 0.184). Subjective patient outcome scores showed no significant differences between groups (Lysholm Score 83.33 ± 7.79 vs. 86.40 ± 9.21; p = 0.621). Conclusions This study indicates sufficient restoration of posterolateral rotational instability, varus instability and posterior drawer after arthroscopic posterolateral corner reconstruction without neurovascular complications. Increased postoperative range of motion and a shorter and less invasive surgical procedure could favor the arthroscopic reconstruction technique according to Arciero over LaPrade’s technique in future treatment considerations.

Complex ankle fractures often include fractures of the posterior malleolus. The most clinically relevant posterior malleolus fracture classifications are computed tomography (CT) based. These classifications aim to enable clear communication and help develop treatment strategies. This study investigates the inter- and intraobserver reliability of the Haraguchi, Bartoníček/Rammelt and Mason posterior malleolar fracture classifications.CT scans of 113 patients with a mean age of 56.2 (SD ± 17.8) years and fractures involving the posterior malleolus were analyzed twice by 4 observers with different levels of training. The posterior malleolar fractures were classified according to Haraguchi et al., Bartoníček/Rammelt et al. and Mason et al. The intraobserver and interobserver reliabilities were determined by calculating Cohen's and Fleiss' kappa values.We found substantial multi-rater interobserver agreement for all three classifications. The Haraguchi classification 0.799 (CI 0.744-0.855) showed the highest agreement, followed by the Bartoníček/Rammelt 0.744 (0.695-0.793) and Mason 0.717 (CI 0.666-0.768) classifications. Subgroup analyses showed substantial to perfect agreement for the Haraguchi and substantial agreement for the Bartoníček/Rammelt and Mason classifications independent of observer expertise. The intraobserver reliability was perfect for three and substantial for one of the observers. However, the classifications have certain pitfalls and do not consider the number of fragments, articular surface impressions, or intercalary fragments.All classifications show substantial, if not perfect inter- and intraobserver reliabilities independent of observer level of expertise.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013–2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either “anatomical”, “acceptable” or as “malreduction”. Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an “anatomic” reduction in 9 (21.4%), “acceptable” in 7 (16.6%) and a “malreduction” in 26 (62%) patients. Comparing the combined “anatomical” and “acceptable” reduction group with the “malreduction” group, worse scores were observed in the “malreduction” group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.

Purpose Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early ( 6 months) arthroscopic arthrolysis of the knee. Methods With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early ( 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery. Results The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p p p 6 months, p Conclusions An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Purpose To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare. Methods A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality. Results The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory. Conclusion Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment. Level of evidence Systematic Review of Level III and Level IV Studies, Level IV.

The use of smartphone apps is an essential part of everyday life. Mobile applications offer enormous opportunities for dealing with challenges in public health, and their number increases every day. This paper aims to review the existing literature on mobile applications in orthopaedic oncology and to summarize the current mobile applications for musculoskeletal tumors. A systematic literature review was conducted regarding articles on mobile applications in orthopaedic and trauma surgery. The focus was on identifying mobile applications that can be used in the treatment of patients with musculoskeletal tumors. Two reviewers independently assessed study eligibility, extracted data, and appraised methodological quality. In addition, the Apple App Store and Google Play Store were searched for suitable mobile applications. Ninety-one articles describing a mobile application in orthopaedic and trauma surgery were identified. Three articles focused on a mobile application for musculoskeletal tumors. Additionally, seven mobile applications were available in the App/Play Stores dealing with bone or soft tissue tumors in orthopaedic oncology without corresponding scientific articles. Increasing numbers of mobile applications are being developed in orthopaedic and trauma surgery. Currently, only three scientific articles on mobile applications in orthopaedic oncology are present, yet several more applications are available without scientific medical evaluation. Since mobile applications can facilitate the everyday life of orthopaedic and trauma surgeons, it is worthwhile to be aware of new developments in this field. A regular scientific evaluation of the subject is important in order to classify the significance of these applications. Supplementary information The online version contains supplementary material available at 10.1007/s10916-021-01774-z.

Despite significant advances in surgical techniques, treatment options for impaired bone healing are still limited. Inadequate bone regeneration is not only associated with pain, prolonged immobilization and often multiple revision surgeries, but also with high socioeconomic costs, underlining the importance of a detailed understanding of the bone healing process. In this regard, we previously showed that mice lacking the calcitonin receptor (CTR) display increased bone formation mediated through the increased osteoclastic secretion of sphingosine-1-phosphate (S1P), an osteoanabolic molecule promoting osteoblast function. Although strong evidence is now available for the crucial role of osteoclast-to-osteoblast coupling in normal bone hemostasis, the relevance of this paracrine crosstalk during bone regeneration is unknown. Therefore, our study was designed to test whether increased osteoclast-to-osteoblast coupling, as observed in CTR-deficient mice, may positively affect bone repair. In a standardized femoral osteotomy model, global CTR-deficient mice displayed no alteration in radiologic callus parameters. Likewise, static histomorphometry demonstrated moderate impairment of callus microstructure and normal osseous bridging of osteotomy ends. In conclusion, bone regeneration is not accelerated in CTR-deficient mice, and contrary to its osteoanabolic action in normal bone turnover, osteoclast-to-osteoblast coupling specifically involving the CTR-S1P axis, may only be of minor relevance during bone healing.

Introduction ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated. Materials and methods One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. Results In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039). Conclusion In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment.

Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p

To provide normal values for physiological patellofemoral tracking in a representative group of healthy individuals, as well as sex differences, using real-time 3T-magnetic resonance imaging (MRI) and to test for the reliability of the presented technique.One hundred knees of healthy individuals with no history of patellofemoral symptoms were scanned with dynamic MRI sequences, during repetitive cycles of flexion (40°) and full extension. Within a 30-seconds time-frame, three simultaneous, transverse slices were acquired. Dynamic mediolateral patellar translation (dMPT) and dynamic patellar tilt (dPT) were measured on two occasions by two independent examiners. Common radiological parameters were measured using static MRI, and correlations were calculated.100 knees (53 right, 47 left; age: 26.7 ± 4.4 years; BMI: 22.5 ± 3.1) of 57 individuals (27 females, 30 males) were included. Mean height was 170.1 ± 7.7 cm in women and 181.8 ± 6.4 cm in men. Average patella diameter was 37.9 ± 2.7 (95% CI 37.1-38.7) mm in women and 42.4 ± 3.2 (95% CI 41.5-43.3) mm in men. In females, the patellar diameters and intercondylar distances were significantly smaller than in males (P.001). Radiological parameters for patellar maltracking were within the normal range. During the range of motion, mean dMPT was 1.7 ± 2.4 (95% CI .9-2.5) mm in females and 1.8 ± 2.7 (95% CI 1.1-2.6) mm in males (P = .766). Mean dPT was 1.3 ± 2.9° (95% CI .4-2.1°) in females and -0.2 ± 3.8° (95% CI -1.2-.9°) in males (P = .036). Neither dMPT nor dPT was correlated with height, BMI, or patellar diameter. Intercondylar distance correlated weakly with dPT (r = -.241; P = .041). Intra- and interrater reliability were excellent for dMPT and dPT.Dynamic mediolateral patellar translation is a size- and sex-independent parameter for proximal patellar tracking. In healthy individuals without patellofemoral abnormalities normal dMPT proximal to the trochlea groove was 1.7 ± 2.5 (1.2-2.2) mm, independent of size or sex. Normal dPT showed a dependency on sex and was 1.3 ± 2.9 (.4-2.1)° in women and -0.2 ± 3.8 (-1.2-0.9)° in men.Level II, diagnostic study.

This study has the aim to investigate the strain and stress in an anterolateral locking plate applied for the fixation of a lateral split fracture. To simulate a complex fracture situation, three segments were separated. With a FEM analysis, representative places for strain and stress measurement were determined. A locked osteosynthesis plate was instrumented with strain gauges and tested on a fractured and a non-fractured Saw Bone model. To simulate different loading situations, four different points of force application, from the center of the condyles to a 15 mm posterior position, were used with a medial-lateral load distribution of 60:40. The simulations as well as the biomechanical tests demonstrated that two deformations dominate the load on the plate: a bending into posterior direction and a bulging of the plate head. Shifting the point of application to the posterior direction resulted in increasing maximum stress, from 1.16 to 6.32 MPa (FEM analysis) and from 3.04 to 7.00 MPa (biomechanical study), respectively. Furthermore, the comparison of the non-fractured and fractured models showed an increase in maximum stress by the factor 2.06–2.2 (biomechanical investigation) and 1.5–3.3 (FEM analysis), respectively.

Porous structure properties are known to conduct initial and long-term stability of titanium alloy implants. This study aims to assess the histomorphometric effect of a 3-D porosity in Ti-6Al-4V implants (PI) on osseointegration in comparison to solid Ti-6Al-4V implants (SI). The PI was produced in a spaceholder method and sintering and has a pore size of mean 400 µm (50 µm to 500 µm) and mimics human trabecular bone. Pairs of PI and equal sized SI as reference were bilaterally implanted at random in the lateral femoral condyle of 16 Chinchilla-Bastard rabbits. The animals were sacrificed after 4 and 12 weeks for histomorphometric analysis. The histomorphometric evaluation confirmed a successful short-term osseohealing (4 weeks) and mid-term osseoremodeling (12 weeks) for both types of implants. The total newly formed bone area was larger for PI than for SI after 4 and 12 weeks, with the intraporous bone area being accountable for the significant difference (p0.05). A more detailed observation of bone area distribution revealed a bony accumulation in a radius of +/- 500 µm around the implant surface after remodeling. The bone-to-implant contact (BIC) increased significantly (p0.05) from 4 to 12 weeks (PI 26.23 % to 42.68 %; SI 28.44 % to 47.47 %) for both types of implants. Due to different surface properties, however, PI had a significant (p0.05) larger absolute osseous contact (mm) to the implant circumference compared to the SI (4 weeks: 7.46 mm vs 5.72 mm; 12 weeks: 11.57 mm vs 9.52 mm [PI vs. SI]). The regional influences (trabecular vs. cortical) on bone formation and the intraporous distribution were also presented. Conclusively, the porous structure and surface properties of PI enable a successful and regular osseointegration and enhance the bony fixation compared to solid implants under experimental conditions.

Background: We developed a quadriceps-tendon graft technique using a double-layered, partial-thickness, soft tissue quadriceps tendon graft (dlQUAD) for anterior cruciate ligament reconstruction (ACLR). This technique allows simple femoral loop button fixation and a limited harvest depth of the quadriceps tendon. Purpose: To evaluate the outcome of patients undergoing revision ACLR using the dlQUAD technique compared with a hamstring tendon graft (HT). Study Design: Cohort study; Level of evidence, 3. Methods: A total of 114 patients who underwent revision ACLR between 2017 and 2018 were included in this retrospective case series. At a mean follow-up of 26.9 ± 3.7 months (range, 24-36), 89 patients (dlQUAD: n = 43, HT: n = 46) were clinically examined. In addition, patients completed the Lysholm score, Tegner activity scale, subjective International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score, and visual analog scale (VAS) for pain. Postoperative failure of the revision ACLR was defined as a side-to-side difference (SSD) in Rolimeter testing ≥5 mm or a pivot-shift grade of 2 or 3. Results: Nine patients (10.1%) were identified with a failed revision ACLR. There was a significantly lower failure rate with dlQUAD versus the HT group (2.3% vs 17.4%; P = .031). The mean postoperative SSD was significantly less in the dlQUAD group (1.3 ± 1.3 mm [range, 0-5] vs 1.8 ± 2.2 mm [range, 0-9]; P = .043). At the latest follow-up, Tegner and IKDC scores significantly improved in the dlQUAD group compared with the HT group (Tegner: 5.8 ± 1.8 vs 5.6 ± 1.5; P = .043; IKDC: 83.8 ± 12.2 vs 78.6 ± 16.8; P = .037). The pain VAS score was also significantly reduced in the dlQUAD group compared with the HT group (0.9 ± 1.1 vs 1.6 ± 2.0; P = .014). Conclusion: The dlQUAD and HT techniques both demonstrated significant improvement of preoperative knee laxity and satisfactory patient-reported outcome measures after revision ACLR. Compared with the HT grafts, the dlQUAD technique showed lower failure rates and small increases in Tegner and IKDC scores.

Tibial plateau fractures are common fractures in adults and can be extremely challenging for surgeons. State-of-the-art therapy is open reduction and internal fixation (ORIF), although major complications of ORIF are surgical site infections (SSIs). This is especially critical on the proximal tibia, which is only sparsely covered by soft tissue and has a close relation to the knee joint. We analyzed SSIs after ORIF to correlate established laboratory parameters to the occurrence of SSIs. A monocentric case–control study in a Level 1 Trauma Center was conducted. Data were acquired from electronic medical records from 2011 until 2016. White blood cell count (WBC) and C-reactive protein (CRP) were used as laboratory parameters and statistically analyzed. In total, 97 patients were included, with four patients suffering from SSIs. Patients with SSIs had a significantly increased WBC count and CRP levels on the third postoperative day. Infection was diagnosed after rehospitalization, 12 ± 4 weeks after initial surgery. Furthermore, a large bony destruction through trauma coincides with a rise of WBC count with no influence on CRP level. We highly recommend a laboratory analysis with WBC count and CRP on the third day after ORIF. Patients with a CRP level above 100 mg/l should be closely watched, even if laboratory parameters few days later are adequate—since a one-time increase above this landmark might be a hint regarding the development of a SSI.

In Fehlstellung konsolidierte Tibiakopffrakturen fuhren haufig zu Schmerzen und gehen mit Instabilitaten, Achsabweichungen, Bewegungseinschrankungen und einem konstanten Verschleis des Gelenks einher. Bei irreparablen Schaden der Gelenkflache oder einer bereits ausgepragten Gelenkarthrose ist in vielen Fallen ein Gelenkersatz notwendig. Wenn moglich sollte jedoch der Erhalt des Gelenks angestrebt werden. Dabei erfordert die Komplexitat der unterschiedlichen Pathologien eine umfassende und standardisierte praoperative Analyse und Planung. Eine standardisierte klinische Untersuchung dient in Zusammenschau mit der radiologischen Bildgebung der Diagnostik von Kniegelenkinstabilitaten. Hierbei ist es essenziell, zwischen ligamentaren und pseudoligamentaren Instabilitaten zu differenzieren. Des Weiteren sind intraartikulare von extraartikularen Deformitaten abzugrenzen. Bei intraartikularen Fehlstellungen mussen knocherne Defekte und Stufen im Rahmen der praoperativen Planung exakt identifiziert und lokalisiert werden. Der operative Zugang kann erst nach einer eingehenden Analyse der posttraumatischen Deformitat und Planung des operativen Prozedere gewahlt werden. Der Zugangsweg sollte, neben einem direkten Blick auf die betroffene Gelenkflache, eine intraartikulare Osteotomie mit anatomischer Rekonstruktion der Gelenkflache und eine osteosynthetische Stabilisierung ermoglichen. Intraartikulare Osteotomien des Tibiakopfs konnen langfristig gute Ergebnisse erzielen.

Die Ruptur des vorderen Kreuzbands (VKB) ist fur die meist jungen, sportlich aktiven Patienten verbunden mit Langzeitkomplikationen wie einer Gonarthrose, Funktionseinschrankung und reduzierten Lebensqualitat. Die VKB-Rekonstruktion stellt derzeit den therapeutischen Goldstandard zur Wiedererlangung der Kniefunktion bei symptomatischer Instabilitat dar. Systematische Literaturanalyse zum funktionellen Outcome nach operativer oder konservativer Therapie in Abhangigkeit von der operativen Versorgungsqualitat. Es erfolgte eine systematische Literaturanalyse nach den PRISMA-Kriterien. Dabei wurde die operative Versorgungsqualitat entsprechend der postoperativen anteroposterioren (AP-)Translation beurteilt. Alle operierten Patienten zeigten eine stabilere AP-Translation als konservativ Therapierte. Eine signifikant bessere Kniefunktion nach operativer Versorgung wiesen 6 Beobachtungsstudien nach, in 7 Studien zeigte sich keine signifikant bessere Kniefunktion. Uberlegene funktionelle Ergebnisse nach VKB-Rekonstruktion im Vergleich zur konservativen Therapie prasentierten 5 von 9 Analysen zur postoperativ wiederhergestellten Kniegelenkstabilitat. Die durchschnittliche Studienqualitat war niedrig. Haufigste Schwachen waren die fehlende Untersucherverblindung, der lange Versorgungszeitraum zwischen Verletzung und Operation, eine eingeschrankte Operationsqualitat sowie eine fehlende Poweranalyse. Tendenziell zeigen Patienten nach VKB-Rekonstruktion uberlegene funktionelle Ergebnisse im Vergleich zur konservativen Therapie. Eine Gleichwertigkeit der konservativen gegenuber der operativen Versorgung konnte nicht nachgewiesen werden. Der konservative Therapieansatz versagt in bis zu 51 % der Falle.

The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface. Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student’s t test. In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p

Vollstandige Gelenkflachendarstellung bei multifragmentarer Gelenkflachendestruktion im Rahmen von uni- oder bikondylaren Tibiakopffrakturen als Voraussetzung fur eine anatomische Rekonstruktion, um das posttraumatische Arthroserisiko zu reduzieren. Unikondylare laterale oder mediale sowie bikondylare intraartikulare Tibiakopffrakturen mit zentralen und/oder dorsalen Frakturanteilen; multifragmentare Destruktion im medialen oder lateralen Tibiaplateau mit Dislokation oder Stufenbildung >2 mm. Infektionen im Zugangsbereich, femorale Kondylenfraktur, intraligamentare Rupturen des Innen- und Ausenbandes oder der posterolateralen Ecke. Medial: Zugang uber den medialen oder anteromedialen Zugang; lateral: uber den antero- oder posterolateralen Zugang zur osteosynthetischen Versorgung der Tibiakopffrakturen. Scharfe Praparation bis auf die medialen/lateralen ligamentaren Begleitstrukturen mit anschliesender Darstellung des medialen/lateralen Femurepikondylus. Medial: ca. 2 × 2 × 1 cm grose Osteotomie des medialen Femurepikodylus als femoralen Innenbandansatz. Lateral: Osteotomie eines etwa 1 × 1 × 0,5 cm grosen Knochenblocks des lateralen Femurepikodylus als femoralen Ausenbandansatz, entweder unter Schonung oder inkl. der ventral im Sulcus popliteus verlaufende Popliteussehne. Dabei sollte eine Verletzung der artikularen Kondylenbereiche vermieden werden. Fruhfunktionelle Nachbehandlung ohne Ruhigstellung in einer gelenkubergreifenden Rahmenorthese mit 10- bis 20-kg-Teilbelastung an Unterarmgehstutzen frakturabhangig fur 6–12 Wochen. Sehr gute Darstellbarkeit multifragmentarer Gelenkflachendestruktionen mit postoperativ anatomischer Rekonstruktion komplexer Frakturmuster ohne postoperative Begleitinstabilitaten.

ZusammenfassungIntraartikuläre Tibiakopffrakturen sind häufig komplex und können eine große chirurgische Herausforderung darstellen. Das Ziel der operativen Versorgung ist die anatomische stufenlose Gelenkrekonstruktion. Die Frakturmorphologie erfordert eine frakturspezifische Zugangsstrategie, welche entscheidende Voraussetzung für ein gutes postoperatives Ergebnis ist. Um eine komplette visuelle Einsicht über die frakturierten Gelenkflächen zu erlangen, können die verschiedenen Zugänge kombiniert oder bedarfsweise erweitert werden. Dabei kann durch eine laterale oder mediale femorale Epikondylenosteotomie die Einsicht auf die betroffene Gelenkfläche maßgeblich verbessert werden. Darüber hinaus ist zu beachten, dass dorsale Anteile der Gelenkfläche meist nur mit dorsalen Zugängen visualisiert werden können! Auch die geplante Positionierung von Platten und Schrauben sollte in der Zugangswahl Berücksichtigung finden!

Injuries of the posterolateral corner (PLC) of the knee lead to chronic lateral and external rotational instability. Successful treatment of PLC injuries requires an understanding of the complex anatomy and biomechanics of the PLC. Several open PLC reconstruction techniques have been published. It is understood that anatomic reconstruction is superior to extra-anatomic techniques, leading to better clinical results. An open, anatomic, fibula-based technique for reconstruction to address lateral and rotational instability has been described. However, when an open technique is used, surgeon and patient are faced with disadvantages, such as soft tissue damage or exposure of vulnerable structures. Few arthroscopic techniques for tibia- or fibula-based reconstruction of rotational posterolateral instability have been described. A complete arthroscopic stabilization of the combined lateral and posterolateral rotational instability of the knee has not yet been described. We therefore present the first all-arthroscopic technique for complete PLC reconstruction, based on an open technique described previously. All relevant landmarks of the PLC can be arthroscopically visualized in detail, allowing safe and effective treatment of PLC injuries.

ZusammenfassungKniegelenkluxationen und -luxationsfrakturen sind selten. Die Komplexität des Kniegelenks sowie die Nähe zu Nerven und Gefäßen können zu einer Vielzahl von Komplikationen und Begleitverletzungen führen. Häufig sind Kniegelenkluxationen Folge eines Hochrasanztraumas. Die Verletzung kann jedoch auch bei geringerer Krafteinwirkung beobachtet werden, in diesem Fall scheint ein hoher BMI ein Risiko darzustellen. Initial liegt der Fokus auf der Diagnostik, der entsprechenden Ruhigstellung und der Therapie von Gefäß- und Nervenverletzungen sowie von Weichteilschäden. Kniegelenkluxationen können primär mittels augmentierter Bandnähte versorgt werden. Alternativ bietet sich die Möglichkeit eines zweizeitigen Vorgehens: Zunächst erfolgt die Naht der Kollateralbänder und anschließend die Versorgung der Kreuzbänder mittels Bandplastik. Bei zeitgleichem Vorliegen einer Fraktur liegt der Fokus meist zunächst auf der Frakturversorgung, eine zeitgleiche Bandnaht ist möglich. Bei optimaler Versorgung können in 80% der Fälle gute bis sehr gute Ergebnisse erzielt werden.

The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0–3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. Prospective multicentre study, II.

Die Skaphoidpseudarthrose ist eine ernst zu nehmende und schwerwiegende Komplikation oft insuffizient behandelter oder zu spat diagnostizierter Skaphoidfrakturen. Ihre Behandlung ist anspruchsvoll und sollte durch in der Handchirurgie erfahrene Arzte erfolgen. Die anatomische Form, die retrograde Blutversorgung und die Biomechanik des Skaphoids erschweren die Heilung. Eine verzogerte oder ausbleibende Frakturheilung des Skaphoids fuhrt zu anhaltenden Schmerzen, Bewegungseinschrankungen und degenerativen Veranderungen im Bereich der Handwurzelknochen und des Handgelenks. Ziel der Behandlung ist die knocherne Ausheilung der Pseudarthrose unter Rekonstruktion der anatomischen Form und Wiederherstellung der axialen Ausrichtung des Skaphoids. Wichtig ist die differenzierte Anwendung unterschiedlicher Therapieoptionen. Voraussetzungen hierfur sind die sorgfaltige Diagnostik sowie die individuelle Klassifizierung der pathologischen Veranderung und der morphologischen Merkmale der Pseudarthrose. Unerlasslich ist die radiologische schnittbildgebende Untersuchung mithilfe der Computertomographie. In der Literatur findet sich kein einheitliches Konzept zur Therapie der Skaphoidpseudarthrose. Die Datenlage erlaubt es nicht, ein signifikant uberlegenes Behandlungsverfahren festzulegen. Die haufigste angewendete operative Therapie zur Behandlung der Skaphoidpseudarthrose ist die autologe Knochentransplantation, kombiniert mit einer Schraubenfixierung. Die vorliegende Arbeit gibt einen Uberblick uber das Management und die Standardverfahren in der primaren Behandlung von Skaphoidpseudarthrosen ohne Durchblutungsstorung.

Background: Plate osteosynthesis depicts the gold standard to surgically treat pubic symphysis disruptions. However, high rates of implant failure after plate osteosynthesis are reported, probably because of the iatrogenic arthrodesis of this fibrocartilaginous joint. Therefore, flexible implants for treatment of pubic symphysis disruptions appear to be a sensible solution. Methods: In this biomechanical screening study, we designed and investigated a flexible implant, which consists of two plates connected with an ultra-high molecular weight polyethylene fiber cord. We mechanically tested eye splices as a possible fixation method of the cords by performing tensile load to failure tests. Afterwards, we developed a biomechanically appropriate plate design and cord routing between the plates. Finally, we biomechanically tested the flexible implant under tensile and shear loading until failure. Findings: When fixing a 1 mm ultra-high molecular weight polyethylene fiber cord with eye splices, a load at failure of 1570.74 N was detected under tensile loading. None of the eye splices failed but the cords itself ruptured. The load at failure of the designed cord routing in criss-cross technique and fixation within the plates amounts 4742.09 N under tensile and 2699.77 N under shear load. Interpretation: We developed a novel flexible implant for repair of pubic symphysis disruptions using ultra-high molecular weight polyethylene fiber cords connected to osteosynthesis plates. We identified eye splices as a mechanically optimal fixation method and proved that the ultra-high molecular weight polyethylene fiber cord routing and fixation of the flexible implant clearly withstands physiological forces acting on the pubic symphysis.

Background Tibial tubercle transfer is frequently used for treating patellar instability. This study aimed to analyze the clinical results following tibial tuberosity transfer with medial patellofemoral ligament (MPFL) reconstruction in the treatment of patellar instability. Methods Seventy-two cases presenting a lateralized tibial tubercle were treated with tibial tuberosity transfer and MPFL reconstruction. Pre-operative and postoperative pain levels and knee function were evaluated using common scoring systems. Cartilage status was assessed at the time of surgery, and the influence of patient-related factors was analyzed. Median and interquartile ranges were used to present the results. Results After a mean of 27.6 (12 -76) months, a re-dislocation rate of 4.2% and significant improvement in knee function from a median of 48.0 (33 -70) to 83.0 (68 -94) and a median of 44.0 (24 -62) to 85.0 (69 -93), based on Kujala (P ≤ 0.001) and Lysholm (P ≤ 0.001) scores were observed. The Tegner score significantly increased from a median of 3.0 (2 -4) to 4.0 (4 -5) (P ≤ 0.001), while the pain level decreased from a median of 5.0 (3 -8) to 2.0 (0 -3) (P ≤ 0.001). Cartilage lesions were found in 55/72 (76.4%) knees. The likelihood of finding II° cartilage lesions was six times higher in cases of ≥ two previous operations. Conclusion Tibial tuberosity transfer with MPFL reconstruction allowed reliable patellar stabilization with a low re-dislocation rate. Patient age and unsuccessful attempts at surgical stabilization posed significant risk factors for cartilage lesions and may have limited postopertive outcomes.

Tibiale knocherne Ausrissfrakturen des hinteren Kreuzbandes (HKB) sind seltene Verletzungen, bei der in Einzelfallen unter konservativer Behandlung eine verzogerte oder ausbleibende Ausheilung beobachtet werden kann. Erfassung der klinischen Ergebnisse von sekundar operativ behandelten Patienten mit einer Pseudarthrose nach knochernem Ausriss des hinteren Kreuzbandes. Einschluss aller Patienten, die ab 2010 im Rahmen eines unter konservativer Therapie fehlverheilten, knochernen Ausrisses des HKB operativ versorgt wurden. Es wurden standardisierte Frage- und Nachuntersuchungsbogen (Visuelle Analogskala [VAS], International Knee Documentation Scale [IKDC]-, Lysholm- und Tegner-Score) verwendet und eine Magnetresonanztomographie(MRT)-Verlaufskontrolle des verletzten Knies angefertigt. Identifizierung von 5 Patienten im Alter von 30 bis 63 Jahren (3 mannlich, 2 weiblich), mit vornehmlich persistierenden Beugeschmerzen und anhaltender Instabilitat unter konservativer Therapie und einer operativen Versorgung im Verlauf. Die Nachuntersuchung von 4 Patienten erbrachte „gute“ Ergebnisse (IKDC-Gesundheitszustand 81 Punkte/subjektive Beurteilung 76 Punkte) nach minimal-invasiver, direkter Verschraubung bei knocherner Durchbauung, jedoch verblieb eine geringe dorsale Restinstabilitat. Die sekundare operative Versorgung von fehlverheilten knochernen HKB-Verletzungen fuhrt zu guten klinischen Ergebnissen. Aufgrund der nachweisbaren Restinstabilitat sollte die Indikation zur primaren Osteosynthese in der Akutphase groszugiger gestellt werden. Studien mit groserer Fallzahl mussten dies noch untermauern. Die Indikation zur MRT-Diagnostik sollte groszugig gestellt werden. Rauchen scheint mit einem erhohten Pseudarthroserisiko verbunden zu sein. Mit der minimal-invasiven dorsalen Verschraubung lassen sich auch zeitverzogert gute Ergebnisse erreichen.

Bone tissue in vertebrates is essential to performing movements, to protecting internal organs and to regulating calcium homeostasis. Moreover, bone has also been suggested to contribute to whole-body physiology as an endocrine organ, affecting male fertility; brain development and cognition; and glucose metabolism. A main determinant of bone quality is the constant remodeling carried out by osteoblasts and osteoclasts, a process consuming vast amounts of energy. In turn, clinical conditions associated with impaired glucose metabolism, including type I and type II diabetes and anorexia nervosa, are associated with impaired bone turnover. As osteoblasts are required for collagen synthesis and matrix mineralization, they represent one of the most important targets for pharmacological augmentation of bone mass. To fulfill their function, osteoblasts primarily utilize glucose through aerobic glycolysis, a process which is regulated by various molecular switches and generates adenosine triphosphate rapidly. In this regard, researchers have been investigating the complex processes of energy utilization in osteoblasts in recent years, not only to improve bone turnover in metabolic disease, but also to identify novel treatment options for primary bone diseases. This review focuses on the metabolism of glucose in osteoblasts in physiological and pathophysiological conditions.