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Introduction Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively. Methods In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the “Quality Improvement in Postoperative Pain Treatment project” (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively. Results The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p p > 0.05). Conclusion This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

Hallux saltans is similar to digitus saltans and produces a spontaneous "snapping" of the big toe. This results in a constriction of the flexor hallucis longus tendon within the osteofibrous retromalleolar canal. The diagnosis was first described in 1940, and only a few case reports exist. We present the diagnosis and the treatment of a patient and give a review of the literature.Der Hallux saltans führt, ähnlich wie beim Digitus saltans, zu einem plötzlichen „Schnappen“ der Großzehe. Dabei kommt es zu einer Einengung der Flexor-hallucis-longus-Sehne innerhalb des osteofibrösen Kanals retromalleolär. Die Diagnose wurde erstmals 1940 beschrieben und es existieren nur einzelne Fallberichte. Wir präsentieren die Diagnostik sowie Therapie bei einem Patienten und geben einen Überblick über die Literatur.

Total hip arthroplasty (THA) is reported to be one of the most painful surgical procedures. Perioperative management and rehabilitation patterns are of great importance for the success of the procedure. The aim of this cohort study was the evaluation of function, mobilization and pain scores during the inpatient stay (6 days postoperatively) and 4 weeks after fast-track THA.A total of 102 consecutive patients were included in this retrospective cohort trial after minimally invasive cementless total hip arthroplasty under spinal anesthesia in a fast-track setup. The extent of mobilization under full-weight-bearing with crutches (walking distance in meters and necessity of nurse aid) and pain values using a numerical rating scale (NRS) were measured. Function was evaluated measuring the range of motion (ROM) and the ability of sitting on a chair, walking and personal hygiene. Furthermore, circumferences of thighs were measured to evaluate the extent of postoperative swelling. The widespread Harris Hip Score (HHS) was used to compare results pre- and 4 weeks postoperatively.Evaluation of pain scores in the postoperative course showed a constant decrease in the first postoperative week (days 1-6 postoperatively). The pain scores before surgery were significantly higher than surgery (day 6), during mobilization (p 0.001), at rest (p 0.001) and at night (p 0.001). All patients were able to mobilize on the day of surgery. In addition, there was a significant improvement in independent activities within the first 6 days postoperatively: sitting on a chair (p 0.001), walking (p 0.001) and personal hygiene (p 0.001). There was no significant difference between the measured preoperative and postoperative (day 6 after surgery) thigh circumferences above the knee joint. Compared to preoperatively, there was a significant (p 0.001) improvement of the HHS 4 weeks after surgery. In 100% of the cases, the operation was reported to be successful and all of the treated patients would choose a fast-track setup again.Application of a fast-track scheme is effective regarding function and mobilization of patients. Low pain values and rapid improvement of walking distance confirms the success of the fast-track concept in the immediate postoperative course. Future prospective studies have to confirm the results comparing a conventional and a fast-track pathway.EINFüHRUNG: Die Hüftgelenktotalendoprothetik zählt zu den schmerzhaften chirurgischen Eingriffen, und perioperative Management- und Rehabilitationsvorgehensweisen sind für den Erfolg von großer Bedeutung. Ziel dieser Studie war die Evaluierung von Funktion, Mobilisierung und Schmerzwerten während des stationären Aufenthalts (6 Tage postoperativ) und 4 Wochen nach Fast-Track-Hüftgelenkendoprothetik.In diese retrospektive Studie wurden 102 Patienten nach minimal-invasiver zementfreier Hüftendoprothesenimplantation unter Spinalanästhesie in einem Fast-Track-Setup eingeschlossen. Der Umfang der Mobilisierbarkeit bei Vollbelastung mit Krücken (Gehstrecke [m] und Pflegebedürftigkeit) sowie Schmerzwerte wurden unter Verwendung einer numerischen Bewertungsskala (NRS) gemessen. Die Funktion wurde bewertet, indem die Beweglichkeit (ROM), die Fähigkeit zum Sitzen auf einem Stuhl und zum Gehen sowie die Durchführung persönlicher Hygienemaßnahmen analysiert wurden. Darüber hinaus wurden die Oberschenkelumfänge gemessen, um das Ausmaß der postoperativen Schwellung zu objektivieren. Der weit verbreitete Harris Hip Score (HHS) wurde verwendet, um die Ergebnisse vor sowie 4 Wochen nach der Operation zu vergleichen.Die Auswertung der Schmerzwerte im postoperativen Verlauf zeigte eine konstante Abnahme in der ersten postoperativen Woche (Tage 1–6 postoperativ). Die Schmerzwerte vor der Operation waren signifikant höher als nach der Operation (Tag 6), während der Mobilisierung (p 0,001), sowie in Ruhe (p 0,001) und in der Nacht (p 0,001). Alle Patienten konnten am Tag der Operation mobilisiert werden. Zusätzlich gab es innerhalb der ersten 6 Tage nach der Operation eine signifikante Verbesserung bei Sitzen auf einem Stuhl (p 0,001), Gehen (p 0,001) und Durchführung persönlicher Hygienemaßnahmen (p 0,001). Es bestand kein signifikanter Unterschied zwischen dem präoperativ und postoperativ gemessenen Oberschenkelumfang oberhalb des Kniegelenks (Tag 6 nach der Operation). Im Vergleich mit dem präoperativen Score zeigte sich 4 Wochen nach der Operation eine signifikante (p 0,001) Verbesserung des HHS. Alle Patienten gaben an, dass die Operation erfolgreich gewesen sei und dass sie sich wieder für die Fast-Track-Vorgehensweise entscheiden würden.Ein Fast-Track-Schema ist hinsichtlich Funktion und Mobilisierung von Patienten erfolgreich umzusetzen. Niedrige Schmerzwerte und eine schnelle Verbesserung der Gehstrecke bestätigen den Erfolg des Fast-Track-Konzepts im unmittelbaren postoperativen Verlauf. Künftige prospektive Studien müssen die Ergebnisse bestätigen, nach Möglichkeit im Vergleich eines konventionellen und eines Fast-Track-Vorgehens.

Introduction Bernese periacetabular osteotomy is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection with residual dysplasia or femoroacetabular impingement. Thus, we wanted to find a simple method to control the effect of correction in the sagittal and coronal plane. Method The acetabular coordinates are shown by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the acetabular fragment with two Schanz screws. This method enables the isolated acetabular reorientation in the coronal, sagittal, and transverse plane. In a sawbone pelvis model, the acetabular rim is marked with a copper wire and a silicon adherent. To show the radiographic effect on acetabular parameters and the rim position, we visualized correction in the coronal and sagittal plane under fluoroscopic control. Results Lateral rotation of the acetabular fragment had the highest impact on radiographic lateral coverage of the femoral head. But also ventral coverage increased during isolated lateral rotation. Anterior rotation showed almost no effect on lateral coverage and just a little effect on ventral coverage but caused severe total acetabular retroversion. Conclusion Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and under-correction. Isolated lateral rotation of the acetabular fragment should be the predominant direction of correction during periacetabular osteotomy. Ambitious anterior correction may be the main source for severe acetabular retroversion following periacetabular osteotomy.

Unicompartmental knee arthroplasty and total knee arthroplasty are well established treatment options for end-stage osteoarthritis, UKA still remains infrequently used if you take all knee arthroplasties into account. An important factor following knee arthroplasty is pain control in the perioperative experience, as high postoperative pain level is associated with persistent postsurgical pain. There is little literature which describes pain values and the need for pain medication following UKA and/or TKA. So far, no significant difference in pain has been found between UKA and TKA. The aim of the study was to evaluate differences in the postoperative course in unicompartmental knee arthroplasty vs. total knee arthroplasty regarding the need for pain medication and patient-reported outcomes including pain scores and side effects. We hypothesized that unicompartmental knee arthroplasty is superior to total knee arthroplasty in terms of postoperative pain values and the need of pain medication. In this project, we evaluated 2117 patients who had unicompartmental knee arthroplasty and 3798 who had total knee arthroplasty performed, from 2015 to 2018. A total of 4144 patients could be compared after performing the matched pair analysis. A professional team was used for data collection and short patient interviews to achieve high data quality on the first postoperative day. Parameters were compared after performing a 1:1 matched pair analysis, multicenter-wide in 14 orthopedic departments. Pain scores were significantly lower for the UKA group than those of the TKA group (p p = 0.004 for non-opioids). The opiate consumption was similarly lower for the UKA group, but not statistically significant (p = 0.15). In the ward, the UKA group needed less opioids (p

Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients.Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential.In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.HINTERGRUND: Das Delir ist ein häufiges und potenziell lebensbedrohliches Krankheitsbild, welches Kliniken in der Versorgung häufig vor große Probleme stellt. Es betrifft vor allem ältere Patienten und ist gerade im höheren Lebensalter multifaktoriell bedingt. Dauerhafte funktionelle und kognitive Funktionseinschränkungen nach einem Delir sind bei geriatrischen Patienten keine Seltenheit.Häufig werden delirante Syndrome nicht erkannt oder fehlgedeutet. Dies ist vor allem bei der hypoaktiven Form des Delirs der Fall. Zur Erkennung eines Delirs stehen verschiedene Screening‑/Testverfahren zur Verfügung, deren routinemäßige Anwendung unabdingbar ist.Durch geeignete präventive Maßnahmen lassen sich in vielen Fällen Delirien vermeiden. Hierbei spielen vor allem nichtmedikamentöse Präventionsstrategien und multidimensionale Ansätze eine wichtige Rolle. Für die medikamentöse Behandlung eines Delirs bei geriatrischen Patienten werden niederpotente, klassische und atypische Neuroleptika sowie für schwere Verläufe Dexmedetomidin empfohlen.

In der postoperativen Rontgenkontrolle nach Huft-TEP-Implantation erfolgt durch die Bestimmung der Komponentenstellung eine objektivierbare Qualitatskontrolle. Die Pfannenposition wird hierbei durch die Steilheit und die Drehung nach vorne beschrieben. Zwischen den radiographisch gemessenen Werten und der tatsachlichen (anatomischen) Pfannenstellung besteht jedoch eine Diskrepanz, die zu Fehlinterpretationen fuhren kann. Um die Diskrepanz zwischen tatsachlicher und radiographisch vermessener Pfannenstellung bildlich darzustellen, wurde in dem Video ein Pfannenhalter verwendet, an dem die Drehung nach vorne und die Pfannensteilheit winkelgenau eingestellt werden kann. Hierdurch kann die Pfannenposition (Anteversion und Inklination) in der radiographischen und anatomischen Definition naher erlautert werden. Der Zuschauer soll einen Eindruck bekommen, ab wann die radiologisch gemessenen Werte nur mit groser Vorsicht zu betrachten sind. In dem Video zeigt sich in der simulierten Rontgen- und Bildsequenz, dass bei gleichbleibender tatsachlicher Pfannensteilheit am Modell mit zunehmender Anteversion uber 20° die Inklination radiographisch flacher gemessen wird. Alleiniges Betrachten der radiographischen Winkelwerte der Anteversion und Inklination kann zu Fehlinterpretationen der tatsachlichen Pfannenstellung fuhren. In bildlicher Darstellung zeigen wir, dass eine unterschiedliche Pfannensteilheit und -drehung anhand der radiographischen Messwerte nicht sicher erkannt werden kann. Die wahre Pfannenposition in der anatomischen Definition lasst sich aus der radiographischen Position errechnen. Hierzu mussen jedoch beide Pfannenwerte (rad. Anteversion und rad. Inklination) berucksichtigt werden.

Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction, results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p &lt, 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p &lt, 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p &lt, 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction.

Background Femoral component subsidence is a known risk factor for early failure of total hip arthroplasty (THA) using cementless stems. The aim of the study was to compare an enhanced recovery concept with early full weight-bearing rehabilitation and partial weight-bearing on stem subsidence. In addition, the influence of patient-related and anatomical risk factors on subsidence shall be assessed. Methods One hundred and fourteen patients underwent primary cementless THA and were retrospectively analyzed. Sixty-three patients had an enhanced recovery rehabilitation with early full weight-bearing and 51 patients had rehabilitation with partial weight-bearing (20 kg) for 6 weeks. Postoperative subsidence was analyzed on standing pelvic anterior–posterior radiographs after 4 weeks and 1 year. Subsidence was measured in mm. Anatomical and prosthetic risk factors (stem size, canal flare index, canal fill ratio as well as BMI and demographic data) were correlated. Results Femoral stem subsidence rate was significantly higher for the group with an enhanced recovery concept compared to the group with partial weight-bearing at the first radiological follow up after 4 weeks [2.54 mm (SD ± 1.86) vs. 1.55 mm (SD ± 1.80)] and the second radiological follow up after 1 year [3.43 mm (SD ± 2.24) vs. 1.94 (SD ± 2.16)] (p 3° had a significant influence on subsidence. Canal flare index and canal fill ratio showed no significant correlation with subsidence as well as BMI and age. Conclusion In the present study, cementless stem subsidence was significantly higher in the group with enhanced recovery rehabilitation compared to partial weight-bearing. Small absolute values and differences were demonstrated and therefore possibly below clinical relevance. Anatomical radiological parameters and anthropometric data did not appear to be risk factors for stem subsidence.

The Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.In a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.Patients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P.001), readmission (9.6% vs 4.3%, P.001), surgical complications (9.1% vs 1.8%, P.001), internal complications (7.3% vs 1.1%, P.001), other complications (24.4% vs 2.0%, P.001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P.001), and transfusion (10.4% vs 1.3%, P.001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P.001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P.001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P.001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P.001).The HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level III-retrospective cohort study.