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The incidence of deep surgical site infections following high tibial osteotomy (HTO) ranges between 0.4 to 4.7%. It is a severe complication with a high risk for poor clinical outcome. The aim of this study was to proof that a salvage algorithm for infected HTO with unstable bone situation leads to an infection-free status and bone union of the osteotomy and that correct limb alignment can be restored with good knee function.The study included seven patients with peri-implant infections following HTO. Infections occurred 83 ± 58.9 days (range: 24-191) after HTO. All patients underwent the "RESTORE" algorithm: patients received (1) REmoval of the HTO hardware and extensive debridement; (2) the osteotomy was STabilized with a hexapod external fixator (Taylor Spatial Frame, TSF); (3) the osteotomy gap was Opened; and (4) the alignment was REconstructed using the TSF, aiming for the intended limb alignment of the initial HTO. Patient-reported outcomes were assessed 22-36 months after removal of the TSF.After 24 weeks (range: 11-35), an infection-free status and bone healing were achieved. In all cases, the limb was saved, and the previously targeted mechanical axis of the lower limb was restored. All patients reached full extension of the knee joint and at least 110° of flexion. For KOOS: Symptoms 67.86 ± 18.1, Pain 73.41 ± 16.58, ADL 78.99 ± 21.32, Sports 52.14 ± 25.96, and QoL 41.96 ± 24.66. OKS 35.71 ± 8.8, SF-12 Physical Health 38.89 ± 10.3, and SF-12 Mental Health 46.86 ± 13.76.The "RESTORE" algorithm is a safe and effective salvage procedure. The concept allows for saving the limb and obtaining the previously planned limb alignment. Patient-reported outcome measures showed slightly lowered values than healthy samples, but substantially better values than patients awaiting HTO. Due to the possibility of initial full weight-bearing, the risk of higher morbidity caused by immobilization is minimized., Competing Interests: H. Baumgartner declares that he has a consultative function for Smith & Nephew. The other authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: Most studies about medial open-wedge high tibial osteotomy (HTO) reported outcomes without focusing on gender differences. Therefore, the study compared the long-term survival rate and postoperative subjective knee function after HTO in female versus male patients with symptomatic medial compartment knee osteoarthritis., Methods: The data of three cohorts with long-term outcomes were analysed (n = 245; 32% females; age: 49 ± 7 years; Kellgren Lawrence Grade I 6.1%, II 32.7%, III 42.4%; IV 18.8%). The minimum follow-up was at least 6 years or an earlier conversion to total knee arthroplasty (TKA). The gender-specific survival rate after HTO was calculated after 5 and 10 years and compared using Kaplan-Meier analysis and the logrank test. Baseline characteristics and subjective knee function (International Knee Documentation Committee [IKDC]/Lysholm) were analysed between both genders., Results: Forty of 78 (51.3%) women and 41 of 167 men (24.5%) underwent TKA. HTO survival in females was significantly lower (p = 0.0010). The 5- and 10-year survival rates were 85.9% and 62.6% for females and 93.4% and 77.7% for males. In females and males, from preoperative to the last follow-up, the IKDC (43 ± 15 to 58 ± 17; 47 ± 14 to 67 ± 18) and the Lysholm (42 ± 18 to 72 ± 18; 55 ± 22 to 77 ± 23) improved significantly (all p < 0.0001). Females had significantly lower preoperative and postoperative IKDC (p = 0.0438; p = 0.0035) and Lysholm scores (p = 0.0002; p = 0.0323). But the absolute improvements of the IKDC and Lysholm were not significantly different between genders., Conclusions: Females had higher conversion rates to TKA and lower knee function at the last follow-up. However, preoperative knee function was lower in females and the absolute improvement following HTO was similar for both genders. In general, females benefit from HTO to treat medial knee arthritis, and TKA could be postponed for half of female patients for more than 10 years. However, surgeons must be aware of the described inferior outcomes in females for realistic patient expectation management., Level of Evidence: Level II., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

High tibial osteotomy (HTO) is a widespread option to avoid or delay total knee arthroplasty (TKA). The present study aimed to assess the long-term survival rate and postoperative subjective knee function after isolated medial open wedge HTO in patients with symptomatic medial compartment knee osteoarthritis (OA) and varus malalignment.Sixty-nine patients (48.8 ± 6.7, 35-66 years; preoperative mechanical tibiofemoral angle [mTFA] -5.3 ± 3.4; -14.9-0.0° varus) treated with medial open wedge HTO using a TomoFix plate were included in this retrospective study, with a follow-up of at least 10 years (11.8 ± 1.0 years). The survival rate after HTO was calculated after 5 and 10 years. Subjective knee function was assessed using Hospital for Special Surgery (HSS), Oxford knee, Lequesne, and Lysholm scores.Thirty-three patients underwent conversion to TKA, on average, 7.0 ± 3.4 (1.3-13.7) years after HTO. Five- and ten-year survival rates were 84.1 and 60.9%, respectively. Patients without conversion to TKA showed a Lysholm score of 64.5 (35-92), Lequesne score of 7 (1-13), HSS score of 71 (56-86), and Oxford knee score of 38.5 (25-44) at the last follow-up (more than 10 years). Significantly higher scores were registered at the last follow-up compared to the preoperative state regarding the Lysholm score (preoperative: 43.5 [12-95]; follow-up: 64.5 [35-92]; p < 0.001). The HSS score (preoperative: 69.5 [43-93]; follow-up: 71 [56-86]; p = 0.6941) showed no statistically significant change during the 10-year follow-up period. The Lequesne score was significantly lower than the preoperative score (preoperative: 11.5 [0.5-22]; follow-up: 7 [1-13]; p < 0.001), indicating a lower handicap.The majority of patients with a valgus medial compartmental knee OA treated with HTO with fixation using the TomoFix plate can expect no conversion to TKA for more than 10 years. Furthermore, patients without conversion to TKA after 10 years still had a significantly higher subjective knee function than preoperatively. Further research is needed to identify risk factors for conversion to TKA. This helps to guide surgeons in selecting patients who will benefit most from HTO., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objective: To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation., Design: A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the "Clinical Tissue Regeneration" (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% "strong tendency," 50%-74% "tendency," 25%-49% "weak tendency," <25% "no tendency")., Results: A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency)., Conclusions: The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle's cartilage injury., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The present narrative review provides a summary of postoperative therapy modalities and their effectiveness following osteotomies around the knee. The topics that are discussed in the scientific discourse include support of cartilage cell regeneration, pain management, drainage insertion, tourniquet use, pharmacological and mechanical thromboembolism prophylaxis, weight-bearing protocols and bone consolidation. There is evidence for the use of pharmacological thromboembolism prophylaxis and weight-bearing protocols. A standardized postoperative treatment concept following osteotomies around the knee cannot be derived due to lack of evidence for the other topics in current literature.

Background: Data are limited regarding the surgical technique or outcomes of double-level osteotomy (DLO) combining medial closing-wedge distal femoral osteotomy and medial closing-wedge high tibial osteotomy in patients with moderate-to-severe valgus deformity., Purpose/hypothesis: To describe the surgical technique and assess the short-term outcomes and surgical accuracy of DLO in patients with a moderate or severe valgus deformity. It was hypothesized that this technique would result in good clinical outcomes with precise deformity correction., Study Design: Case series; Level of evidence, 4., Methods: Eight patients (mean age, 44.2 ± 10.9 years) with a moderate or severe valgus knee treated with DLO (9 knees; mechanical tibiofemoral angle [mTFA], 10.3°± 3.5°) were included. The mean follow-up was 25.1 ± 11.1 months. Preoperative to postoperative changes in radiographic parameters (mTFA, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, joint line convergence angle) and clinical scores (Hospital for Special Surgery score, Oxford Knee Score, Lysholm score) were assessed. Surgical accuracy was calculated by subtracting the achieved postoperative correction from the preoperatively planned targeted correction., Results: The mTFA changed significantly from 10.3°± 3.5° preoperatively to -1.8°± 3.4° postoperatively ( P < .001); the mechanical lateral distal femoral angle and mechanical medial proximal tibial angle changed significantly by 5.1°± 2.7° and 5.9°± 2.2°, respectively ( P < .001 for both); and the posterior distal femoral angle decreased significantly from 85.9°± 3.1° to 84.2°± 2.4° ( P < .01). There was no significant difference between pre- and postoperative joint line convergence angles (3.3°± 2.3° to 2.6°± 2.1°). The accuracy of the correction was high: the mTFA achieved postoperatively differed from the mTFA planned preoperatively by a mean of 2.7°± 1.9° (range, 0.6°-6.6°). Significant pre- to postoperative improvement was seen for all outcome scores (Hospital for Special Surgery, from 67 ± 11 to 93 ± 4; Oxford Knee Score, from 29 ± 7 to 43 ± 3; Lysholm, from 41 ± 24 to 89 ± 8; P < .001 for all)., Conclusion: High surgical accuracy was achieved, and patients who underwent varus DLO for valgus knees showed improved knee function at short-term follow-up. Varus DLO can be a surgical option to restore the optimal alignment and joint line obliquity in patients with moderate or severe valgus malalignment., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Support for this study was received from the Open Access Publishing Fund of the University of Tübingen. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Eberhard Karls Universitat Tübingen (ref No. 731/2020BO2)., (© The Author(s) 2024.)

Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study's primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6-85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ 2 ) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen's Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury's location and the HO's location after 12 weeks ( p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.

The incidence of distal femur fractures increases in the geriatric patient. The primary treatment goal in these fractures is early mobilisation to prevent secondary injuries associated with immobility. In light of the increasing spectrum of therapeutic options for postoperative fracture treatment, including double plating, nail-plate combination and distal femur replacement as postoperative treatments, weight-bearing recommendations are becoming increasingly important. The aim of this study was thus to analyse the weight-bearing recommendations and associated therapy results within the literature of the past 9 years and compare the recommendations to our own approach., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Raised complication rates have been reported for total hip arthroplasty (THA) in posttraumatic hip joints after acetabular fractures with prior open reduction and internal fixation (ORIF). The present study evaluated (I) postoperative surgical site infection and the risk of early infection following THA in posttraumatic hip joints after acetabular fractures and (II) the discriminatory ability of preoperative C-reactive protein (CRP) blood levels for periprosthetic joint infection (PJI)., Materials and Methods: Patients were included who had undergone THA (2014-2019) after prior ORIF, and nonsurgically treated acetabular fractures. Patients' demographics and the duration between fracture and THA implantation were assessed. Preoperative diagnostic testing (laboratory results, hip aspirations) as well as the results of intraoperative microbiological swabs and sonication were also evaluated. Postoperative complications were recorded., Results: Sixty-seven patients (51 men/16 women) were included, with a mean age of 54.7 ± 14.0 years (range: 18.0-82.9). The mean time between acetabular fracture and THA was 13.5 ± 14.9 years (0.2-53.5). Four subgroups were classified: subgroup I (nonsurgical, n = 15), subgroup II (complete removal of osteosynthesis, n = 8), subgroup III (partial removal of osteosynthesis, n = 15), and subgroup IV (remaining osteosynthesis, n = 29). Preoperative CRP blood levels were normal. CRP levels had no discriminatory ability to predict PJI (AUC: 0.43). Positive microbiological swabs were assessed in subgroups III (n = 1) and IV (n = 2). Complications during follow-up occurred in subgroups I (one aseptic loosening [6.7%]), III (one wound revision [6.7%], two low-grade infections [13.3%]), and IV (three low-grade infections [10.3%])., Conclusion: High infection rates were found in patients with THA after acetabular fracture with remaining implants or partial implant removal. Serum CRP alone seems to be a poor predictor. Therefore, an extensive diagnostic algorithm can help to detect an occult infection, including preoperative hip aspiration (microbiological samples and measurements of synovial CRP, WBC, and alpha-defensin levels). Intraoperative tissue samples and sonication results should be obtained during THA implantation., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Methods: Peer-reviewed literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLTs) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available for a particular diagnostic or therapeutic concept, including the grade of recommendation. Besides the scientific evidence, all group members rated the statements to identify possible gaps between literature and current clinical practice., Conclusion: In patients with minimal symptoms, OLT progression to ankle osteoarthritis is unlikely. Risk factors for progression are the depth of the lesion on MRI, subchondral cyst formation, and the extent of bone marrow edema. Conservative management is the adaptation of activities to the performance of the ankle joint. A follow-up imaging after 12 months helps not to miss any progression. It is impossible to estimate the probability of success of conservative management from initial symptoms and imaging. Cast immobilization is an option in OLTs in children, with a success rate of approximately 50%, although complete healing, estimated from imaging, is rare. In adults, improvement by conservative management ranges between 45% and 59%. Rest and restrictions for sports activities seem to be more successful than immobilization. Intra-articular injections of hyaluronic acid and platelet-rich plasma can improve pain and functional scores for more than 6 months. If 3 months of conservative management does not improve symptoms, surgery can be recommended.

Purpose: The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term., Methods: Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: -11.0 ± 3.0° (-6.0 to -17.0), age: 49.1 ± 9.5 (31-65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5-43) months)., Results: The duration that the patients were unable to work was 12.2 ± 4.4 (6-20) weeks. The PCS improved from 32.1 ± 11.3 (14.5-53.3) preoperatively to 54.6 ± 8.5 (25.2-63.7) (p < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1-67.7) to 57.2 ± 3.1 (47.3-61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population (p < 0.001), whereas the preoperative MCS was similar between the two groups (n.s.). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0-5.0) to 4.0 (2.0-7.0) (p < 0.001)., Conclusion: Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO., Level of Evidence: Study type: therapeutic, IV., (© 2022. The Author(s).)

Meniscal injuries lead to changes in pressure distribution in the knee joint. The risk of developing gonarthrosis increases by the amount of resected meniscal tissue. Based on 4 MRI examinations conducted over an 8‑year time period, the present case report shows the progress of cartilage degeneration after a traumatic medial meniscus lesion and subsequent partial meniscus resection in a 46-year-old male patient. Congenital or accident-independent risk factors, such as a varus limb deformity must be considered during a medical report., (© 2022. The Author(s).)

The present narrative review provides a summary of current concepts for the treatment of ankle fractures in elderly patients. Despite a high complication rate, open reduction and internal fixation is the gold standard for operative care. However, individual patient-based treatment decision considering the soft-tissue status, the fracture pattern, as well as the patient's mobility and comorbidities is mandatory to achieve sufficient patient outcomes. Due to high complication rates after surgery in the past, techniques such as fibular nails or minimal invasive techniques should be considered.

PURPOSE OF THE STUDY Osteotomies around the knee are an established technique for treating knee osteoarthritis and other knee conditions by redistributing the body's weight and force within and around the knee joint. The aim of this study was to determine if the Tibia Plafond Horizontal Orientation Angle (TPHA) is a reliable measure for describing ankle alignment of the distal tibia in the coronal plane. MATERIALS AND METHODS This retrospective study included patients who underwent supracondylar rotational osteotomies for correction of femoral torsion. All patients had standing radiographs taken preoperatively and postoperatively with both knees pointed forward. Five variables, including Mechanical Lateral Distal Tibia Angle (mLDTA), Mechanical Malleolar Angle (mMA), Malleolar Horizontal Orientation Angle (MHA), Tibia Plafond Horizontal Orientation Angle (TPHA), and Tibio Talar Tilt Angle (TTTA), were collected. The preoperative and postoperative measurements were compared to each other using the Wilcoxon signed rank test. RESULTS A total of 146 patients were included in the study, with a mean age of 51.47 ± 11.87 years. There were 92 (63.0%) males and 54 (37.0%) females. MHA decreased from 14.0° ± 5.32° preoperatively to 10.59° ± 3.93° (p < 0.001) postoperatively, and TPHA decreased from 4.88° ± 4.07° preoperatively to 3.82 ± 3.10° (p = 0.013) postoperatively. The change in TPHA was significantly correlated with the change in MHA (r = 0.185, CI 0.023 - 0.337; p = 0.025). No differences were found between the measurements of mLDTA, mMA, and mMA pre- and postoperatively. DISCUSSION The orientation of the ankle should be taken into consideration during preoperative planning of osteotomies and should be measured in cases of postoperative ankle pain. CONCLUSIONS The TPHA is a reliable measure for describing ankle alignment of the distal tibia in the frontal plane. Key words: osteotomy, ankle, realignment, coronal alignment, preoperative planning.

Introduction: The influence of limb malrotation on long-leg radiographs (LLR) is frequently discussed in literature. This systematic review aimed to describe the influence of limb rotation on alignment measurements alone and in combination with knee flexion, and determine its clinical impact., Materials and Methods: A literature search was conducted in June 2021 using the databases MEDLINE, Cochrane, Web of Science (Clarivate Analytics), and Embase. The search term ((radiograph OR X-ray) AND (position OR rotation) AND limb alignment) was used. Database query, record screening, and study inclusion and exclusion were performed by two reviewers independently. Experimental studies (using either specimens or synthetic bones) or clinical studies (prospective or retrospective using radiographs of patients) analyzing the influence of limb rotation on anatomic and mechanical limb alignment measurements were included. Characteristics and results of the included studies were summarized, simplified, and grouped for comparison to answer the research question. Studies were compared descriptively, and no meta-analysis was performed., Results: A total of 22 studies were included showing large heterogeneity, comprising studies with cadavers, patients, and synthetic bones. Most studies (7 out of 8) reported that external rotation (ER) causes less apparent valgus and leads to more varus and internal rotation (IR) causes more valgus and leads to less varus. However, there is no consensus on the extent of rotation influencing alignment measures. Studies reported about an average change of > 2° (n = 4) and < 2° (n = 4) hip-knee-ankle angle (HKA) between 15°IR and 15°ER. There is a consensus that the impact of rotation on mechanical alignment is higher if additional sagittal knee angulation, such as knee flexion, is present. All five studies analyzing the influence of rotation combined with knee flexion (5°-15°) showed an HKA change of > 2° between 15°IR and 15°ER., Conclusion: Malrotation is frequently present on LLR, possibly influencing the measured alignment especially in knees with extension deficit. Surgeons must consider this when measuring and treating deformities (high tibial osteotomy or total knee arthroplasties), and analyzing surgical outcomes. Especially in patients with osteoarthritis with knee extension deficits or postoperative swelling, the effect of malrotation is significantly greater., (© 2021. The Author(s).)

Background: Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs., Methods: Patients undergoing a one-staged conversion to THA (2013-2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA., Results: Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5-10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years., Conclusion: This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision., (© 2021. The Author(s).)

Introduction: In absence of deformity or injury of the contralateral leg, the contralateral leg length is used to plan limb lengthening. Length variability on long-leg weight-bearing radiographs (LLR) can lead to inaccurate deformity correction. The aim of the study was to (1) examine the variability of the measured limb length on LLR and (2) to examine the influence of the position of the magnification device., Materials and Methods: The limb lengths of 38 patients during deformity correction with a taylor-spatial-frame were measured retrospectively on 7.3 ± 2.6 (4-13) LLR per patient. The measured length of the untreated limb between LLR were used to determine length variability between LLR in each patient. To answer the secondary aim, we took LLR from a 90 cm validation distance. A magnification device was placed in different positions: at the middle of the 90 cm distance (z-position), 5 cm anterior and 5 cm posterior from the z-position, at the bottom and top of the validation distance as well as 5 cm medial and 15 cm lateral from the z-position., Results: The measured length variability ranged within a patient from 10 to 50 mm. 76% of patients had a measured limb length difference of ≥ 2 cm between taken LLR. Compared to length measurement of the 90 cm test object with the magnification device in the z-position (90.1 cm), positioning the device 5 cm anterior led to smaller (88.6 cm) and 5 cm posterior led to larger measurements (91.7 cm). The measured length with the magnification device at the bottom, top, medial or lateral (90.4; 89.9; 90.2; 89.8 cm) to the object differed not relevantly., Conclusions: High variability of limb length between different LLR within one patient was observed. This can result from different positions of the magnification device in the sagittal plane. These small changes in positioning the device should be avoided to achieve accurate deformity correction and bone lengthening. This should be considered for all length and size measurements on radiographs., (© 2021. The Author(s).)

Purpose: The presence of os acromiale is of clinical relevance before performing shoulder surgery but ethnic differences and little information regarding associated factors seem to be present. Population-based studies to clarify these topics are essential so the purpose of this study was to assess the prevalence, anatomy, and associations of os acromiale in a general adult population., Methods: Both shoulders of 3050 participants from the population-based Study of Health in Pomerania (SHIP) were assessed on magnetic resonance imaging (MRI). Associations with the os acromiale were calculated for sex, age, body height, body weight, and heavy mechanical oscillations on the upper extremity., Results: In total, 1.9% (58/3050) had an os acromiale, while 21 were unilateral left, 23 were unilateral right, and 14 were bilateral. Sixty-eight meso-acromions, three pre-acromions, and one meta-acromion were detected. Os acromiale were more frequent in men (right side: p = 0.037, left side: p = 0.005). Overall, no differences in sides (p = 0.808), to participants' age (right: p = 0.993, left: p = 0.499), body height (right side: p = 0.241, left side: p = 0.154), and the exposure to heavy mechanical oscillations on the upper extremity (right: p = 0.054, left: p = 0.117) were detected., Conclusion: Our results support the genetic theory for the aetiology of the os acromiale due to the lower prevalence of the os acromiale in north-eastern Germany compared to the worldwide prevalence (1.9 to 7%) and the lacking association to lifestyle, age, gender, or sides. Additionally, it is important to be aware of possible os acromiale before surgery., (© 2022. The Author(s).)

Introduction: Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the remaining planes and adjacent joints are still to be defined. It was, therefore, the aim of this study to determine the influence of a distal femoral rotation osteotomy on the coronal limb alignment and on the ischiofemoral space of the hip joint., Materials and Methods: Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar rotational osteotomies of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip-knee-ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), and the ischiofemoral space were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test., Results: Twenty-seven patients underwent isolated supracondylar external rotation osteotomy to reduce the overall antetorsion of the femur. The osteotomy resulted in a 2.4° ± 1.4° mean increase in HKA and 2.4 mm ± 1.7 mm increase in the ischiofemoral space (p < 0.001)., Conclusion: Supracondylar external rotation osteotomy of the femur leads to valgisation of the coronal limb alignment and increases the ischiofemoral space. This is resultant to the reorientation of the femoral antecurvature and the femoral neck. When planning a rotational osteotomy of the lower limb, this should be appreciated and may also aid in the decision regarding osteotomy site., (© 2020. The Author(s).)

Purpose: The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI)., Methods: Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum))., Results: From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively., Conclusion: Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year., Level of Evidence: Level IV., (© 2020. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: Identifying anatomical risk factors on recurrent dislocation after medial reefing is important for deciding surgical treatment. The present study aimed to retrospectively analyze the preoperative magnetic resonance imaging (MRI)-based parameters of patients treated with medial reefing and whether these parameters lead to a higher risk of recurrent dislocation., Methods: Fifty-five patients (18.6 ± 6.6 years) who underwent medial reefing after primary traumatic patellar dislocation (84% with medial patellofemoral ligament [MPFL] rupture) were included. Patients were followed up for at least 24 months postoperatively (3.8 ± 1.2 years) to assess the incidence of recurrent patellar dislocation. In patients without recurrent dislocation, the Kujala and subjective IKDC scores were assessed. Moreover, the tibial tubercle-trochlear groove (TT-TG), sulcus angle, patellar tilt, patellar shift, and lateral trochlea index (LTI) were measured. The patellar height was measured using the Caton-Dechamps (CDI), Blackburne-Peel (BPI), and Insall-Salvati index (ISI). The cohort was subclassified into two groups with and without recurrent dislocation. Differences between groups were analyzed with respect to the MRI parameters., Results: Forty percent had a pathological sulcus angle of > 145°, 7.2% had an LTI of < 11°, 47.3% had a patellar tilt of > 20°, and 36.4% had a TT-TG of ≥ 16 mm. Increased patellar height was observed in 34.5, 65.5, and 34.5% of the patients as per CDI, BPI, and ISI, respectively. Nineteen (34.5%) patients suffered from recurrent dislocation. Compared with patients without recurrent dislocation, those with recurrent dislocation had a significantly lower LTI (p = 0.0467). All other parameters were not significantly different between the groups. Risk factor analysis showed higher odds ratios (OR > 2), although not statistically significant, for MPFL rupture (OR 2.05 [95% confidence interval 0.38-11.03], LTI (6.6 [0.6-68.1]), TT-TG (2.9 [0.9-9.2]), and patellar height according to ISI (2.3 [0.7-7.5]) and CDI (2.3 [0.7-7.5])). Patients without recurrent dislocation had a Kujala score of 93.7 ± 12.1 (42-100) points and an IKDC score of 90.6 ± 11.7 (55.2-100) points., Conclusion: Anatomical, MRI-based parameters should be considered before indicating medial reefing. A ruptured MPFL, an LTI < 11°, a TT-TG ≥ 16 mm, a patellar tilt > 20 mm, and an increased patellar height according to ISI and CDI were found to be associated, although not significantly, with a higher risk (OR > 2) of recurrent patellar dislocation after medial reefing. Thorough preoperative analysis is crucial to reduce the risk of recurrent dislocation in young patient cohorts., Level of Evidence: Level IV., (© 2021. The Author(s).)

Purpose: The purpose of this prospective study was to analyze the impact of obesity on the clinical and radiological outcomes 6 years after open-wedge high tibial osteotomy (HTO)., Methods: A total of 120 prospectively recorded patients with medial compartment osteoarthritis underwent open-wedge HTO between 2008 and 2011. The study cohort was frequently examined over a minimum of a 6-year follow-up. The cohort was divided into three groups according to body mass index (BMI): normal weight patients (BMI < 25 kg/m 2 ), pre-obese patients (BMI 25-30 kg/m 2 ) and obese patients (BMI > 30 kg/m 2 ). Clinical and functional outcomes (Oxford Knee Score, Hospital for Special Surgery Score, Lequesne Score, Tegner Activity Scale), subjective health-related quality of life (SF-36), change in mechanical limb alignment (mTFA) as well as conversion to unicompartmental or total knee arthroplasty (TKA) were evaluated. To compare clinical scoring between the groups, univariate variance analysis was applied. Changes in outcome variables over time were analyzed with dependent t tests., Results: From 120 patients, 85 were followed-up over a 6.7-year period on average (6-11.8 years) after HTO. The mean BMI was 28.6 ± 4.6 kg/m 2 . Each group showed a significant pre- to postoperative increase in all recorded scores (p < 0.05). In absolute terms, both mental and clinical scores of overweight patients did not reach the peak values of the normal weighted population during the period of observation. There was a conversion to TKA in 10.5% after an average of 50.1 ± 25.0 months following surgery. A total of five complications occurred without significant differences (BMI < 25: n = 1, BMI 25-30: n = 2, BMI > 30: n = 2; n.s.). There was a mean pre- to postoperative (six weeks after surgery) correction difference of 6.9° ± 3.2° (mTFA) with higher loss of correction over time in overweight patients., Conclusion: In terms of clinical outcome and health-related quality of life, overweight patients may receive a benefit from open-wedge HTO to the same extent as patients with normal weights and show similar complication rates. However, they have inferior preoperative clinical and functional results and mid-term results after open-wedge HTO compared to patients with normal weights., Level of Evidence: Level III., (© 2021. The Author(s).)

Aims: The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD)., Methods: A total of 54 human cadaver forearms (ten singles, 22 pairs) (19 to 90 years) were systematically assessed by clinical radiograph (XR), dual-energy X-ray absorptiometry (DXA), CT, as well as high-resolution peripheral quantitative CT (HR-pQCT). Cortical bone thickness (CBT) of the distal radius was measured on XR and CT scans, and two cortical indices mean average (CBTavg) and gauge (CBTg) were determined. These cortical indices were compared to the BMD of the distal radius determined by DXA (areal BMD (aBMD)) and HR-pQCT (volumetric BMD (vBMD)). Pearson correlation coefficient (r) and intraclass correlation coefficient (ICC) were used to compare the results and degree of reliability., Results: The CBT could accurately be determined on XRs and highly correlated to those determined on CT scans (r = 0.87 to 0.93). The CBTavg index of the XRs significantly correlated with the BMD measured by DXA (r = 0.78) and HR-pQCT (r = 0.63), as did the CBTg index with the DXA (r = 0.55) and HR-pQCT (r = 0.64) (all p < 0.001). A high correlation of the BMD and CBT was observed between paired specimens (r = 0.79 to 0.96). The intra- and inter-rater reliability was excellent (ICC 0.79 to 0.92)., Conclusion: The cortical index (CBTavg) at the distal radius shows a close correlation to the local BMD. It thus can serve as an initial screening tool to estimate the local bone quality if quantitative BMD measurements are unavailable, and enhance decision-making in acute settings on fracture management or further osteoporosis screening. Cite this article: Bone Joint Res  2021;10(12):820-829.

Purpose: The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD., Methods: A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD., Results: Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (β-0.4, confidence-interval - 0.5 to - 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment., Conclusion: These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints., Level of Evidence: IV., (© 2021. The Author(s).)

Purpose: Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function., Methods: Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters., Results: The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles., Conclusion: If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function., Trial Registration: 83 250/2011BO2.

Objectives: The study aimed to investigate the diagnostic performance of simulated ultra-low-dose CT (ULD-CT) for torsion measurement of the lower limb., Methods: Thirty retrospectively identified patients were included (32.3 ± 14.2 years; 14 women, 16 men). ULD-CT simulations were generated at dose levels of 100%, 10%, 5%, and 1% using two reconstruction methods: standard filtered back projection (FBP) and iterative reconstruction (ADMIRE). Two readers measured the lower limb torsion in all data sets. The readers also captured image noise in standardized anatomical landmarks. All data sets were evaluated regarding subjective diagnostic confidence (DC; 5-point Likert scale). Effective radiation dose of the original data sets and the simulated ULD-CT was compared., Results: There was no significant difference of measured lower limb torsion in any simulated dose level compared to the original data sets in both readers. Dose length product (DLP) of the original examinations was 402.1 ± 4.3 mGy cm, which resulted in an effective radiation dose of 4.00 ± 2.12 mSv. Calculated effective radiation dose in ULD-CT at 1% of the original dose was 0.04 mSv. Image noise increased significantly with dose reduction (p < 0.0001) and was dependent on the reconstructional method (p < 0.0001) with less noise using ADMIRE compared to FBP. Both readers rated DC at doses 100%, 10%, and 5% with 5.0/5: there were no ratings worse than 3/5 at 1% dose level., Conclusions: The results suggest that radiation dose reduction down to 1% of original CT dose levels may be achieved in CT torsion measurements of the lower limb without compromising diagnostic accuracy., Key Points: • Modern CT delivers exceptional high image quality in musculoskeletal imaging, especially for evaluation of osseous structures. • Usually, this high image quality is accompanied by significant radiation exposure to the patient and may not always be required for the intended purpose, e.g., pure delineation of cortical bone of the lower limb. • This study shows the tremendous prospects of radiation dose reduction without compromising diagnostic confidence in CT torsion measurement of the lower limb.

Background: The subjective health related quality of life in patients with degenerative joint diseases is an important variable to evaluate the treatment outcome. In this study, mid-term results of open wedge HTO were analysed and compared to the subjective quality of life (SF 36) of the general population. Furthermore, the relationships of preoperative assessed subscales of the health-related quality of life (SF 36) and the conversion to knee arthroplasty were analysed., Methods: The cohort consisted of 120 patients who were prospectively followed-up after open wedge HTO. At five follow-up points of time, patients were examined and asked about their subjective, health-related quality of life using the SF 36 score., Results: 104 patients were included and evaluated until the last follow-up (mean: 81.2 ± 11.3 months after open wedge HTO; follow-up rate: 86.7%). Six years after open wedge HTO, similar values in several psychologic subscales of the SF 36 (BP, GH, V, MH) and the mental health component summary score (MCS) compared to the general population were found. The physical health component summary score (PCS) showed a significant improvement relative to the preoperative values. Nine out of 104 patients (8.7%) received a knee arthroplasty (50.1 ± 25.0 months). Low preoperative values of the subscales "physical functioning" (PF) and "bodily pain" (BP) were identified as risk factors in terms of conversion to a total knee arthroplasty., Conclusions: Patients with medial unicompartimental knee osteoarthrosis treated with open wedge HTO showed very good results. The health-related quality of life was nearly as high as in the general population. Patients with preoperative low physical function and high pain values have a higher risk to have a conversion to knee arthroplasty. Surgeons should be aware of these factors if an open wedge HTO is considered., Competing Interests: The authors declare that there is no conflict of interest.//Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Osteotomies represent well-established treatment-options for the redistribution of loads and forces within and around the knee-joint. Effects of these osteotomies on the remaining planes and adjacent joints are not fully understood. The aim of this study was to determine the influence of a distal-femoral-rotation-osteotomy on the coronal alignment of the ankle. It was hypothesized that supracondylar-external-rotation-osteotomy of the distal femur leads to a change in the coronal orientation of the ankle joint., Methods: Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar-rotational-osteotomy of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy-site. The hip-knee-ankle-angle (HKA), the mechanical-lateral-distal-femur-angle (mLDFA), and Tibia-Plafond-Horizontal-Orientation-Angle (TPHA) around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test., Results: Twenty-seven patients with high femoral antetorsion (31.3° ± 4.0°) underwent supracondylar-external-rotation-osteotomy. The osteotomy led to a reduced antetorsion (17.4 ± 5.1; p < 0.001) and to a valgisation of the overall limb-alignment. The HKA decreased by 2.4° ± 1.4° (p < 0.001). The TPHA decreased by 2.6° (p < 0.001)., Conclusions: Supracondylar external rotation osteotomy of the femur leads to lateralization of the weight bearing line at the knee and ankle due to valgisation of the coronal limb alignment. The mobile subtalar joint has to compensate (inversion) for the resulting valgus orientation of the ankle to ensure contact between the foot and the floor. When planning a rotational osteotomy of the lower limb, this should be appreciated - especially in patients with a preexisting valgus alignment of the lower extremities or restricted mobility in the subtalar joint.

Introduction: The need-based information transfer in education as well as for the recruitment of patients becomes more and more relevant. Here, the internet has emerged as an increasingly important factor in recent years and therefore information pages on hospital homepages can be very helpful. However, it is known that basic text comprehension skills are lacking among large populations., Method: The aim of the present study was to evaluate the readability of the patient information available on the websites of trauma departments of German university hospitals. For this purpose, a search for information material on 10 different diagnoses was carried out. Out of 360 texts possible, 185 were found and assigned to 2 superordinate thematic areas (emergency vs. elective operations), subjected to a systematic text analysis via software "Text-Lab" and rated using 5 known readability indices (Amstad, G-SMOG, LIX, HIX, WSTF)., Results: The indices used for both thematic complexes consistently showed poor readability, so that the texts only seem sufficiently comprehensible to readers with higher education. (Amstad: 21.4 ± 20.8; G-SMOG: 11.6 ± 2.0; WSTF 13.3 ± 2.1; LIX: 60.9 ± 7.6; HIX: 4.1 ± 3.2)., Conclusion: For the medical information provided by university hospitals, there is a clear need for improvement in order to make the adequate acquisition of knowledge accessible to a broader spectrum of patients., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: A detailed understanding of scaphoid anatomy helps anatomic fracture reduction, and optimal screw position. Therefore, we analysed (1) the size and shape variations of the cartilage and osseous surface, (2) the distribution of volumetric bone mineral density (vBMD) and (3) if the vBMD values differ between a peripheral and a central screw pathway?, Methods: Forty-three fresh frozen hand specimens (17 females, 26 males) were analysed with high-resolution peripheral quantitative computed tomography (HR-pQCT) and dissected to compute a 3D-statistical osseous and cartilage surface model and a 3D-averaged vBMD model of the scaphoid. 3D patterns were analysed using principal component analysis (PCA). vBMD was analysed via averaging HR-pQCT grey values and virtual bone probing along a central and peripheral pathway., Results: (1) PCA displayed most notable variation in length ranging from 1.7 cm (- 2SD) to 2.6 cm (mean) and 3.7 cm (+ 2SD) associated with differences of the width and configuration of the dorsal surface (curved and narrow (4 mm) to a wider width (9 mm)). (2) High vBMD was located in the peripheral zone. Lowest vBMD was observed in the centre and waist. (3) Virtual probing along a peripheral pathway near to the cartilage surfaces for the capitate and lunate allowed the center region to be bypassed, resulting in increased vBMD compared to a central pathway., Conclusion: High anatomical variations regarding the osseous and cartilage surfaces were associated with three distinct concentrically arranged zones with notable different vBMD. The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation, education and research.

Background: Minimally invasive plate osteosynthesis (MIPO) is one of the generally accepted surgical techniques for the treatment of humeral shaft fractures. However, despite the high bone union rate, a variety of complications are still prevailing. Moreover, the current literature lacks data comparing the anterolateral MIPO approach using dynamic compression plates accommodating different numbers of screws. The aim of this study was to analyze the biomechanical performance of comminuted humeral shaft fractures fixed with dynamic compression plates using either two or three screws per fragment., Methods: Six pairs of fresh-frozen human cadaveric humeri from donors aged 66.8 ± 5.2 years were randomized to two paired study groups for simulation of bridge-plated comminuted shaft fracture type AO/OTA 12-C1/2/3 without interfragmentary bony support, using a dynamic compression plate positioned on the anterolateral surface and fixed with two (group 1) or three (group 2) screws per fragment. All specimens underwent nondestructive quasistatic biomechanical testing under lateral bending, anterior bending, axial bending, and torsion in internal rotation, followed by progressively increasing cyclic torsional loading in internal rotation until failure., Results: Initial stiffness of the plated specimens in lateral bending, anterior bending, axial bending, and torsion was not significantly different between the groups ( P ≥ 0.22). However, cycles to 10°, 15°, and 20° torsional deformation and cycles to construct failure were significantly higher in group 2 compared with group 1 ( P ≤ 0.03)., Conclusions: From a biomechanical perspective, no significant superiority is identified in terms of primary stability when using two or three screws per fragment for bridge compression plating of comminuted humeral shaft fractures. However, three-screw configurations provide better secondary stability and maintain it with a higher resistance towards loss of reduction under dynamic loading. Therefore, the use of a third screw may be justified when such better secondary stability is required., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Guilherme Seva Gomes et al.)

Cortical thickness determined at the humerus can serve as an easy and reliable screening tool to predict the local bone status when quantitative bone mineral density (BMD) measurements are not available. It can therefore serve as a rapid screening tool in fragility fractures to identify patients requiring further diagnostic or osteoporosis treatment., Introduction: Quantitative bone mineral density (BMD) of the humerus is difficult to determine but relevant for osteoporosis and fracture treatment. Dual-energy X-ray absorptiometry (DXA) of the femur and lumbar spine overestimates the humeral BMD and is not ubiquitously available. Therefore, this study evaluated whether the cortical bone thickness (CBT) of the humerus or DXA of the forearm is able to predict humeral BMD., Methods: Humeral BMD of 54 upper cadaver extremities (22 pairs, 10 single) (19-90 years) was determined by high-resolution peripheral-quantitative-computed-tomography (HR-pQCT) (volumetric BMD (vBMD)) and DXA (areal BMD (aBMD)) of the proximal humerus and distal forearm. Average and gauge cortical bone thickness (CBTavg/ CBTg) of the humeral diaphysis was determined from standard radiographs (XR) and computed-tomography (CT) and compared to the humeral BMD. Pearson (r) and intraclass-correlation-coefficients (ICC) were used to compare results and rater-reliability., Results: CBTavg from XR strongly correlated with the humeral BMD (r = 0.78 aBMD (DXA) and r = 0.64 vBMD (HR-pQCT) (p < 0.0001)). The CBTg revealed a weaker correlation (r = 0.57 aBMD and r = 0.43 vBMD). CBT derived from XR strongly correlated to those from the CT (r = 0.82-0.90) and showed an excellent intra- and inter-rater correlation (ICC 0.79-0.92). Distal forearm aBMD correlated well with the humeral aBMD (DXA) (r = 0.77) and paired specimens highly correlated to the contralateral side (humerus r = 0.89, radius r = 0.97)., Conclusions: The CBTavg can reliably be determined from standard radiographs and allows a good prediction of quantitative humeral bone mineral density (aBMD or vBMD) if measurements are not available. Furthermore, the distal forearm or the contralateral humerus can serve as a side to estimate the BMD if the ipsilateral side is impaired.

Torsional deformity is a frequent complication following nail osteosynthesis of a subtrochanteric fracture. This complication is difficult to assess intraoperatively, but can cause major functional restrictions. The authors consider that a clinical assessment should be complemented by a postoperative radiological control standardised with torsion CT. Thus, torsion deformity can be recognised immediately and easily corrected if necessary. This can help to avoid long-term damage that requires considerable surgery. The video shows details of torsion correction after a ca. 5-week old subtrochanteric femoral fracture, which had been initially treated with a femur nail. Before torsion correction, the internal torsion on the right femur was 22° and the external torsion on the left femur was 2°. Thus, the total deformation of the external torsion on the left side was 24°. We note the indication for removal of the nail, torsion correction and reosteosynthesis with long PFNA. The postoperative CT control confirmed that the torsion correction was adequate with internal torsion of 25° on the operated left side., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Long-leg radiographs are used to plan and supervise the correction of bone deformity in patients treated with the Taylor Spatial Frame (TSF). Often radiographs are performed with malpositioning of the limb leading to wrong alignment measurements. The aim of this retrospective study was to show the usefulness of a simple device which might enhance the reproducibility of limb rotation on long-leg radiographs., Materials and Methods: We included 20 consecutive patients with TSF treatment and at least three long-leg radiographs (4.9 ± 1.3). Eight out of 20 patients received radiographs with the help of a rotation rod (device with two clamps and a carbon tube). It is placed at the most frontal tab of the reference ring while conducting the radiograph. By this means, limb rotation can be controlled. To show the usefulness of this device, two observers measured the relation of the distances between the middle of the reference ring to the medial and lateral fourth hole on the reference ring (TSF-RR). The standard deviation and range of the TSF-RR of all radiographs for each patient was calculated and compared between patients without and with the rotation rod., Results: The standard deviations of TSF-RR in patients without the rotation rod was significantly higher compared to patients with rotation rod (observer 1: p = 0.0228, observer 2: p = 0.0038). Also, the range of the TSF-RR within one patient is significant higher (observer 1: p = 0.0279, observer 2: p = 0.0038) in patients without the rotation rod compared to patients with the rotation rod., Conclusions: The variability of rotation on radiographs was lower with the rotation rod. Therefore, more reproducible and better comparable radiographs can be conducted. Radiologic exposure might be reduced as repetition of wrongly positioned limbs on radiographs are less frequent.

Purpose: The purpose of this study was to compare patients with osteochondral lesions of the talus (OCLT) with and without concomitant chronic ankle instability (CAI)., Methods: Data from the German Cartilage Registry (KnorpelRegister DGOU) for 63 patients with a solitary OCLT were used. All patients received autologous matrix-induced chondrogenesis (AMIC) for OCLT treatment. Patients in group A received an additional ankle stabilisation, while patients in group B received AMIC alone. Both groups were compared according to demographic, lesion-related, and therapy-related factors as well as baseline clinical outcome scores at the time of surgery. The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used., Results: Patients in group A were older compared to group B [median 34 years (range 20-65 years) vs. 28.5 years (range 18-72 years)]; the rate of trauma-associated OCLTs was higher (89.7% vs. 38.3%); more patients in group A had a previous non-surgical treatment (74.1% vs. 41.4%); and their OCLT lesion size was smaller [median 100 mm 2 (range 15-600 mm 2 ) vs. 150 mm 2 (range 25-448 mm 2 )]. Most OCLTs were located medially in the coronary plane and centrally in the sagittal plane in both groups. Patients in group A had worse scores on the FAOS quality-of-life subscale compared to patients in group B., Conclusion: Patients with OCLT with concomitant CAI differ from those without concomitant CAI according to demographic and lesion-related factors. The additional presence of CAI worsens the quality of life of patients with OCLT. Patients with OCLT should be examined for concomitant CAI, so that if CAI is present, it can be integrated into the treatment concept., Level of Evidence: IV.

The Taylor Spatial Frame (TSF) can be used for the treatment of bone infections, deformity correction, contracture correction or to reconstruction by segment transportation. The TSF is very solid and allows even a full weight bearing mobilization. The TSF consists at least of two partial or full rings connected by six telescopic struts. It allows simultaneous correction of deformities in all possible planes without frame modification only by adjusting the strut length. The accurate frame assembly is very important to achieve a stable frame construct and to reduce pin infections, pin loosening or wrong deformity correction. Therefore, good knowledge of the frame assembly is necessary to achieve treatment success. This video demonstrates and teaches the key knowledge of TSF assembly using an artificial bone with varus deformity., Competing Interests: The authors Leonard Grünwald und Marc-Daniel Ahrend have no conflicts of interests to declare. The author Heiko Baumgartner declares, that he received travelling expenses for a presentation related to the company Smith + Nephew./Die Autoren Leonard Grünwald und Marc Ahrend geben an, dass kein Interessenkonflikt besteht. Der Autor Heiko Baumgartner war als Vortragender für die Fa. Smith + Nephew tätig und hat hierfür Reisekostenerstattungen erhalten., (Thieme. All rights reserved.)

Background: Post-traumatic elbow stiffness is a frequent and disabling complication after elbow trauma. Surgical release is needed if conservative treatment fails. In contrast to open surgical release, arthroscopic arthrolysis is a good and least invasive option to restore joint mobility. The aim of this study was to evaluate the clinical outcomes, range of motion (ROM), and function of post-traumatic elbow contracture after arthroscopic arthrolysis and to assess health-related quality of life (HRQL)., Methods: Between 2007 and 2013, 44 patients with post-traumatic elbow stiffness were treated by arthroscopic arthrolysis and followed up in a consecutive series. Clinical (ROM) and functional analyses (Disabilities of the Arm, Shoulder, and Hand Questionnaire [DASH], Mayo Elbow Performance Index [MEPI]) were performed at final follow-up 3 (1-7) years postoperatively. Furthermore, HRQL was evaluated (EQ-5D, 36-Item Short Form Health Survey [SF-36])., Discussion: The average arc of elbow motion increased from 84° ± 28° preoperatively to 120° ± 18° postoperatively. All applied scores significantly improved pre- to postoperatively: the MEPI (59.8 ± 17.3 / 84.3 ± 14.0), DASH (43.5 ± 23.1 / 16.8 ± 15.6), EQ-5D (72.8 ± 16.6 / 84.0 ± 13.6), and SF-36 showed improved results in all categories. Univariate logistic regression revealed that preoperative pain level predicts a poorer postoperative outcome measured with the MEPI score. Revision arthroscopy was needed in 1 case because of persistent pain., Conclusions: Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life. The complication rate as well as the revision rate is very low., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)