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Abstract Background This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury. Methods The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed. Results On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs. Conclusions After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

Abstract Background The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. Methods Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. Results Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r

Abstract Background Extensive research regarding instabilities and prevention of kyphotic malalignment in the thoracolumbar spine exists. Keystones of this treatment are posterior instrumentation and anterior vertebral height restoration. Anterior column reduction via a single-stage procedure seems to be advantageous regarding complication, blood loss, and OR-time. Mechanical elevation of the anterior cortex of the vertebra may prevent the necessity of additional anterior stabilization or vertebral body replacement. The purpose of this study was to examine (1) if increased bony reduction in the anterior vertebral cortex could be achieved by utilization of an additional reduction tool, (2) if postoperative loss of vertebral height could be reduced, and (3) if anterior column reduction is related to clinical outcome. Methods From one level I trauma center, 173 patients underwent posterior stabilization for fractures of the thoracolumbar region between 2015 and 2020. Reduction in the vertebral body was performed via intraoperative lordotic positioning or by utilization of an additional reduction tool (Nforce, Medtronic). The reduction tool was mounted onto the pedicle screws and removed after tightening of the locking screws. To assess bony reduction, the sagittal index (SI) and vertebral kyphosis angle (VKA) were measured on X-rays and CT images at different time points ((1) preoperative, (2) postoperative, (3) ≥ 3 months postoperative). Clinical outcome was assessed utilizing the Ostwestry Disability Index (ODI). Results Bisegmental stabilization of AO/OTA type A3/A4 vertebral fractures was performed in 77 patients. Thereof, reduction was performed in 44 patients (females 34%) via intraoperative positioning alone (control group), whereas 33 patients (females 33%) underwent additional reduction utilizing a mechanical reduction tool (instrumentation group). Mean age was 41 ± 13 years in the instrumentation group (IG) and 52 ± 12 years in the control group (CG) (p

Since December 2019, few issues have garnered as much global attention as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-19). The imposed lockdowns in 2020/21, which led to the closure of all gyms, barred people from participating in their favourite sports activities. This study explores athletes’ self-evaluations of their performance levels upon return to training facilities post-reopening. Data were collected in May 2021, after the end of the second lockdown, using a national online questionnaire. The study recorded 20 demographic and training-specific parameters to discern the factors influencing self-perceived performance upon resuming gym activities after the 2020/2021 lockdown. A total of 1378 respondents participated in the study. Of the total number of participants, 27.5% (365) reported regaining 100% of their original performance level after reopening their studios, a proportion that comprised 212 males, 150 females, and 3 individuals of unspecified gender. Additionally, 35.7% (474) estimated their performance level to be up to 75%, followed by 30% (398) recording their performance level at 50%, and a minority of 6.8% (90) determining their performance level to be up to 25%. Exercise intensity prior to lockdown, training experience, sex, and concurrent practice of another sport significantly influenced the athletes’ self-assessment of their current fitness levels (p > 0.001, p > 0.001, p > 0.001, and 0.006, respectively). We need to understand the factors that shape self-perception, especially in case of another lockdown, in order to provide preventive assistance concerning mental and physical well-being. Positive influences on self-perception include prior athletic experience, intensive training before the lockdown, and continued participation in sports throughout the lockdown. Younger age is also favourable, but this may not necessarily reflect the benefits of youth; rather, it could indicate the current lack of accessible online sports activities for older individuals. Women, however, might have a less favourable perception of their own athletic performance.

Background: Recreational fitness sports are popular worldwide and rank first among organised sports. This study aims to bridge a knowledge gap by examining which exercises are most prone to causing pain symptoms, as a possible precursor for injury, and analysing the body regions that are most frequently affected. Methods: Using an online questionnaire, 20 demographic and training-specific items and 49 sport-specific exercises were recorded. Frequent exercises as well as the incidence and distribution of pain symptoms that the athletes experienced during or in relation to their training were evaluated. Results: The study assessed common exercises and documented the frequency and distribution of pain symptoms experienced by athletes during or in relation to their training. A total of 1387 respondents were included in this study. Of these, 732 (53.1%) experienced pain during their fitness training, with 333 (24.2%) being female and 397 (22.3%) being male. The method of creating a training plan showed a significant influence (p < 0.001): athletes who devised their own plans reported pain or instability more frequently than those in the comparison groups. Guided exercises on machines resulted in the lowest frequency of pain (11.54%), while exercises with free weights were associated with the highest pain rate among respondents (19.94%). Specifically, exercises such as the back squat, deadlift, bench press, and triceps dips were identified as the exercises most commonly associated with pain. The most frequently reported pain region was the shoulder, followed by the lower back and knees. Conclusion: The findings reveal a significant number of unreported pain symptoms. The disparity between rigorous training volumes and the absence of professional care frequently leads to injuries and pain. It is incumbent upon sports medicine to investigate the root causes of these complaints (pain or instability) to implement preventive measures against potential injuries.

Objective: Neurological complications are the most common complications in lateral spine surgery.The aim of this study was to determine the feasibility and anatomical accuracy of a 3D reconstruction and printed model of the lumbosacral plexus with regard to lateral spine surgery. Methods: We performed 3 T-MRI scans of two fresh frozen cadavers (A&B). The scans were processed by ©axial3D (Belfast, Northern Ireland, UK) facilitating stereolithography to create a 3D printed model of the lumbosacral plexus. Subsequently both cadavers were dissected on to assess the anatomical courses of the lumbosacral plexus. Results: The 3D model of the lumbosacral plexus of cadaver A corresponded to the anatomical features of the dissection and impressively portrayed the individual nerve branches with regard to LLIF at the relevant disc levels. Due to advanced decomposition, no data could be obtained from the MRI of cadaver B that would have made 3D printing possible. However, the dissection of cadaver B revealed the configuration of nerve fibers running within the muscle tissue that are at risk during the approach. Conclusion: From a scientific point of view, the 3D rendering process used for this study resulted in a precise 3D model of the desired structures in a well-preserved cadaver. However, the production process must undergo further in-vivo validation and automation with regard to the software, in order to develop clinical value in daily use.

Abstract Background Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures. Purpose The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment. Methods Over a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively. Results Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p

Aims: Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods: From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results: Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion: Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678.

Abstract Background In fracture-related infections (FRI), both the diagnosis of the infection and the identification of the causative pathogen are crucial to optimize treatment outcomes. Sonication has been successfully used for periprosthetic joint infections (PJI); however, its role in FRI remains unknown. Our aim was to determine the diagnostic accuracy (sensitivity, specificity) of sonicate fluid culture (SFC). The primary objective was to compare SFC with peri-implant tissue culture (PTC) overall and among subgroups using the consensus definition by Metsemakers et al. The secondary objective was to determine the yield of SFC in possible fracture-related infections (PFRI). Methods From March 2017 to May 2019, 230 cases of retrieved implants were retrospectively reviewed. To perform sonication, explants were placed in sterile polypropylene jars intraoperatively. After treatment in an ultrasonic bath (Bandelin, Berlin, Germany), sonicate fluid was incubated into blood culture bottles, and conventional culturing was eventually performed. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar’s test was used to compare proportions among paired samples while Fisher’s exact test was used for comparison between categorical variables. Results Of the 230 cases, 107 were identified as FRI, whereas 123 were aseptic revision cases (ARC). Of the latter, 105 were labeled as PFRI. Sensitivity of SFC was higher in comparison with PTC, although this did not reach statistical significance (90.7% vs. 84.1%; p = .065). The specificity of SFC was significantly lower than that of PTC (73.2% vs. 88.6%; p = .003). In PFRI, SFC yielded significantly more positive results than PTC (33/105 vs. 14/105; p = .003). Overall, 142 pathogens were identified by SFC, whereas 131 pathogens were found by PTC. Conclusions We found that sonication of fracture fixation devices may be a useful adjunct in FRI, especially in “low-grade” infections lacking confirmatory clinical criteria. Standardized diagnostic protocols are warranted in order to further optimize the diagnostic accuracy.

Abstract Aim The correction accuracy of the Taylor Spatial Frame (TSF) fixator depends considerably on the precise determination of the mounting parameters (MP). Incorrect parameters result in secondary deformities that require subsequent corrections. Different techniques have been described to improve the precision of MP measurement, although exact calculation is reportedly impossible radiologically. The aim of this study was to investigate the accuracy of intraoperative and postoperative radiographic measurement methods compared to direct MP measurement from TSF bone mounting. Methods A tibial Sawbone® model was established with different origins and reference ring positions. First, reference MPs for each origin were measured directly on the frame and bone using a calibrated, digital vernier calliper. In total 150 MPs measured with three different radiographic measurement techniques were compared to the reference MPs: digital radiographic measurements were performed using soft-copy PACS images without (method A) and with (method B) calibration and calibrated image intensifier images (method C). Results MPs measured from a non-calibrated X-ray image (method A) showed the highest variance compared to the reference MPs. A greater distance between the origin and the reference ring corresponded to less accurate MP measurements with method A. However, the MPs measured from calibrated X-ray images (method B) and calibrated image intensifier images (method C) were intercomparable (p = 0.226) and showed only minor differences compared to the reference values but significant differences to method A (p

Abstract Background Even though surgical techniques and implants have evolved, periprosthetic joint infection (PJI) remains a serious complication leading to poor postoperative outcome and a high mortality. The literature is lacking in studies reporting the mortality of very elderly patients with periprosthetic joint infections, especially in cases when an intensive care unit (ICU) treatment was necessary. We therefore present the first study analyzing patients with an age 80 and higher suffering from a periprosthetic joint infection who had to be admitted to the ICU. Methods All patients aged 80 and higher who suffered from a PJI (acute and chronic) after THR or TKR and who have been admitted to the ICU have been included in this retrospective, observational, single-center study. Results A total of 57 patients met the inclusion criteria. The cohort consisted of 24 males and 33 females with a mean age of 84.49 (± 4.0) years. The mean SAPS II score was 27.05 (± 15.7), the mean CCI was 3.35 (± 2.28) and the most patient had an ASA score of 3 or higher. The PJI was located at the hip in 71.9% or at the knee in 24.6%. Two patients (3.5%) suffered from a PJI at both locations. Sixteen patients did not survive the ICU stay. Non-survivors showed significantly higher CCI (4.94 vs. 2.73; p = 0.02), higher SAPS II score (34.06 vs. 24.32; p = 0.03), significant more patients who underwent an invasive ventilation (132.7 vs. 28.1; p = 0.006) and significantly more patients who needed RRT (4.9% vs. 50%; p

Abstract Background Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections. Methods Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included. Results Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured. Conclusions Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.

Abstract Background Sonication is a valuable tool in the diagnosis of periprosthetic joint infections (PJI). However, conditions and definition criteria for PJI vary among studies. The aim of this study was to determine the diagnostic performance (i.e., specificity, sensitivity) of sonicate fluid culture (SFC) against periprosthetic tissue culture (PTC), when using European Bone and Joint Infection Society (EBJIS) criteria. Methods From March 2017 to April 2018, 257 implants were submitted for sonication. PJI was defined according to the EBJIS criteria as well as according to the International Consensus Meeting criteria of 2018 (ICM 2018). Only cases with at least one corresponding tissue sample were included. Samples were cultured using traditional microbiological plating techniques. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar’s test was used to compare proportions among paired samples. Subgroup analysis was performed dividing the cohort according to the site of PJI, previous antibiotic treatment, and time of manifestation. Prevalence of pathogens was determined for all patients as well as for specific subgroups. Results Among the 257 cases, 145 and 112 were defined as PJI and aseptic failure, respectively. When using the EBJIS criteria, the sensitivity of SFC and PTC was 69.0 and 62.8%, respectively (p = .04). Meanwhile, the specificity was 90.2 and 92.9%, respectively (p = .65). When adopting ICM 2018 criteria, the sensitivity of SFC and PTC was 87.5 and 84.4% (p = .63) respectively, while the specificity was 85.1 and 92.5% (p = .05), respectively. The most commonly identified pathogens were coagulase-negative staphylococci (26% overall), while 31% of PJI were culture-negative and 9% polymicrobial. Conclusions SFC exhibited significantly greater sensitivity versus PTC when using the EBJIS criteria. Nevertheless, the diagnosis of PJI remains a difficult challenge and different diagnostic tools are necessary to optimize the outcome.

Abstract Background Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility. Methods We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients’ demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon’s experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher’s exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS. Results Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872–6.079), stovepipe femur (OR 1.749, 95% CI .823–3.713), junior surgeon (OR 1.204, 95% CI .596–2.432), and on-call-duty surgery (OR 1.471, 95% CI .711–3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41). Conclusions IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Background: The exoskeleton HAL (hybrid assistive limb) has proven to improve walking functions in spinal cord injury and chronic stroke patients when using it for body-weight supported treadmill training (BWSTT). Compared with other robotic devices, it offers the possibility to initiate movements actively. Previous studies on stroke patients did not compare HAL-BWSTT with conventional physiotherapy (CPT). Therefore, we performed a crossover clinical trial comparing CPT and HAL-BWSTT in chronic stroke patients with hemiparesis, the HALESTRO study. Our hypothesis was that HAL-training would have greater effects on walking and posture functions compared to a mixed-approach CPT.Methods: A total of 18 chronic stroke patients participated in this study. Treatment consisted of 30 CPT sessions and of 30 sessions of BWSTT with a double leg type HAL exoskeleton successively in a randomized, crossover study design. Primary outcome parameters were walking time and speed in 10-meter walk test (10MWT), time in timed-up-and-go test (TUG) and distance in 6-min walk test (6MWT). Secondary outcome parameters were the functional ambulatory categories (FAC) and the Berg-Balance Scale (BBS). Data were assessed at baseline, at crossover and at the end of the study, all without using and wearing HAL.Results: Our study demonstrate neither a significant difference in walking parameters nor in functional and balance parameters. When HAL-BWSTT was applied to naïve patients, it led to an improvement in walking parameters and in balance abilities. Pooling all data, we could show a significant effect in 10MWT, 6MWT, FAC and BBS, both therapies sequentially applied over 12 weeks. Thereby, FAC improve from dependent to independent category (3 to 4). One patient dropped out of the study due to intensive fatigue after each training session.Conclusion: HAL-BWSTT and mixed-approach CPT were effective therapies in chronic stroke patients. However, compared with CPT, HAL training with 30 sessions over 6 weeks was not more effective. The combination of both therapies led to an improvement of walking and balance functions. Robotic rehabilitation of walking disorders alone still lacks the proof of superiority in chronic stroke. Robotic treatment therapies and classical CPT rehabilitation concepts should be applied in an individualized therapy program.

Background: CrossFit is one of the fastest growing “high-intensity functional training” methods in recent years. Due to the very demanding motion sequences and high loads, it was initially assumed that there was an extremely high risk of injury. However, studies have shown that injury rates are given between 0.74–3.3 per 1000 h of training, which is not higher than in other individual sports such as weightlifting. The purpose of the study was to estimate the type of pain symptoms that are directly related to CrossFit, to estimate the frequency of injuries that occur within a population of recreational CrossFit athletes, and, finally, to identify the factors influencing the frequency of pain during CrossFit training. Methods: A total of 414 active CrossFit athletes completed an online survey inclusive of 29 items focusing on individual physical characteristics and training behavior, as well as simultaneous or previously practiced sports. Results: There was a significantly higher proportion of knee pain in athletes who had previously or simultaneously played another sport (p = 0.014). The duration, intensity, or type of personal training plan developed, along with personal information such as age, gender, or BMI, had no significant influence on the pain data. We could not find any significant variance between the groups that we formed based on the differently stated one-repetition max (RMs). There were differences in athletes who stated that they did specific accessory exercises for small muscle groups. Above all, athletes performing exercises for the hamstrings and the gluteus medius indicated fewer pain symptoms for the sacro-iliac joint (SIJ)/iliac and lower back locations. Conclusions: It is important not to see CrossFit as a single type of sport. When treating a CrossFit athlete, care should be taken to address inter-individual differences. This underlines the significant differences of this study between the individual athletes with regard to the ability to master certain skills or their previous sporting experience. The mere fact of mastering certain exercises seems to lead to significantly more pain in certain regions. In addition, there seems to be a connection between the previous or simultaneous participation in other sports and the indication of pain in the knee region.

Purpose of the study was to retrospectively analyze the complication rates after operatively treated femoral shaft fractures in childhood and adolescence. Retrospective evaluation of 42 children with operatively treated femoral shaft fractures between 2000 and 2014. Fractures were classified as 27 A type, 12 B type and 3 C type fractures according the OTA/AO classification. 8 (19.05%) fractures were open. Age averaged 10.2 years (3-16). Fracture treatment was recorded as temporary or definitive external fixation, ESIN, plate fixation or IMN. Complications such as wound infection, re-fractures, nonunion and malunion were analyzed. Six (14.29%) fractures were temporarily stabilized using an external fixator. In 22 (52.38%) children the femoral shaft fracture was stabilized using ESINs. 10 (23.81%) children had a plate fixation and 9 (21.43%) adolescents were treated using an IMN. ESIN treated children were significantly younger (P=0.000) and had less weight (P=0.000) than children treated with both other methods. Complications were two (4.76%) superficial and two deep (4.76%) wound infections, one (2.38%) re-fracture with the ESIN in situ, one (2.38%) nonunion and one (2.38%) malunion. Six (14.29%) children required a reoperation for a complication. Risk factors for complications were temporarily applied external fixators, open fractures, C Type fractures (P=0.031) and an increasing age (P=0.048) and weight (P=0.047) of the child. The majority of children in our study population were successfully treated using ESIN presenting a low complication rate. Complications were observed following open fractures and more complex fracture types. Furthermore we observed an increasing complication rate with increasing ages and weights of the children.

We report the case of a 13-year-old boy, who suffered a posterior hip dislocation from playing soccer. Closed reduction was performed urgently. Because of a nonconcentric hip after closed reduction, further imaging was done. An intra-articular bony fragment was identified. Arthroscopic treatment was performed. Through an anterior portal we were able to locate the intra-articular bony fragment, which was located within the region of the fovea. After lifting of the caudal enfolded labral complex, we were able to remove the fragment. Evidence of a grade 3 cartilage defect was present at the femoral head. We were able to reduce the enfolded posterior labral complex, which was stable afterwards without the necessity of additional suture fixations. The concentric hip reduction was confirmed on an anteroposterior view of the hip postoperatively. The patient was instructed to toe tip weight-bearing for 6 weeks with limited range of motion to 60° of hip flexion. Eight weeks after surgery, he was free of pain and discomforts. From our experience, the arthroscopic intervention after pediatric hip dislocation associated with intra-articular bony fragments or posterior labral complex injuries, represents to be a preferred minimally invasive method in contrast to open surgical procedures.

Scapula neck fractures are rare injuries, leaving several treatment options. Standardized markers for operative treatment are a decreased glenopolar angle ≤22°, lateral border offset (LBO) of the glenoid ≥20 mm, angular deformity ≥45°, or LBO ≥15 mm plus angular deformity ≥35°.If operative treatment is not performed before union, the fracture heals malaligned with possible mechanical complications due to a medialized glenoid and the protruding lateral border. Common operative treatment comprises a corrective osteotomy for the anatomic correction of the malunited fracture, leaving intra-articular pathologies like adhesive capsular stiffness unaddressed.Our presented arthroscopic technique for the treatment of sequelae of scapula neck fractures combines a 270° capsulotomy with arthroscopic resection of a protruding lateral border. With use of this technique, excellent shoulder function can be restored with a minimally invasive procedure. Therefore, arthroscopic treatment could be favorable in selected cases of malunited scapula neck fractures.

Purpose: Exoskeletons have been developed for rehabilitation of patients with walking impairment due to neurological disorders. Recent studies have shown that the voluntary-driven exoskeleton HAL® (hybrid assistive limb) can improve walking functions in spinal cord injury and stroke. The aim of this study was to assess safety and effects on walking function of HAL® supported treadmill therapy in patients with limb-girdle muscular dystrophy (LGMD).Materials and Methods: Three LGMD patients received 8 weeks of treadmill training with HAL® 3 times a week. Outcome parameters were 10-meter walk test (10 MWT), 6-minute walk test, and timed-up-and-go test (TUG). Parameters were assessed pre and post training and 6 weeks later (follow-up).Results: All patients completed the therapy without adverse reactions and reported about improvement in endurance. Improvements in outcome parameters after 8 weeks could be demonstrated. Persisting effects were observed after 6 weeks for the 10 MWT and TUG test (follow-up).Conclusions: HAL® treadmill training in LGMD patients can be performed safely and enables an intensive highly repetitive locomotor training. All patients benefitted from this innovative method. Upcoming controlled studies with larger cohorts should prove its effects in different types of LGMD and other myopathies.

Background: Silver nanoparticles (Ag-NP) are one of the fastest growing products in nano-medicine due to their enhanced antibacterial activity at the nanoscale level. In biomedicine, hundreds of products have been coated with Ag-NP. For example, various medical devices include silver, such as surgical instruments, bone implants and wound dressings. After the degradation of these materials, or depending on the coating technique, silver in nanoparticle or ion form can be released and may come into close contact with tissues and cells. Despite incorporation of Ag-NP as an antibacterial agent in different products, the toxicological and biological effects of silver in the human body after long-term and low-concentration exposure are not well understood. In the current study, we investigated the effects of both ionic and nanoparticulate silver on the differentiation of human mesenchymal stem cells (hMSCs) into adipogenic, osteogenic and chondrogenic lineages and on the secretion of the respective differentiation markers adiponectin, osteocalcin and aggrecan.Results: As shown through laser scanning microscopy, Ag-NP with a size of 80 nm (hydrodynamic diameter) were taken up into hMSCs as nanoparticulate material. After 24 h of incubation, these Ag-NP were mainly found in the endo-lysosomal cell compartment as agglomerated material. Cytotoxicity was observed for differentiated or undifferentiated hMSCs treated with high silver concentrations (≥20 µg·mL−1 Ag-NP; ≥1.5 µg·mL−1 Ag+ ions) but not with low-concentration treatments (≤10 µg·mL−1 Ag-NP; ≤1.0 µg·mL−1 Ag+ ions). Subtoxic concentrations of Ag-NP and Ag+ ions impaired the adipogenic and osteogenic differentiation of hMSCs in a concentration-dependent manner, whereas chondrogenic differentiation was unaffected after 21 d of incubation. In contrast to aggrecan, the inhibitory effect of adipogenic and osteogenic differentiation was confirmed by a decrease in the secretion of specific biomarkers, including adiponectin (adipocytes) and osteocalcin (osteoblasts).Conclusion: Aside from the well-studied antibacterial effect of silver, little is known about the influence of nano-silver on cell differentiation processes. Our results demonstrate that ionic or nanoparticulate silver attenuates the adipogenic and osteogenic differentiation of hMSCs even at non-toxic concentrations. Therefore, more studies are needed to investigate the effects of silver species on cells at low concentrations during long-term treatment.

Cell-compatible and antibacterial surfaces are needed for implants, which frequently have complex and rough surfaces. Bio-inspired columnar nanostructures can be grown on flat substrates; however, the application of these nanostructures on clinically relevant, complex, and rough surfaces was pending. Therefore, a titanium plasma spray (TPS) implant surface was coated with titanium nano-spikes via glancing angle magnetron sputter deposition (GLAD) at room temperature. Using GLAD, it was possible to cover the three-dimensional, highly structured macroscopic surface (including cavities, niches, clefts, and curved areas) of the TPS homogeneously with nano-spikes (TPS+), creating a cell-compatible and antibacterial surface. The adherence and spreading of mesenchymal stem cells (MSC) were similar for TPS and TPS+ surfaces. However, MSC adherent to TPS+ expressed less and shorter pseudopodia. The induced osteogenic response of MSC was significantly increased in cells cultivated on TPS+ compared with TPS. In addition, Gram-negative bacteria (E. coli) adherent to the nano-spikes were partly destructed by a physico-mechanical mechanism; however, Gram-positive bacteria (S. aureus) were not significantly damaged.

Abstract In case of patients with spinal cord injury and concomitant acromioclavicular (AC) jointdislocation the treatment is challenging, as in this special patient group the function of the shoulder joint is critical because patients depend on the upper limb for mobilization and wheelchair-locomotion. Therefore the goal of this study was to examine, if the treatment of chronic AC-joint dislocation using the Weaver- Dunn procedure augmented with a hook-plate in patients with a spinal cord injury makes early postoperative wheelchair mobilization and the wheelchair transfer with full weightbearing possible. In this case the Weaver- Dunn procedure with an additive hook-plate was performed in a 34-year-old male patient with a complete paraplegia and a posttraumatic chronic AC-joint dislocation. The patient was allowed to perform his wheelchair transfers with full weight bearing on the first postoperative day. The removal of the hook-plate was performed four months after implantation. At the time of follow-up the patient could use his operated shoulder with full range of motion without restrictions in his activities of daily living or his wheel-chair transfers.

Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient’s history revealed intra-venous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.

A traumatic infra-renal aortic dissection is a rare but life-threatening injury that follows deceleration injuries. The mechanism of blunt abdominal aortic injury involves both direct and indirect forces. The successful management of patients with traumatic injuries depends on a prompt suspicion of the injury and early diagnosis and therapy. Missed injuries in trauma patients are well-described phenomena and implementation of the ATLS® trauma schedule led to a decrease in the number of missed injuries, but trauma computed tomography (CT) scans in injured patients are still not standard. We report on a 54-year old Caucasian female patient who was involved in a car accident. The fellow passenger of the car was seriously injured. The patient had been previously treated at two different hospitals, and a dislocated acetabular fracture had been diagnosed. Because of this injury, the patient was transferred to our institution, a level 1 trauma-center where, according to the nature of the accident as a high-energy trauma, a complete polytrauma management was performed at the time of admission. During the body check, a moderate tension of the lower parts of the abdomen was detected. During the CT scan, an aneurysm of the infra-renal aorta with a dissection from the height of the second lumbar vertebral body to the iliac artery was observed. The patient required an operation on the day of admission. After 19 days post-trauma care the patient was able to leave our hospital in good general condition. Therefore, missed injuries in multiple injury patients could be fatal, and it is essential that the orthopedic surgeon leaves room for suspicion of injuries based on the nature of the trauma. Traumatic injuries of the abdominal aorta are rare. According to the ATLS® trauma schedule, all of the patients who have experienced high-energy trauma and associated fractures should undergo routine screening using a trauma CT scan with contrast agents to detect potential life-threatening injuries. In case of abdominal trauma, an aortic dissection, which can easily be overlooked, has to be considered.

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intra-articular calcaneal fractures. Fourteen intra-articular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Boehler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group.

The posttraumatic proximal cross-union of the forearm in childhood is a rare complication after radial head, neck or proximal forearm fractures and elbow dislocations. There is no standardized treatment. Several surgical procedures with or without interposition techniques are described in the literature. The aim of this study was to analyze all children with cross-unions who underwent surgery over the last 15 years. From 1998 to 2013, 8 children with a posttraumatic proximal cross-union of the forearm (Type 3 according to Vince and Miller) received surgical treatment with resection of the cross-union or radial head. Mean age at the time of initial trauma was 9.0±2.56 years (range 6-14 years), age at the time of surgery was 11.9±3.09 years (range 7-16 years). Mean time of resection of the cross-union was 23.2 months. Follow-up time was 10.6 months (range 1-36 months). Five patients had a resection of the cross-union without any interposition techniques, in 2 cases with an additional arthrolysis of the elbow. One patient had an interposition of a local fascia flap. In 2 cases, a primary excision of the radial head, six and seven years, respectively, after trauma, was performed. All patients, except one, had non-steroidal anti-inflammatory drugs therapy after surgery. A post-operative irradiation was performed in 3 cases. The mean postoperative range of motion for pronation/supination was 36/0/53°. Controversy remains about the best procedure to adopt for posttraumatic cross-union in childhood. After analysis of our data and the literature, we recommend the resection of the cross-union within 6-24 months of occurrence without necessarily using any interposition techniques. All patients reported an improvement with regard to ordinary activities. In cases of long-term cross-union for several years with ankylosis of the elbow and bony deformities of the proximal radius, an excision of the radial head as salvage procedure is recommended.