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Purpose: With the growing technical options of power transmission and energy-saving options in electric drives, the number of E-bike-related accidents especially in an elderly population has increased. The aim of the current study was to compare if the increased velocity in comparison to conventional bikes translates into different injury patterns in the cranio-cervical and head region., Methods: A retrospective cohort study was performed in patients admitted to our level one trauma center between 2009 and 2019 after being involved in an accident with either an E-bike, bicycle, or motorcycle and suffered cranio-cervical or traumatic brain injury., Outcomes: cranio-cervical/intracranial injury pattern. Data interpretation was conducted in an interdisciplinary approach., Results: From 3292 patients treated in this period, we included 1068 patients. E-bikers were significantly older than bicyclists (or motorcyclists) and lay between the other two groups in terms of helmet use. Overall injury patterns of E-bikers resembled those found in motorcyclists rather than in bicyclists. E-bikers had a higher incidence of different cerebral bleedings, especially if no helmet was worn. Helmet protection of E-bikers resulted in a comparable frequency of intracranial bleeding to the helmeted bicyclists., Conclusion: The overall pattern of head and cervical injuries in E-bikers resembles more to that of motorcyclists than that of bicyclists. As they are used by a more senior population, multiple risk factors apply in terms of complications and secondary intracranial bleeding. Our study suggests that preventive measures should be reinforced, i.e., use of helmets to prevent from intracranial injury., (© 2024. The Author(s).)

Although patients with rheumatoid arthritis (RA) typically exhibit symmetrical joint involvement, some patients develop alternative disease patterns in response to treatment, suggesting that different molecular mechanism may underlie disease progression depending on joint location. Here, we identify joint-specific changes in RA synovium and synovial fibroblasts (SF) between knee and hand joints. We show that the long non-coding RNA HOTAIR, which is only expressed in knee SF, regulates more than 50% of this site-specific gene expression in SF. HOTAIR is downregulated after stimulation with pro-inflammatory cytokines and is expressed at lower levels in knee samples from patients with RA, compared with osteoarthritis. Knockdown of HOTAIR in knee SF increases PI-Akt signalling and IL-6 production, but reduces Wnt signalling. Silencing HOTAIR inhibits the migratory function of SF, decreases SF-mediated osteoclastogenesis, and increases the recruitment of B cells by SF. We propose that HOTAIR is an important epigenetic factor in joint-specific gene expression in RA., (© 2023. The Author(s).)

Introduction: The main objective of this study is to examine chronic pain and limping in relation to lower extremity and pelvic fracture location in addition to fracture combinations if multiple fractures are present on the same leg that have not been previously reported. We hypothesize that fracture pattern and location of lower extremity and pelvis fractures of multiple injured patients influence their long-term pain outcome., Materials and Methods: Retrospective cohort study. Patients with treated multiple lower limb and pelvic fractures at a level 1 trauma center and followed up for at least 10 years postinjury were assessed. Lower leg pain subdivided into persistent, load-dependent and intermittent pain, as well as limping were recorded by using self-administered patient questionnaires and standardized physical examinations performed by a trauma surgeon. Descriptive statistics were used to present comparative measurements between groups., Results: Fifty-seven percent of patients (n = 301) showed chronic lower limb pain 10 years postinjury. Ten percent of all patients with chronic pain displayed persistent pain, and here the most common fracture combination was tibial shaft fractures in combination with femoral shaft or proximal tibial fractures (13%). One hundred fifty-one patients reported load-dependent pain, with the most common fracture combinations being fractures of the foot in combination with femoral shaft fractures or distal tibial fractures (11%). One hundred twenty patients reported intermittent pain, with the most common fracture combinations involving the shaft of the tibia with either the femoral shaft or distal tibia (9%). Two hundred fifteen patients showed a persistent limp, and here the most common fractures were fractures of the femoral shaft (19%), tibial shaft (17%), and pelvis (15%)., Conclusions: In multiple injured patients with lower extremity injuries, the combination of fractures and their location are critical factors in long-term outcome. Patients with chronic persistent or load-dependent pain often had underlying femoral shaft fractures in combination with joint fractures., (© 2022. The Author(s).)

The "Remote Interactive Surgery Platform" (RISP) is an augmented reality (AR)-based platform for surgical telementoring. It builds upon recent advances of mixed reality head-mounted displays (MR-HMD) and associated immersive visualization technologies to assist the surgeon during an operation. It enables an interactive, real-time collaboration with a remote consultant by sharing the operating surgeon's field of view through the Microsoft (MS) HoloLens2 (HL2). Development of the RISP started during the Medical Augmented Reality Summer School 2021 and is currently still ongoing. It currently includes features such as three-dimensional annotations, bidirectional voice communication and interactive windows to display radiographs within the sterile field. This manuscript provides an overview of the RISP and preliminary results regarding its annotation accuracy and user experience measured with ten participants.

Electric bicycles (e-bikes) have gained enormous popularity in recent years, and as a result, they have successively become more involved in traffic accidents. The aim of the present study was to assess differences in severity and localization of injuries to the lower extremities after accidents with e-bikes, conventional bicycles, and motorcycles. A retrospective cohort-analysis of patients who sustained traumatic accidents with two-wheeled vehicles transferred to a level 1 trauma center in Switzerland was performed. We assessed patient demographics, injury pattern, and trauma severity (ISS), with a subgroup analysis of outcomes stratified by vehicle. In total, 624 patients (71% male) with injuries to the lower extremities after bicycle ( n = 279), electric bike ( n = 19), and motorcycle ( n = 326) accident were included. The mean age of all assessed patients was 42.4 years (SD 15.8), with a significantly higher age in the e-bike cohort ( p = 0.0001). High-velocity injuries were found significantly more often in the motorcycle and e-bike group. The motorcycle group had a significantly higher mean ISS (17.6) than the other groups ( p = 0.0001). E-bike accidents produce a different injury profile to the lower extremities compared to motorcycle or bicycle accidents. Higher age, higher velocity, and different protective equipment seem to have an impact on these fracture patterns.

Background: The automated digital surveillance of physical activity at home after surgical procedures could facilitate the monitoring of postoperative follow-up, reduce costs, and enhance patients' satisfaction. Data on the willingness of patients with orthopedic trauma to undergo automated home surveillance postoperatively are lacking., Objective: The aims of this study were to assess whether patients with orthopedic trauma would be generally willing to use the proposed automated digital home surveillance system and determine what advantages and disadvantages the system could bring with it., Methods: Between June 2021 and October 2021, a survey among outpatients with orthopedic trauma who were treated at a European level 1 trauma center was conducted. The only inclusion criterion was an age of at least 16 years. The paper questionnaire first described the possibility of fully automated movement and motion detection (via cameras or sensors) at home without any action required from the patient. The questionnaire then asked for the participants' demographics and presented 6 specific questions on the study topic., Results: In total, we included 201 patients whose mean age was 46.9 (SD 18.6) years. Most of the assessed patients (124/201, 61.7%) were male. Almost half of the patients (83/201, 41.3%) were aged between 30 and 55 years. The most stated occupation was a nine-to-five job (62/199, 30.8%). The majority of the participants (120/201, 59.7%) could imagine using the proposed measurement system, with no significant differences among the genders. An insignificant higher number of younger patients stated that they would use the automated surveillance system. No significant difference was seen among different occupations (P=.41). Significantly more young patients were using smartphones (P=.004) or electronic devices with a camera (P=.008). Less than half of the surveyed patients (95/201, 47.3%) stated that they were using tracking apps. The most stated advantages were fewer physician visits (110/201, 54.7%) and less effort (102/201, 50.7%), whereas the most prevalent disadvantage was the missing physician-patient contact (144/201, 71.6%). Significantly more patients with a part-time job or a nine-to-five job stated that data analysis contributes to medical progress (P=.047)., Conclusions: Most of the assessed participants (120/201, 59.7%) stated that they would use the automated digital measurement system to observe their postoperative follow-up and recovery. The proposed system could be used to reduce costs and ease hospital capacity issues. In order to successfully implement such systems, patients' concerns must be addressed, and further studies on the feasibility of these systems are needed., (©Julian Scherer, Vithush Yogarasa, Thomas Rauer, Hans-Christoph Pape, Sandro-Michael Heining. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.02.2023.)

Skydiving have gained mainstream popularity over the past decades. However, limited data exist on the injury risk or type associated with skydiving. This systematic review evaluated the injuries and fatalities of civilian skydivers. A PRISMA-guided literature search was performed in MEDLINE, Web of Science, Cochrane Library, and Embase using the following MeSH terms: "skydiving" or "parachute" alone or in combination with "injury" or "trauma" was performed including all studies through June 2022 in both English and German. Additionally, injury reports from the German, American, and British Parachute Associations were reviewed. Of the 277 articles matching the selected search terms, 10 original articles and 34 non-scientific reports from various skydiving associations were included. More than 62 million jumps were evaluated, with an average of 3,200,000 jumps per year, which showed an average injury rate of 0.044% and an average fatality rate of 0.0011%. The most common injuries sustained by recreational skydivers involved the lumbar spine and lower extremities. Injuries were most commonly reported during the landing sequence. With modern equipment and training methods, fatalities occur in less than 1 per 100,000 cases, and serious injuries requiring hospitalization in less than 2 per 10,000 cases. This puts the assessment of skydiving as a high-risk sport into perspective.

Objectives: Concomitant anterolateral complex (ALC) injury may contribute to persistent rotatory knee instability following anterior cruciate ligament (ACL) reconstruction. There is no consensus on how to best identify concomitant ALC injury preoperatively, nor how well ALC injury identified on imaging modalities correlates with clinical examination of knee instability. The purpose of this retrospective study was to determine the incidence of concomitant ALC injury in ACL-injured knees, as determined by arthroscopy to preoperative radiography, ultrasound, and MRI., Methods: A total of 117 patients with a unilateral primary ACL injury who underwent individualized anatomic ACLR between June 2016 and May 2019 were enrolled. Preoperative imaging modalities, including X-ray, ultrasound, and MRI, were evaluated for concomitant ALC injury. Clinical examination under anesthesia, including the anterior drawer, Lachman, and pivot shift tests were performed. Anterolateral capsule injury, as defined by hemorrhage and/or capsular tearing on diagnostic arthroscopy, was also determined. Correlative analyses of ALC injury incidence and severity were performed across imaging modalities and against clinical examination grades., Results: ALC injury incidence across imaging modalities was as follows: X-ray (3%), arthroscopy (19%), MRI (53%), and US (63%). The ALC injury rate on arthroscopy was significantly less than MRI (p < 0.001) or ultrasound (p < 0.001). ALC injury incidence and severity were significantly correlated between MRI and US grading scales (p = 0.02), but no correlations among other imaging modalities were found. Similarly, no imaging modality meaningfully correlated with physical examination maneuvers., Conclusion: The incidence of ALC injury varies across imaging modalities, with lower injury rates found on arthroscopy (19%) compared to MRI (53%) and US (63%). Increasing ALC injury severity grades on imaging does not predict increasing anterolateral knee laxity on clinical examination., Level of Evidence: V, retrospective case series., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Volker Musahl reports a relationship with Smith and Nephew Inc that includes consulting or advisory and funding grants. Volker Musahl reports a relationship with Arthrex Inc that includes funding grants. Freddie Fu reports a relationship with American Journal of Sports Medicine that includes board membership. Freddie Fu reports a relationship with Knee Surgery Sports Traumatology and Arthroscopy that includes board membership. Freddie Fu reports a relationship with Smith and Nephew Inc that includes funding grants. Freddie Fu reports a relationship with DePuy Mitek Inc that includes funding grants. Freddie Fu reports a relationship with Conmed Linvatec that includes funding grants. Freddie Fu reports a relationship with Cook Myosite that includes funding grants. Freddie Fu reports a relationship with Arthrex Inc that includes funding grants., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Figure skating is associated with a high prevalence of sport-specific injuries and overuse symptoms. Impacts are of greater magnitude in jumps with more revolutions that are thus connected to a greater risk of injury. While figure skating programs seem to have recently increased in difficulty, performance trends have not yet been reported in the literature. We hypothesized increasing performance and decreasing age trends of the best athletes who competed at international level in recent years. Furthermore, we aimed to identify and analyse objective performance parameters and to assess a potential link between age and the risk of injury. The development of the number of double, triple and quadruple jumps in the singles figure skating events at the World and European Championships since the introduction of the new ISU Judging System in the 2004/2005 season was analysed using regression statistics and Student's T-Tests. In all groups, the numbers of jumps with fewer rotations significantly decreased in the favour of jumps with more rotations. Women only started to perform jumps with four rotations in 2019. In the men, the number of quadruple jumps increased from an average of less than one to more than three in recent years (European and World Championships, both p < 0.001). In the European, but not in the World Championships, the average age increased in the men and decreased in the women (European Championships, men and women p = 0.006). Our study was the first to assess performance trends in elite figure skating. The incidence of injuries and overuse syndromes in figure skating needs to be monitored cautiously, as increases can be expected following recent gains in performance and jump complexity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Rauer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

In pair skating and ice dance, performance seems to have increased at international competitions, which is potentially associated with changes in athlete age. We hypothesized increasing age, numbers of total points and more complex jumps of the best elite couples at international championships in recent years. Corresponding data were assessed via the results databases of the European and World Championships, as well as the Winter Olympics since 2005. Linear regression statistics were conducted, and significance was assessed via one-way ANOVAs. There were no significant changes in age. Increases in total points were found in both disciplines (World and European Championships both p < 0.001 for both disciplines, Olympics pair skating p = 0.003, ice dance n/a). Significant increases were found in the number of double and triple twist jumps at the European Championships (Double p = 0.046, triple p = 0.041), but not at the World Championships or the Olympics. At the World Championships, single solo jumps decreased ( p = 0.031) in favor of triple jumps, which increased ( p = 0.020), without a similar effect at the European Championships or Olympics. In conclusion, increases in total points and more complex jumps were observed at international championships without associated changes in age. Attention should be given to possible changes in the incidence of acute and overuse injuries following this development.

Background: Telemedicine can take many forms, from telephone-only consultations to video consultations via a smartphone or personal computer, depending on the goals of the treatment. One of the advantages of videoconferencing is the direct visual contact between patients and therapists even over long distances. Although some telemedicine models require specially designed add-on devices, others get by with off-the-shelf equipment and software and achieve similarly successful successful results. This depends, among other things, on the nature of the injury, the desired outcome of therapy, and the medical consultation. In the last decade, the science and practice of telemedicine have grown exponentially and even more so during the COVID-19 pandemic. Depending on the traumatic lesion, posttraumatic and postoperative treatment and care of patients who experience trauma may require medical or physical therapy consultations in a clinic or office. However, due to the COVID-19 lockdown, direct physical follow-up was more difficult, and therefore, telemedicine solutions were sought and implemented., Objective: The aim of this study was to assess satisfaction with telemedical aftercare in patients with orthopedic trauma., Methods: Between March and July 2020, a standardized interview using a standardized questionnaire-Freiburg Index of Patient Satisfaction (FIPS)-among patients with orthopedic trauma who received telemedical postsurgical or physiotherapeutic care was conducted. The FIPS is composed of 5 questions regarding treatment and 1 question on the overall treatment satisfaction. Furthermore, we assessed patients' demographics and their telemedical use. Subgroup analysis was performed for age groups (<65 years vs ≥65 years), the used device, and gender., Results: In total, we assessed 25 patients with a mean age of 43 (SD 24.31) years (14 female). The majority of patients (n=19, 76%) used their smartphone for consultations. The mean overall FIPS score assessed was 2.14 (SD 0.87). The mean FIPS score for younger patients was 2.23 (SD 0.90) vs 1.91 (SD 0.82) for older patients. The vast majority of the surveyed patients (n=20, 80%) were absolutely confident with their smartphone or tablet use., Conclusions: Most patients surveyed stated a high satisfaction with the telemedical follow-up. Older patients showed a higher satisfaction rate than their younger counterparts. It seems that telemedical postsurgical or physiotherapeutic care is a viable option, especially in times of reduced contact, like the current COVID-19 pandemic. Thus, telemedicine offers the opportunity to ensure access to effective patient care, even over long distances, while maintaining patient satisfaction., (©Thomas Rauer, Julian Scherer, Pascal Stäubli, Jonas Gerber, Hans-Christoph Pape, Sandro-Michael Heining. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.09.2022.)

Background: As electric bicycles (e-bikes) become increasingly popular, reports of injuries associated with e-bike usage are also rising. Patterns, characteristics, and severity of injuries following e-bike crashes need further investigation, particularly in contrast to injuries from conventional bicycle crashes., Methods: This prospective observational study included 82 patients treated at a Level II trauma center for injuries resulting from an electric or conventional bicycle crash. Data were collected over one year (05.09.2017-19.09.2018) during in- and outpatient visits. A study-specific case report form was used to identify the bicycle type, cycling behavior (e.g., use of a helmet, safety gear, alcohol), and circumstances of the crash (e.g., road conditions, speed, cause of the incident, time of day, season). Additional information about patient demographics, treatment, and injury characteristics, such as the Injury Severity Score (ISS) and body region injured, were documented. Results were analyzed using chi-square, Fisher's exact, or Wilcoxon tests. Simple logistic or linear regression models were used to estimate associations., Results: Of the 82 patients, 56 (67%) were riding a conventional bike and 27 (33%) were using an e-bike. Most incidents were either single-bicycle crashes (66%) or automobile collisions (26%), with no notable difference in prevalence rates between groups. Although a higher proportion of conventional bikers were male (67% vs. 48%), the difference was not significant. E-bikers were older (median 60 years (IQR 44-70) vs. 45 years (IQR 32-62); p = 0.008), were hospitalized more often (48% vs. 24%, p = 0.025), and had worse ISS (median 3 (IQR 2-4) vs. 1 (IQR 1-3), p < 0.001), respectively. Body regions most affected were the extremities (78%) and external/skin (46%), and these were distributed similarly in both groups. Concomitant injury patterns of the thorax/chest with external/skin were higher among e-bikers (p < 0.001). When we controlled for the difference in the median age of the two groups, only the injury severity score of e-bikers remained significantly worse., Conclusions: Hospitalization and chest trauma rates were higher among e-bikers. After controlling for the older age of this group, the severity of their injuries remained worse than in conventional cyclists. Initial clinical assessments at trauma units should include an evaluation of the thorax/chest, particularly among elderly e-bikers., Level of Evidence: Level III., (© 2022. The Author(s).)

Background: A discoid lateral meniscus (DLM) is a congenital anomaly of the knee in which the lateral meniscus has an "O" shape and contains irregular, abnormal collagenous tissue. A DLM can cause mechanical symptoms and pain. Treatment of a symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached at the capsule. Reports in the literature recommend a residual width of 6 to 8 mm., Purpose/hypothesis: The purpose of this research was to determine the width of the lateral meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6 to 8 mm will be sufficient to approximate normal anatomy., Study Design: Cross-sectional study; Level of evidence, 3., Methods: We made direct measurements of the radial width of the lateral meniscus from the outer rim at the popliteal hiatus to the inner edge in 19 specimens (age, 2-120 months.) We measured one 4-year-old specimen with a bilateral complete DLM. We also measured 39 digital images of specimens (age, 1-132 months) using ImageJ. Finally, we made direct arthroscopic measurements of 8 skeletally mature specimens., Results: The average width of specimens <3 years old was 5.5 mm. The average width of the 10-year-old specimens was 12 mm. The average width of the skeletally mature specimens was 16 mm. A 4-year-old DLM specimen measured 19 mm., Conclusion: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6 to 8 mm is insufficient for children ≥8 years old. A width of at least a full centimeter approximates the normal for 8-year-olds and at least 15 mm for adolescents.

Background: Electric bicycles (E-bikes) are an increasingly popular means of transport, and have been designed for a higher speed comparable to that of small motorcycles. Accident statistics show that E-bikes are increasingly involved in traffic accidents. To test the hypothesis of whether accidents involving E-bikes bear more resemblance to motorcycle accidents than conventional bicyclists, this study evaluates the injury pattern and severity of E-bike injuries in direct comparison to injuries involving motorcycle and bicycle accidents., Methods: In this retrospective cohort study, the data of 1796 patients who were treated at a Level I Trauma Center between 2009 and 2018 due to traffic accident, involving bicycles, E-bikes or motorcycles, were evaluated and compared with regard to injury patterns and injury severity. Accident victims treated as inpatients at least 16 years of age or older were included in this study. Pillion passengers and outpatients were excluded., Results: The following distribution was found in the individual groups: 67 E-bike, 1141 bicycle and 588 motorcycle accidents. The injury pattern of E-bikers resembled that of bicyclists much more than that of motorcyclists. The patients with E-bike accidents were almost 14 years older and had a higher incidence of moderate traumatic brain injuries than patients with bicycle accidents, in spite of the fact that E-bike riders were nearly twice as likely to wear a helmet as compared to bicycle riders. The rate of pelvic injuries in E-bike accidents was twice as high compared with bicycle accidents, whereas the rate of upper extremity injuries was higher following bicycle accidents. Conclusion: The overall E-bike injury pattern is similar to that of cyclists. The differences in the injury pattern to motorcycle accidents could be due to the higher speeds at the time of the accident, the different protection and vehicle architecture. What is striking, however, is the higher age and the increased craniocerebral trauma of the E-bikers involved in accidents compared to the cyclists. We speculate that older and untrained people who have a slower reaction time and less control over the E-bike could benefit from head protection or practical courses similar to motorcyclists.

Introduction: Polytrauma and traumatic brain injury (TBI) patients are among the most vulnerable patients in trauma care and exhibit increased morbidity and mortality. Timely care is essential for their outcome. Severe TBI with initially high scores on the Glasgow Coma (GCS) scores is difficult to recognise on scene and referral to a Major Trauma Center (MTC) might be delayed. Therefore, we examined current referral practice, injury patterns and mortality in these patients., Materials and Methods: Retrospective, nationwide cohort study with Swiss Trauma Register (STR) data between 01/012015 and 31/12/2018. STR includes patients ≥16 years with an Injury Severity Score (ISS) >15 and/or an Abbreviated Injury Scale (AIS) for head >2. We performed Cox proportional hazard models with injury type as the primary outcome and mortality as the dependent variable. Secondary outcomes were inter-hospital transfer and age., Results: 9,595 patients were included. Mortality was 12%. 2,800 patients suffered from isolated TBI. 69% were men. Median age was 61 years and median ISS 21. Two thirds of TBI patients had a GCS of 13-15 on admission to the Emergency Department (ED). 26% of patients were secondarily transferred to an MTC. Patients with isolated TBI and those aged ≥65 years were transferred more often. Crude analysis showed a significantly elevated hazard for death of 1.48 (95%CI 1.28-1.70) for polytrauma patients with severe TBI and a hazard ratio (HR) of 1.82 (95%CI 1.58-2.09) for isolated severe TBI, compared to polytrauma patients without TBI. Patients directly admitted to the MTC had a significantly elevated HR for death of 1.63 (95%CI 1.40-1.89), compared to those with secondary transfer., Conclusions: A high initial GCS does not exclude the presence of severe TBI and triage to an MTC should be seriously considered for elderly TBI patients., Competing Interests: The authors have declared that no competing interests exist.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V., Competing Interests: Competing interests: TD, BBR, ADL,ES, EHS, TR, SJM, MVP and JK: none declared. LE: Smith and Nephew: fellowship grant. ORA: Conmed: Speakers Bureau. DJO: honoraria; JWX: Arthrex: consulting fees, non-consulting fees, royalties; Trice Medical: consulting fees; FHF: Smith & Nephew: educational support, hospitality payments. VM: Smith & Nephew: educational support, consulting fees, speaking fee; Arthrex: educational support., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Objectives: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making., Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence., Results: Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries., Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery., Competing Interests: Competing interests: CF–Karl Storz: IP royalties, paid consultant; Medacta: IP royalties, paid consultant, paid presenter or speaker; Zimmer: Research support. SLS–Arthrex: paid consultant; Smith & Nephew: paid consultant; CONMED: knee design team, paid consultant; Flexion Therapeutics: paid consultant; JRF Ortho: paid consultant; Olympus: paid consultant; Vericel: paid consultant; Zimmer: research support. BPL–Wolters Kluwer Health - Lippincott Williams & Wilkins: publishing royalties, financial or material support. Panther group authorship: Lars Engebretsen–Smith & Nephew grants, editor of JBJS and BJSM. Christopher C Kaeding–grant support from DJO, educational support from CDC medical, consulting fees from Zimmer Biomet, non-consulting fees from Arthrex. Jon Karlsson–Editor-in-Chief KSSTA. Ryosuke Kuroda–grants and personal fees from Smith & Nephew, grants and personal fees from Zimmer Biomet, grants from Stryker Japan KK, grants and personal fees from Johnson & Johnson KK, personal fees from Medacta International, personal fees from Arthrex, personal fees from Japan Tissue Engineering, personal fees from Hirosaki Life Science Innovation, personal fees from Arthrex Japan G.K.Volker Musahl–educational grants from Smith &Nephew and educational grants from Arthrex. Stephen J Rabuck–educational support from Mid-Atlantic Surgical, Siebold - Medacta International personal fees. Carola van Eck–eduational support from Arthrex, Mid-Atlantic Surgical and Smith & Nephew and grant support from DJO and Zimmer Biomet. Dharmesh Vyas–educational support from Mid-Atlantic Surgical, hospitality payments from Arthrex., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injur y Level of evidence: Level V., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed., Methods: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method., Results: In general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated., Conclusion: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment., Level of Evidence: V.

Purpose: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making., Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence., Results: Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries., Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery., Level of Evidence: IV.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V.

Background: Transitional fractures are fractures in adolescents where partial closure of the epiphyseal growth plate has occurred. These fractures are most commonly reported in the distal tibia. With respect to the distal radius, only a few case reports describing transitional fractures exist. Furthermore, relatively little is known about epiphyseal closure of the distal radius. A case series of four transitional fractures of the distal radius is presented by comparing non-operative and operative treatment options. At present, this is the largest case series in the literature dealing with this rare injury., Case Presentation: We present three cases of four transitional fractures of the distal radius including 1-year follow-up. Patient age ranged from 16 to 18 years including a gender ratio of two males to one female. Clinical and radiographic assessments took place 6 and 12 weeks and 1 year after trauma/surgery. Three transitional fractures were treated with open reduction and internal volar plate fixation followed by functional rehabilitation. One transitional fracture was treated non-operatively. All cases showed an excellent functional outcome., Conclusions: The primary treatment goal in transitional fractures is anatomic reduction of the articular surface. Non-operative treatment of transitional fractures of the distal radius is the most commonly reported treatment option. Additionally, different fixation options have been described, including the use of Kirschner wires (K-wires) and lag screws. The presented cases demonstrate that volar plate fixation followed by functional rehabilitation is a valuable treatment option in significantly displaced transitional fractures of the distal radius. Furthermore, we discuss the pathogenesis as well as the different treatment options by critical reviewing the literature.

Introduction: Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making., Methods: This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm3 bone-loss or an egg-shell situation, where the patient refused arthroplasty., Results: This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups., Conclusion: In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study., Competing Interests: The authors have declared that no competing interests exist.

Background: Although of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures., Methods: Radiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch., Results: The overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system., Conclusions: The low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2020.)

Background: Rotatory knee instability is an abnormal, complex three-dimensional motion that can involve pathology of the anteromedial, anterolateral, posteromedial, and posterolateral ligaments, bony alignment, and menisci. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented., Main Body: The most common instability pattern, anterolateral rotatory knee instability in an anterior cruciate ligament (ACL)-deficient patient, will be discussed in detail. Although intra-articular ACL reconstruction is the gold standard treatment for ACL injury in physically active patients, in some cases current techniques may fail to restore native knee rotatory stability. The wide range of diagnostic options for rotatory knee instability including manual testing, different imaging modalities, static and dynamic measurement, and navigation is outlined. As numerous techniques of extra-articular tenodesis procedures have been described, performed in conjunction with ACL reconstruction, to restore anterolateral knee rotatory stability, a few of these techniques will be described in detail, and discuss the literature concerning their outcome., Conclusion: In summary, the essence of reducing anterolateral rotatory knee instability begins and ends with a well-done, anatomic ACL reconstruction, which may be performed with consideration of extra-articular tenodesis in a select group of patients.

Background: Surgical implant material has changed over time, from metal to stainless steel to titanium. In recent decades a new material, carbon-fibre-reinforced polyether ether ketone, has been introduced. The aim of this study was to assess the clinical and radiological feasibility and functional outcome after treatment of distal radius fractures with this new implant., Methods: Inclusion criteria: AO type B distal radius fractures treated with 2.7 mm CF/PEEK plates at one Level 1 trauma centre between 2016 and 2017. Follow-up period 1 year, measurement of range of motion and radiographic assessment, histological analysis of debris only after plate removal., Results: Out of 112 eligible patients, 10 (8.9%) patients were included. Mean operation time was 65 ± 10 min. Radiographic healing was confirmed by radiologists at 6 weeks follow-up. During one-year follow-up, no adverse events were reported and functionality and patients subjective satisfaction improved significantly ( p  < 0.05). Only one plate was removed, with no histological signs of inflammation or allergic reaction., Conclusions: The 2.7 mm CF/PEEK plate osteosynthesis appears to be a reliable and safe implant for certain types of distal radius fracture. Assessment of fracture union is substantially more practical and functionality improved significantly over 1 year., Competing Interests: Competing interestsNone of the authors have any conflicts of interests to declare. The authors received no pharmaceutical or industrial support for this study. No further direct or indirect financial support or other assets were transferred to the authors or their family members for this study. There was no type of support by the industrial producer of the implants used in this study, including grant support, financial reimbursement for travel, speaker fees, stocks and bonds, or any other financial or otherwise relevant relationship with this particular vendor. None of these conflicts exist for any of the authors. We are stating and emphasizing the absence of any conflict in order to avoid any perception of industrial bias.

Introduction: Falling on the outstretched arm is a frequent trauma. The consequences can be isolated fractures of the distal radius, combined fractures of the distal radius and distal ulna - whereas the isolated fracture of the distal ulna is an uncommon trauma., Presentation of Case: We report on a 20- year- old male who presented at the emergency department after a motorcycle accident, suffering pain at his left forearm and left wrist. After an unremarkable x-ray in two planes, a CT- scan of the left wrist was performed and detected an isolated distal ulna fracture. The patient was treated with a forearm cast which led to a satisfying long term outcome., Discussion: Based on the presented case the anatomical peculiarities of the distal radioulnar joint and the different trauma mechanisms as well as the resulting lesions, the diagnostic modalities and the treatment options are discussed., Conclusion: We recommend performing an additional CT scan of the wrist in case of credible complaints after trauma to avoid baulking this very rare type of fracture., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Avulsion fractures of the calcaneal tuberosity are predominantly seen in patients with poor bone quality, the commonly used lag screw fixation might not be strong enough even with bony fragments of sufficient size. We present a case of a closed displaced avulsion fracture of the calcaneal tuberosity due to blunt trauma to the calf in a 74-year-old female. Open reduction and internal fixation with two 3.5-mm cannulated cortical screws with washers was performed, and anatomic reduction was achieved. Without further trauma, secondary displacement of the fracture occurred on day 3. Revision was performed with a single 3.5-mm cortical screw and transosseous fixation with 2 suture anchors, followed by partial weightbearing for 6 weeks. At 12 weeks postoperative, the fracture had completely healed, and she was doing well at 16 months after the revision surgery. Transosseous suture anchor fixation of an osteoporotic avulsion fracture of the calcaneal tuberosity seems to provide better and stronger fixation than that using lag screws., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)