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A 74-year-old male patient was referred with signs of sepsis 5 days after having been diagnosed with a rib fracture following a fall out of bed. Novel hypodensities were visible on thoracic X‑rays and laboratory tests revealed elevated inflammatory parameters. Subsequently performed thoracic computed tomography (CT) scan showed burst fracture of the 3rd thoracic vertebra, posttraumatic esophageal rupture at the same level and mediastinitis. Furthermore, marked degenerative changes of the spinal column (diffuse idiopathic skeletal hyperostosis) were present. The patient underwent emergency thoracotomy and esophagectomy. Gastric pull-up with esophagogastrostomy was postponed for 3 days. After 14 days on the intensive care unit (ICU) and 12 days of i.v. antibiotics, the patient was transferred to the general ward and 7 weeks after trauma the patient was infection-free without difficulties in swallowing. Up to the latest follow-up 41 months following injury, several endoscopic dilations with a bougie due to constrictions at the anastomosis have been performed. Similar to previous cases in the literature, esophageal injury was diagnosed delayed, with the patient already having developed severe complications. This extremely seldom injury should be suspected in young patients following high-energy trauma, but also in older patients after low-energy trauma but known degenerative changes of the vertebral column., (© 2024. The Author(s).)

Background: In the ongoing development of bioresorbable implants, there has been a particular focus on magnesium (Mg)-based alloys. Several Mg alloys have shown promising properties, including a lean, bioresorbable magnesium-zinc-calcium (Mg-Zn-Ca) alloy designated as ZX00. To our knowledge, this is the first clinically tested Mg-based alloy free from rare-earth elements or other elements. Its use in medial malleolar fractures has allowed for bone healing without requiring surgical removal. It is thus of interest to assess the resorption behavior of this novel bioresorbable implant., Questions/purposes: (1) What is the behavior of implanted Mg-alloy (ZX00) screws in terms of resorption (implant volume, implant surface, and gas volume) and bone response (histologic evaluation) in a sheep model after 13 months and 25 months? (2) What are the radiographic changes and clinical outcomes, including patient-reported outcome measures, at a mean of 2.5 years after Mg-alloy (ZX00) screw fixation in patients with medial malleolar fractures?, Methods: A sheep model was used to assess 18 Mg-alloy (ZX00) different-length screws (29 mm, 24 mm, and 16 mm) implanted in the tibiae and compared with six titanium-alloy screws. Micro-CT was performed at 13 and 25 months to quantify the implant volume, implant surface, and gas volume at the implant sites, as well as histology at both timepoints. Between July 2018 and October 2019, we treated 20 patients with ZX00 screws for medial malleolar fractures in a first-in-humans study. We considered isolated, bimalleolar, or trimalleolar fractures potentially eligible. Thus, 20 patients were eligible for follow-up. However, 5% (one patient) of patients were excluded from the analysis because of an unplanned surgery for a pre-existing osteochondral lesion of the talus performed 17 months after ZX00 implantation. Additionally, another 5% (one patient) of patients were lost before reaching the minimum study follow-up period. Our required minimum follow-up period was 18 months to ensure sufficient time to observe the outcomes of interest. At this timepoint, 10% (two patients) of patients were either missing or lost to follow-up. The follow-up time was a mean of 2.5 ± 0.6 years and a median of 2.4 years (range 18 to 43 months)., Results: In this sheep model, after 13 months, the 29-mm screws (initial volume: 198 ± 1 mm 3 ) degraded by 41% (116 ± 6 mm 3 , mean difference 82 [95% CI 71 to 92]; p < 0.001), and after 25 months by 65% (69 ± 7 mm 3 , mean difference 130 [95% CI 117 to 142]; p < 0.001). After 13 months, the 24-mm screws (initial volume: 174 ± 0.2 mm 3 ) degraded by 51% (86 ± 21 mm 3 , mean difference 88 [95% CI 52 to 123]; p = 0.004), and after 25 months by 72% (49 ± 25 mm 3 , mean difference 125 [95% CI 83 to 167]; p = 0.003). After 13 months, the 16-mm screws (initial volume: 112 ± 5 mm 3 ) degraded by 57% (49 ± 8 mm 3 , mean difference 63 [95% CI 50 to 76]; p < 0.001), and after 25 months by 61% (45 ± 10 mm 3 , mean difference 67 [95% CI 52 to 82]; p < 0.001). Histologic evaluation qualitatively showed ongoing resorption with new bone formation closely connected to the resorbing screw without an inflammatory reaction. In patients treated with Mg-alloy screws after a mean of 2.5 years, the implants were radiographically not visible in 17 of 18 patients and the bone had homogenous texture in 15 of 18 patients. No clinical or patient-reported complications were observed., Conclusion: In this sheep model, Mg-alloy (ZX00) screws showed a resorption to one-third of the original volume after 25 months, without eliciting adverse immunologic reactions, supporting biocompatibility during this period. Mg-alloy (ZX00) implants were not detectable on radiographs after a mean of 2.5 years, suggesting full resorption, but further studies are needed to assess environmental changes regarding bone quality at the implantation site after implant resorption., Clinical Relevance: The study demonstrated successful healing of medial malleolar fractures using bioresorbable Mg-alloy screws without clinical complications or revision surgery, resulting in pain-free ankle function after 2.5 years. Future prospective studies with larger samples and extended follow-up periods are necessary to comprehensively assess the long-term effectiveness and safety of ZX00 screws, including an exploration of limitations when there is altered bone integrity, such as in those with osteoporosis. Additional use of advanced imaging techniques, such as high-resolution CT, can enhance evaluation accuracy., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons.)

Objective: Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory., Indications: The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions., Contraindications: If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants., Surgical Technique: Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas., Postoperative Management: Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma., Facts: If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low., (© 2023. The Author(s).)

Purpose: Simulator arthroscopy training has gained popularity in recent years. However, it remains unclear what level of competency surgeons may achieve in what time frame using virtual training. It was hypothesized that 10 h of training would be sufficient to reach the target level defined by experts based on the Diagnostic Arthroscopic Skill Score (DASS)., Methods: The training concept was developed by ten instructors affiliated with the German-speaking Society of Arthroscopy and Joint Surgery (AGA). The programme teaches the basics of performing arthroscopy; the main focus is on learning and practicing manual skills using a simulator. The training was based on a structured programme of exercises designed to help users reach defined learning goals. Initially, camera posture, horizon adjustment and control of the direction of view were taught in a virtual room. Based on these skills, further training was performed with a knee model. The learning progress was assessed by quantifying the exercise time, camera path length and instrument path length for selected tasks. At the end of the course, the learners' performance in diagnostic arthroscopy was evaluated using DASS. Participants were classified as novice or competent based on the number of arthroscopies performed prior to the assessment., Results: Except for one surgeon, 131 orthopaedic residents and surgeons (29 women, 102 men) who participated in the seven courses agreed to anonymous data analysis. Fifty-eight of them were competents with more than ten independently performed arthroscopies, and 73 were novices, with fewer than ten independently performed arthroscopies. There were significant reductions in exercise time, camera path length and instrument path length for all participants after the training, indicating a rapid increase in performance. No difference in camera handling between the dominant and non-dominant sides was found in either group. The competents performed better than the novices in various tasks and achieved significantly better DASS values on the final performance test., Conclusions: Our data have demonstrated that arthroscopic skills can be taught effectively on a simulator, but a 10-h course is not sufficient to reach the target level set by experienced arthroscopists. However, learning progress can be monitored more objectively during simulator training than in the operating room, and simulation may partially replace the current practice of arthroscopic training., Level of Evidence: III., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background This study aimed at analysing risk factors for development of acute compartment syndrome (ACS) in tibial plateau fractures, and to construct a nomogram predicting ACS-risk. Patients and Methods 243 patients (102 males; mean age: 50.7 [range: 18-85] years) with 253 tibial plateau fractures treated between 2010 and 2019 at a level-1 trauma centre were retrospectively included. Uni- and multivariate logistic regression analysis with odds ratios (OR) were performed to assess variables predicting ACS. Based on the multivariate model, ROC curve, Youden index, and nomogram were constructed. Results ACS developed in 23 patients (9.1%), with risk factors being male gender (OR: 10.606; p<0.001), BMI (OR: 1.084; p = 0.048), polytrauma (OR: 4.085; p = 0.003), and Schatzker type IV-VI fractures (OR: 6.325; p = 0.004). Age, ASA score, diabetes, renal insufficiency, hypertension, smoking or open fracture were not significantly associated with ACS-risk (all p>0.05). In the multivariate analysis, male gender (OR: 7.392; p = 0.002), and Schatzker type IV-VI fractures (OR: 5.533; p = 0.009) remained independent negative ACS-predictors, irrespective of polytrauma (p = 0.081), or BMI (p = 0.194). Area under the ROC curve was 0.840. Youden index revealed a cut-off value of ≥ 18%, upon which patients are at extremely high risk for ACS. Conclusions Particular attention should be paid to male patients with high-energy fractures of the tibial plateau towards any signs of ACS of the affected extremity to initiate early treatment. The compiled nomogram, consisting of four easily quantifiable clinical variables, may be used in clinical practice to individually predict ACS risk. Any risk score ≥ 18% should prompt critical monitoring towards ACS, or even prophylactic fasciotomy during primary surgery., Competing Interests: Declaration of Competing Interest None of the authors has any conflicts of interest related to the present manuscript to declare., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures. A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes. Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P = 0.997), or approaches (two studies; RR: 0.36; P = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P = 0.004) but not different between approaches (2 studies; RR: 0.95; P = 0.960). Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

Purpose: To develop and validate a novel score to more objectively assess the performance of diagnostic knee arthroscopy using a simulator., Methods: A Diagnostic Arthroscopy Skill Score (DASS) was developed by ten AGA (AGA-Society for Arthroscopy and Joint-Surgery) instructors for the assessment of arthroscopic skills. DASS consists of two parts: the evaluation of standardized diagnostic knee arthroscopy (DASS part1 ) and the evaluation of manual dexterity, including ambidexterity and triangulation, using objective measurement parameters (DASS part2 ). Content validity was determined by the Delphi method. One hundred and eleven videos of diagnostic knee arthroscopies were recorded during simulator training courses and evaluated by six specially trained instructors using DASS. Construct validity, measurement error calculated by the minimum detectable change (MDC), internal consistency using Cronbach's alpha and interrater and intrarater reliability were assessed. The Bland-Altman method was used to calculate the intrarater agreement., Results: Six skill domains were identified and evaluated for each knee compartment. DASS, DASS part1, and DASS part2 showed construct validity, with experts achieving significantly higher scores than competents and novices. MDC was 4.5 ± 1.7 points for DASS part1 . There was high internal consistency for all domains in each compartment from 0.78 to 0.86. The interrater reliability showed high agreement between the six raters (ICC = 0.94). The evaluation of intrarater reliability demonstrated good and excellent agreement for five raters (ICC > 0.80) and moderate agreement for one rater (ICC = 0.68). The Bland-Altman comparison showed no difference between the first and second evaluations in five out of six raters. Precision, estimated by the regression analysis and comparison with the method of Bland and Altman, was excellent for four raters and moderate for two raters., Conclusions: The results of this study indicate good validity and reliability of DASS for the assessment of the surgical performance of diagnostic knee arthroscopy during simulator training. Standardized training is recommended before arthroscopy surgery is considered in patients., Level of Evidence: II., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins' I2, publication bias with Harbord's p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections. Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058., Competing Interests: ICMJE Conflict of interest statement: None of the authors has any conflicts of interest related to the current study to declare., (© 2021 The author(s).)

Background: Periprosthetic fractures (PPF) following total knee (TKA) and hip arthroplasty (THA) have become more common over the years. The aim of the present study was to assess morbidity and mortality following surgery for PPF of hip and knee., Patients and Methods: Altogether, 124 patients (mean age: 77 years; 77.4% female) with PPF of the hip (n=97) and knee (n=27), treated between 2005 and 2017 at a level-1 trauma centre, were retrospectively included. In order to assess risk factors for postoperative morbidity, Fine and Gray's model was used to compensate for death as the competing event. Risk factors for mortality were estimated with uni- and multivariate Cox-regression models., Results: Vancouver B2 fractures were most common (n=39; 42.4%), followed by B1 fractures (n=23; 25.0%). Lewis-Rorabeck Type I fractures (n=14; 51.9%) were most frequent in PPF of the knee. Overall complication rates were 44.0% and 29.9% for PPF of the knee and hip, respectively, with three patients having both early and late complications, 25 patients developing early complications and 19 patients undergoing surgery for implant-related, late complications. In the multivariate Fine and Gray model, advanced patient age (HR: 0.956; 95%CI: 0.922-0.991; p=0.014) and prosthesis exchange (vs. ORIF; HR: 0.242, 95%CI: 0.068-0.859; p=0.028) were associated with lower risk of implant-related complications, irrespective of gender (p=0.450) and a surgical delay > 2 days (p=0.411). One- and 5-year overall survival-rates were 97.9% and 93.1%, respectively. Gender, type of fixation (ORIF vs. prosthesis exchange), surgical delay > 2 days, BMI and age at surgery were neither in the univariate, nor multivariate Cox-regression model associated with an increased mortality rate., Conclusion: Postoperative morbidity caused by implant-related complications is higher in younger patients and those receiving ORIF. With the statistical approach used, potential underestimation of actual complication rates may have been avoided, taking into account death as the competing event. Despite being based on a retrospective, heterogenous patient collective treated at a level-1 trauma centre, our results indicate that careful planning of the surgical procedure beyond 2 days, taking into consideration both patient's age and activity level, has no negative effect on patient outcome., Competing Interests: Declaration of Competing Interest None of the authors has any conflicts of interest related to the present manuscript to declare., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: With the rising number of hip surgeries, simple and cost-effective tools for surgery risk assessment are warranted. The analysis of heart rate variability (HRV) may not only provide critical insights into the general frailty of patients with hip surgery, but also allow for better differentiation of health profiles in different hip surgery groups. Using HRV analysis, the present study compared cardiovascular as well as anthropometric parameters between patients with hip surgery, the hip fracture surgery group (HFS) and the total hip arthroplasty group (THA), and a control group., Methods: 71 participants (56.3% women), aged 60-85 years, took part, divided into three groups-patients after hip surgery (21 HFS and 30 THA patients) and a control group (20 participants). Electrocardiogram was recorded at baseline and after the application of a physical stressor (grip strength). A 3 (group) × 2 (time) repeated measures ANOVA, and a chi square test were carried out to test for group differences., Results: Higher weight (p = .002), body mass index (p = .001), and systolic blood pressure (p = .034) were found in THA patients compared to HFS patients. Lower calf circumference (p = .009) and diastolic blood pressure (p = .048) were observed for the HFS group compared to the control group. For cardiovascular parameters, significant differences emerged between the HFS group and the control group in HR (p = .005), SDNN (p = .034) and SD2 (p = .012). No significant differences in cardiovascular parameters were observed between the two hip surgery groups: neither at baseline nor during stressor recovery., Conclusions: While HRV seems to differentiate well between HFS patients and controls, more research with larger samples is needed to scrutinize similaritites and differences in cardiovascular profiles between HFS and THA patients.

The purpose of this study was to assess anticoagulant medication as an independent factor influencing the occurrence of a severe traumatic brain injury in geriatric patients. Data were collected from the TraumaRegister DGU ® between January 2015 and December 2018. We included patients with an age of ≥65 years with a blunt TBI; an AISHead ≥2 but no other relevant injuries. Patients were divided into five subgroups: no anticoagulant medication, anti-platelet drugs, vitamin K antagonists, direct-oral-anticoagulants, and heparinoids. Separation between moderate TBI (AISHead 2-3) and severe TBI (AISHead ≥ 4) and multivariable regression analysis were performed. The average age of 10,559 included patients was 78.8 years with a mean ISS of 16.8 points and a mortality of 22.9%. The most common cause of injury was a low fall of <3 m with 72.8%. With increasing age, the number of patients without any anticoagulant therapy decreased from 65.9% to 29.9%. The intake of coagulation medication increased mortality significantly. Severe TBI was observed in 51% of patients without medication and ranged from 61 to 67% with anticoagulant drugs. After adjusting for confounding variables, the intake of VKA or DOACs was significantly associated with an increased risk of severe TBI. The use of anticoagulant medication is an independent factor and is associated with an increased severity of TBI depending on the type of medication used.

Objective: The so-called ankle block represents a local anesthesia form which enables easy performance of all surgical procedures of the foot and ankle., Indications: Interventions distal to the medial and lateral malleoli., Contraindications: Acute and chronic infections in the area of injection; allergy to the local anesthesia., Surgical Technique: All five sensory foot nerves are blocked. The two deep lying nerves, the tibial nerve and the deep fibular nerve, can be directly anesthetized perineurally using anatomical landmarks. The other three nerves are subcutaneously infiltrated near their branches., Results: The success rate ranges from 88 to 94%; smaller areas may also be further blocked intraoperatively. The ankle block is a cost-effective procedure which can also be performed without problems in multimorbid patients due to its minor side effects.

Background: The Mangled Extremity Severity Score is a decision-making tool for limb amputation after trauma. The Disabilities of the Arm, Shoulder and Hand questionnaire was developed to quantify posttraumatic functional deficits of the upper extremity. This study aims to determine the correlation between these two assessments., Methods: In this study, a retrospective review of all patients with upper extremity injuries who had been treated with vascular reconstruction at two centres between 2005 and 2014 was performed. The respective Mangled Extremity Severity Score was calculated for each participant. Patients were recalled for follow-up examination and assessment of the Disabilities of the Arm, Shoulder and Hand Score., Results: In this study, 14 patients met the inclusion criteria. The mean total Mangled Extremity Severity Score was 5.9 and the mean total Disabilities of the Arm, Shoulder and Hand Score was 30 points. There was no statistically significant correlation between these assessments (Spearman's rank correlation coefficient: 0.49, p=0.075)., Conclusion: The Disabilities of the Arm, Shoulder and Hand Score did not correlate significantly with the Mangled Extremity Severity Score.

Tarsal coalition is an often unrecognised cause of foot and ankle pain and represents a congenital osseous, cartilaginous or fibrous connection between two or more tarsal bones. Fractures in combination with tarsal coalitions are rarely described in the literature. We report the case of a 43-year-old male patient with a talocalcaneal coalition who sustained an open comminuted calcaneal fracture and a closed transverse cuboid fracture. Due to the asymptomatic tarsal coalition and the already firmly fixed subtalar joint, the patient was treated with open reduction and internal fixation (ORIF) with satisfactory outcomes instead of ORIF in combination with subtalar arthrodesis. Ten months after the trauma, the patient was satisfactory and could return to his regular work. There is currently no evidence for the gold standard treatment of calcaneal fractures with combined tarsal coalitions. Due to the satisfactory results of this case, authors conclude that in case with prior asymptomatic coalitions, singular ORIF without subtalar arthrodesis may be performed.

The present study evaluates the medium-term functional and radiological outcome as well as complications following an arthroscopic tibial inlay reconstruction of the posterior cruciate ligament (PCL). A total of 39 patients (mean age: 32.6 ± 12.4 years) with acute and chronic PCL instabilities received a single-bundle all-inside arthroscopic tibial inlay reconstruction with quadriceps tendon autograft and were available for clinical follow-up on average after 3.8 ± 1.8 years. Assessment was conducted utilizing visual analogue scale (VAS), International Knee Documentation Committee (IKDC), Tegner, Lysholm, and knee injury and osteoarthritis outcome (KOOS) scores. VAS, Tegner, Lysholm, and subjective IKDC-scores averaged to 2.75 ± 1.95, 4 (1-9), 77.19 ± 17.54, and 75.18 ± 19.29 points, respectively. Mean KOOS results were 80.66 ± 1.98 for pain, 74.72 ± 17.72 for symptoms, 88.44 ± 13.95 for activities of daily life, 65.35 ± 27.96 for sports and recreation, and 60.01 ± 25.36 for quality of life. Overall IKDC-score rating was A2, B28, C5, and D4. The overall complication rate of 5.4% was caused by one superficial infection, one patellar fracture, and one lesion to the popliteal artery. Arthroscopic tibial inlay reconstruction is a valuable procedure regarding medium-term subjective and objective outcome measures. Return to sports, subjective satisfaction, and objective stability are predictable. The complication rate is acceptable but particular precaution is recommended to protect the popliteal artery and adjacent structures at risk., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Various surgical techniques have been described for the fixation of acromioclavicular (AC) dislocations. However, recurrent dislocation is one of the main complications associated with the majority of these techniques. We report a case of postoperative AC joint redislocation. In order to overcome recurrent dislocation after revision surgery, a reconstruction of the conoid and trapezoid ligament with the use of a free tendon graft in combination with a FiberTape was provided within a novel surgical technique. After 12 months, the patient was very satisfied with the functional outcome. The patient achieved excellent results in the Constant (98 points), SPADI (0 points), and QuickDASH score (0 points). The described technique results in an anatomic reconstruction of the AC joint. The nonrigid nature of the intervention seems to restore the normal arthrokinematics by reconstructing the coracoclavicular ligaments with an autograft which is then protected by the AC Dog Bone artificial ligaments during the healing period. The arthroscopic approach to the AC joint with minimal exposure reduces the risks and complications of the intervention. This is the first case in literature that utilizes the artificial dog bone ligament securing the autograft in an anatomic AC reconstruction.

Introduction: A paradox seems to exist: exercising leads to clotting activation in conventional clotting tests, but exercising persons have a low risk of thrombosis. In this study we tried to evaluate the effect of exercise performance status on in vitro plasma thrombin generation, which represents an overall function test of hemostasis., Materials and Methods: We compared 56 trained subjects to 98 healthy age matched sedentary volunteers. Blood samples were analyzed for thrombin generation using calibrated automated thrombography. Microparticles were quantified using ELISA. Additionally prothrombin fragments 1 + 2, thrombin-antithrombin complex, tissue factor pathway inhibitor, antithrombin and prothrombin were measured. The group of the trained subjects performed an incremental cycle-ergometer exercise test after taking the blood sample., Results: A significantly lower endogenous thrombin potential was observed in the group of the trained subjects compared to the sedentary individuals (p = 0.007). Microparticles (ELISA) were significantly lower in the trained subjects compared to the sedentary subjects (p = 0.001). Prothrombin fragments 1 + 2 (p < 0.001) and thrombin-antithrombin complex (p = 0.01) were significant higher in the trained subjects and antithrombin (p = 0.02) as well as prothrombin (p < 0.0001) were significantly lower in this group, whereas tissue factor pathway inhibitor values did not show significant differences. Both maximal and submaximal power output was significantly negatively related to endogenous thrombin potential (r = -0.43, r = -0.45) and thrombin peak (r = -0.44, r = -0.42)., Conclusions: Trained subjects have a lower endogenous thrombin potential than sedentary subjects possibly explaining the lower incidence of thrombosis in this group despite a higher acute clotting activation during strenuous exercise., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Intramedullary nailing of pertrochanteric femoral fractures has grown in popularity over the past 2 decades likely because this procedure is associated with a low risk for postoperative morbidity and a fast recovery of function. The evaluation of outcomes associated with pertrochanteric nailing has mainly been based on objective measures. The purpose of the present study is to correlate patients' health-related quality of life results after intramedullary nailing of pertrochanteric fractures with objective outcome measures., Methods: We conducted a single-center study including 62 patients (mean age 80 ± 10 years) with pertrochanteric fractures treated with a Gamma 3 Nail. Health related quality of life was measured using the Short Form-36. These results were compared to both US and Austrian age and sex-adjusted population norms. The objective outcome measures studied at one year postoperatively included Harris Hip Score, range of motion, leg length, body mass index, neck-shaft angle and grade of osteoarthritis., Results: According to the Harris Hip Score 43 patients (67%) had excellent or good results. There was no significant difference in the average neck-shaft angle comparing affected hip to non-affected hip at 12 months postoperatively. The average osteoarthritis score, for both the injured and uninjured hip, did not differ significantly. We found significant differences between the bodily pain, social functioning and mental health subscales and two summary scores of the Short-Form 36 in comparison to Austrian population norms. Complication rate was 8%., Conclusions: The results of this study confirm that intramedullary nailing with the use of a Gamma Nail is a safe treatment option for stable and unstable pertrochanteric fractures. Despite good functional and radiographic results we noticed a substantial fall off in patients' quality of life up to 12 months after operation.

Background: The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA)., Methods: Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05)., Results: Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values., Conclusions: Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

We present a case of a patient with severe facial trauma who was treated at the scene by a physician-staffed trauma life support team. Because of massive oropharyngeal bleeding in addition to a difficult neck anatomy in a very obese patient, a cannot-intubate, cannot-ventilate situation occurred. Control of the airway could finally be achieved by surgical cricothyroidotomy. The current literature concerning emergency cricothyroidotomy is discussed.

Purpose: The objective of this retrospective study was to evaluate postoperative morbidity, risk of complications, and patient discomfort after ambulatory tibial bone harvesting procedures under local anesthesia., Patients and Methods: Between 2000 and 2005, bone was harvested from the head of the tibia for internal or external maxillary augmentation in 79 patients. A medial osteoplastic approach to the donor region was used. All patients' records were reviewed. Forty-five of the 79 patients later came in for follow-up examination. A traumatologist examined the donor region both clinically and radiologically. Subjective disorders and experiences of the patients were documented using a standardized questionnaire., Results: The patient records revealed that 80% did not report significant complaints or gait disturbances after bone harvesting, and only 5% reported postoperative complaints or gait disturbances lasting longer than 2 weeks. In 1 case, a nondisplaced fracture healed without further complications. Clinical and radiologic examinations of 45 patients revealed full regeneration of the donor region in all cases. Some 91% of the patients described the outpatient bone harvesting procedure under local anesthesia as "not distressing" and would undergo such an intervention again if required., Conclusions: This study demonstrates that both complaints and risk of complications after outpatient bone harvesting from the proximal tibia under local anesthesia can be considered very low, especially as far as outpatient maxillary augmentation (eg, sinus floor elevation) is concerned.

Lower leg fractures are common and complex injuries in soccer players. Twenty-five mainly recreational soccer players who sustained a tibial shaft fracture were treated with the AO-UTN (Unreamed Tibial Nail). This prospective series included 25 males with a mean age of 28.1 years. These patients were prospectively followed for a mean period of 4.7 years. Clinical and radiographic data was collected. In addition, 20 patients completed an outcomes based questionnaire. In all but one case, the mechanism of injury was a contact with an opposing player. Shin guards provided little prevention against these fractures. The majority of these tibial shaft fractures were consistent with a short oblique or transverse fracture pattern. All fractures were stabilized with the UTN on the day of injury. Four patients had concurrent compartment syndromes and underwent a fasciotomy. Average time until bony consolidation was 11.3 weeks. No patients returned to competitive soccer activities earlier than five months after the initial injury (average 9.5). Only 11 out of 20 soccer players returned to the same level of sporting activity. Six patients never returned to playing soccer again after this injury, even without complications. The fracture of the tibial shaft in soccer players is a severe injury that can be treated safely with the UTN without major complications, but nevertheless only 50% of a mainly-recreational playing population return to the same competitive level as before the injury.

There are conditions that preclude the use of the posterior interosseous flap for reconstruction of the dorsum of the hand. Based on a series of 34 cases, these conditions are outlined and alternative solutions discussed. The posterior interosseous flap was employed for closure in 30 cases. In four cases different methods were used due to severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex defect requiring a composite flap and an anatomical variation. Thin free flaps were employed alternatively. All flaps survived but there was marginal flap necrosis in two posterior interosseous flaps. The posterior interosseous flap proved its usefulness and reliability in reconstruction of the hand in this series. In four cases, free lateral arm and temporoparietal fascial flaps were employed. Flaps based on the main vessels of the forearm were not used due to their significant donor site morbidity.

A new approach to reconstruction of the Achilles tendon and overlying soft tissue is presented. A fascia lata graft is used to reconstruct the tendon and is enwrapped by the fascia that is included in a fasciocutaneous lateral arm flap. Five patients were treated with this technique; three of them after surgical Achilles tendon repair, rerupture, and consecutive infection, one after a full-thickness burn with loss of the tendon and one with a history of ochronosis and necrosis of the whole tendon and overlying soft tissue. There were no anastomotic complications and all flaps healed primarily. Functional evaluation with the Cybex II dynamometer was done at least 49 months after reconstruction. A good functional and cosmetic result was obtained in all patients and donor site morbidity was acceptable. These results are well within the results of other surgical treatment options reported in the literature.

In 1996, the AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary device for the treatment of unstable per-, intra- and subtrochanteric femoral fractures. In a prospective study, we treated 55 patients having proximal femoral fractures with the PFN from 1997 to 2000. In 34 patients, we achieved what was close to anatomic reduction of the main fracture fragments. Immediate full weight bearing was permitted in 49 patients. During the follow-up period of 15 months, complications occurred in 12 patients. 2 patients had a cut-out of the implant because we used too short proximal gliding screws. In 5 patients, closed fracture reduction could not be done and open fracture reduction with use of cerclage became necessary. Careful surgical technique and modification of the PFN can reduce the high complication rate. In conclusion, the PFN is a good minimal invasive implant of unstable proximal femoral fractures, if closed reduction is possible. If open reduction of the fracture becomes necessary and several fragments are found (especially of the greater trochanter), we prefer to use a dynamic hip screw (DHS) with the trochanter stablizing plate.

External fixation as a modality is a versatile and minimally invasive stabilization option that should not be forgotten even as new and specially designed implants for nearly each bone become more fashionable. As a temporary traction device, the external fixator can help condition the soft tissues and, if closed reduction was sufficient, it can stay in place for definitive treatment. The external fixator can be used as an intraoperative distraction device and as a helpful tool for reduction, which can stay in place as a temporary immobilization. External fixation instead of plaster cast allows for better care of skin and soft tissues. External fixation also has its advantages as a minimally invasive external compression device in specific indications for arthrodesis, especially in infected cases.

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student's two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

In order to gain satisfying results in the treatment of acute hyperflexion trauma to the foot, it is absolutely necessary to achieve an exact primary diagnosis because injuries to the tarsometatarsal joint are frequently missed primarily. Aim of this prospective clinical study was to evaluate the diagnostic reliability of conventional radiography, CT and MRI compared to each other. 75 consecutive patients after hyperflexion trauma to the foot were included. There were 47 males and 28 females with a mean age of 38 years. After admittance, pa-, lateral and 45 degrees oblique radiographs were taken as well as stress views in comparison to the contralateral foot. Furthermore, CT and MRI were performed in any patient. By conventional radiography, 48 metatarsal and 24 tarsal fractures were diagnosed as well as 17 cases of malalignment of the Lisfranc joint. Stress radiographies were not able to provide a more accurate diagnosis. By CT scans, however, 86 metatarsal and 74 tarsal fractures were detected. Moreover, we found malalignment in 31 and bony avulsions of Lisfranc's ligament in 4 patients. By MRI, finally, 85 metatarsal, 100 tarsal fractures and 31 cases of malalignment were diagnosed. Additionally, partial or complete tears of Lisfranc's ligament were depicted in 22 patients. The present study could clearly show the superiority of CT and MRI to conventional radiography in diagnosis of bony and ligamentous disorders of the Lisfranc joint. Therefore, extended diagnosis has to be demanded in all cases of hyperflexion trauma to the foot.

Autogenous bone is the gold standard graft for sinus augmentation. The harvest of autogenous bone grafts from intraoral sites does often not provide sufficient bone volume and quality. A modified technique of harvesting a tibial cancellous graft is presented. With a micro-bone saw, a bony lid is prepared at the medial condyle of the tibia. The lid stays attached to the tendinous pes anserinus. Following the harvest, the lid is repositioned accurately. This method offers some distinct advantages. A sufficient amount of biologically highly valuable cancellous bone may be harvested for sinus grafting and possibly other surgeries with bone augmentation. The procedure may be performed under local anaesthesia and does not require hospitalisation. Neither major complications nor serious postoperative morbidity were observed.

Unlabelled: The percent of maximal heart rate (%HRmax) model is widely used to determine training intensities in healthy subjects and patients when prescribing training intensities in these groups of subjects., Purpose: The aim of the study was to investigate the influence of the time course of the heart rate performance curve (HRPC) on the accuracy of target training heart rate., Methods: Sixty-two young healthy male subjects performed an incremental cycle ergometer exercise test until voluntary exhaustion. Subjects were then divided into four groups according to the time course of the HRPC. Groups were classified in regular HR response (kHR2 > 0.2), indifferent HR response (0 < kHR2 < 0.2), linear HR response (kHR2 = 0), and inverted HR response (kHR2 < 0). The first and the second lactate turn point (LTP1, LTP2) as well as the heart rate turn point (HRTP) were determined as submaximal markers of performance. Linear regression lines were calculated for HR in the three regions of energy supply defined by LTP1 and LTP2., Results: HR at LTP1 and HRmax was not significantly different between all four groups. HR at LTP2 was dependent on the time course of the HRPC and was significantly lower (P < 0.05) as kHR2 decreased. Power output and blood lactate concentration at LTP1, LTP2 and maximal workload (Pmax) were not significantly different between the groups., Conclusion: From our data, we conclude that target training HR detected by means of the %HRmax method may be overestimated in cases where the HR response is not regular, as it was found in many of our subjects.

Purpose: We propose a standardized sonographic examination technique to evaluate the muscles of the hypothenar region and describe their normal sonographic appearance., Methods: The hypothenar region was studied with sonography in 20 healthy volunteers using 5-12-MHz linear-array transducers. The assessment included dynamic testing., Results: All hypothenar muscles could be identified in all subjects and their courses followed entirely. In addition, their function could be assessed by scanning during active and passive movements., Conclusions: Knowledge of the normal sonographic anatomy of the hypothenar region is essential for evaluation of pathologic conditions., (Copyright 2001 John Wiley & Sons, Inc.)

The aim of this study was to evaluate the anatomy of the wrist joint capsule on the distal radius. As such the extent of the joint capsule and the limits of attachment in relation to the articular surface were determined. Furthermore, the study also determined whether there was any reflection of the capsule onto the distal radius. Fifty cadaveric specimens, preserved according to Thiel's method, were assessed. After careful dissection the distance between the chondral line of the carpal articular surface and three defined points on each of the palmar and dorsal aspects of the radius were measured. In none of the specimens was there any variation in the course and extent of the joint capsule. Using external fixators for managing fractures of the distal radius, pins and wires can be placed subchondrally close to the articular capsule. The risk of intraarticular infection, due to pin tract infection in intraarticularly positioned pins, is very low.

Aim of Study: It is the aim of this investigation to describe the normal ultrasonographical appearance of the glenohumeral joint in childhood., Methods: Ultrasound investigation was performed in 20 healthy children aged between 6 weeks and 19 years (median: 6 years) using 12 MHz linear probes. A dynamic examination of both shoulders was carried out. Probe positions according to standard planes were used, and attention was paid to visualise the growth regions., Results: Ultrasound images of the periarticular soft tissue in children do not differ markedly from those in adults. However, there are basic structural differences of the epiphyseal and apophyseal regions. In the newborn period the proximal humeral epiphysis mainly consists of cartilage and changes to the adult shape after the appearance of three secondary ossification centers and growth plates. Interestingly, the chondral buds of the acromion or coracoid process offer additional imaging facilities for ultrasound examination in children., Conclusions: Ultrasound examination of the glenohumeral joint in children offers a more precise evaluation when compared to adults, due to the presence of additional ultrasonographical "windows" and depiction of parts of the humeral epiphysis. This imaging technique is well tolerated by children.

Intramedullary stabilisation of long bones is an established treatment option since Küntscher. Especially for tibial nailing different methods were proposed in the past, were as the use of a fracture table was more or less the standard procedure. Since 4 years now we are nailing tibial fractures without fracture table. We are now using more and more a simple carbon fibre-frame, easily assembled by parts of the AO external fixator. So we can minimize the additional iatrogenic soft tissue damage during surgery and the logistic preoperative set-up in the operation theatre is shorter.

Objective: The goal of this study was to compare the capabilities of conventional radiography, CT, and MR imaging in revealing ligamentous and bony changes in patients after hyperflexion injuries., Subjects and Methods: Forty-nine patients with hyperflexion injuries of the foot were included in our study. Conventional radiography, weight-bearing radiography, CT, and MR imaging were performed. All images were reviewed with respect to ligamentous and bony abnormalities and alignment alterations. Eleven patients with joint malalignment underwent surgery, which is considered the gold standard in these patients. Five patients with joint malalignment refused surgery., Results: For all 49 patients, conventional radiographs revealed 33 metatarsal and 20 tarsal fractures. Eight patients presented with tarsometatarsal joint (Lisfranc's joint) malalignment. Weight-bearing radiographs showed joint malalignment in the same eight patients only. CT showed 41 tarsal fractures and 53 metatarsal fractures. Joint malalignment was evident in 16 patients. MR imaging revealed 41 metatarsal fractures and 18 metatarsal bone bruises. Tarsal bones were fractured at 39 sites and there were nine tarsal bone bruises. Metatarsal fractures were mostly localized in the second metatarsal bone; tarsal fractures, in the cuboid. Joint malalignment was evident in 16 patients; in 11 of these 16 patients, Lisfranc's ligament was disrupted. Surgery confirmed bony and ligamentous changes and joint malalignment in 11 patients., Conclusion: Conventional radiographs including weight-bearing images are not sufficient for routine diagnostic workup of patients with acute hyperflexion injuries of the foot. CT should serve as the primary imaging technique for such patients.