Personalized Management in Orthopedics and Traumatology

Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer. Full article

Background: Acute compartment syndrome is a major surgical emergency with complex pathophysiology and a highly unpredictable pattern of evolution. We hypothesized that the onset of acute compartment syndrome of the leg or forearm is associated with variations in the surface temperature of the distal segment (foot or hand) with a distinct pattern, which acts as an early warning sign. Materials and Methods: We developed a monitoring device that consists of two thermic sensors attached to a modular limb splint, which continuously measure the temperature difference between the proximal and distal regions of the limb (i.e., arm–hand, thigh–foot). Firstly, we investigated both the arm–hand and thigh–foot temperature gradients of hospitalized patients’ healthy limbs (43 patients, 56 upper limbs, 64 lower limbs) in order to establish a baseline. Secondly, we examined the correlation between the thermic gradients and intracompartmental pressure values in compartment syndrome limbs (20 patients, 6 upper limbs, 14 lower limbs). Results: For the control group, the mean values for the normal limb thermic gradients were −0.17 °C for the upper limbs. and 0.03 °C for the lower limbs. In the impending compartment syndrome group (defined by intracompartmental pressure values), the mean index was −0.38 °C. In the fully developed compartment syndrome group, the mean value was 4.11 °C. Discussions: Analysis was performed using the ANOVA one-way statistical method. This showed significant differences between the compartment syndrome group and the impending and control groups. A decreasing trend in the thermic gradient in patients with impending compartment syndrome compared with the control group was noted. Conclusions: The thermic gradient of limbs presenting signs of impending compartment syndrome decreases as a result of the increased temperature of the distal segment. This pattern can be used as an early diagnostic method for acute compartment syndrome. This technique is non-invasive and bears no risk to the patient, allowing facile continuous monitoring during immobilization. Full article

The aim of this study was to compare the radiological and functional outcomes of the extended lateral and sinus tarsi approaches for managing displaced intraarticular calcaneal fractures. This retrospective study involved 44 patients with displaced intra-articular calcaneal fractures. The patients were treated with either the extended lateral or sinus tarsi approach and followed up for at least a year. The radiological and clinical outcomes were compared between the approaches. The waiting time for surgery was shorter and the complication rate was lower in the sinus tarsi approach group than in the other group. There were no significant differences in the American Orthopedic Foot and Ankle Society ankle–hindfoot score, Foot Function Index, or visual analog scale score between the groups. In both groups, the radiological outcomes (Böhler angle, calcaneal width, and calcaneal height) were better postoperatively than preoperatively. The sinus tarsi approach is a safe and effective alternative to the extended lateral approach for managing displaced intraarticular calcaneal fractures. It is associated with a lower complication rate and a shorter waiting time for surgery than the extended lateral approach, with similar functional and radiological outcomes. Full article

Late-discovered developmental hip dysplasia deformities often necessitate complex surgical treatments and meticulous preoperative planning. The selection of osteotomies is contingent upon the patient’s age and the specific structural deformity of the hip. In our anatomical hip model, derived from the data of a 12-year-old patient, we performed virtual osteotomies that are commonly recommended for such cases. We precisely constructed geometric models for various osteotomies, including the Dega, Pemberton, Tönnis, Ganz, Chiari pelvic, and Pauwels femoral osteotomies. We employed Autodesk Inventor for the finite element analysis of the hip joint and the corrective osteotomies. In comparing one-stage osteotomies, we noted that the Dega and Ganz pelvic osteotomies, especially when combined with the Pauwels femoral osteotomy, yielded the most favorable outcomes. These combinations led to enhanced femoral head coverage and reduced intra-articular pressure. Furthermore, we calculated the femoral head-to-acetabulum volume ratio for both the Dega and Pauwels osteotomies. The encouraging results we obtained advocate for the integration of finite element analysis in virtual osteotomies of the pelvis and femur as a preoperative tool in the management of developmental hip dysplasia. Full article

Purpose: We aim to compare radiation exposure and implant-related complications of the freehand (FH) technique versus intraoperative image-guided navigation (IN) for pedicle screw placement in adolescent idiopathic scoliosis (AIS) and estimate associated lifetime attributable cancer risks. Methods: A retrospective analysis of prospectively collected data from 40 consecutive AIS patients treated with pedicle screw instrumentation using the FH technique was performed. The dose area product (DAP) and effective dose (ED) were calculated. Screw-related complications were analysed, and the age- and gender-specific lifetime attributable cancer risks were estimated. The results were compared to previously published data on IN used during surgery for AIS. Results: There were no implant-related complications in our cohort. Implant density was 86.6%. The mean Cobb angle of the main curve was 75.2° (SD ± 17.7) preoperatively and 27.7° (SD ± 10.8) postoperatively. The mean ED of our cohort and published data for the FH technique was significantly lower compared to published data on the IN technique (p < 0.001). The risk for radiogenic cancer for our FH technique AIS cohort was 0.0014% for male patients and 0.0029% for female patients. Corresponding risks for IN were significantly higher (p < 0.001), ranging from 0.0071 to 0.124% and from 0.0144 to 0.253% for male and female patients, respectively. Conclusion: The routine use of intraoperative navigation in AIS surgery does not necessarily reduce implant-related complications but may increase radiation exposure to the patient. Full article

Background: The elements of previously designed questionnaires do not take into consideration the burdens encountered in an inpatient hospital setting. The purpose of this study is to validate elements of a non-compliance survey in an in-hospital setting and discuss aspects of compliance with telerehabilitative physiotherapy in the early postoperative period. Methods: A literature search was conducted to identify elements that prevent patients from performing their prescribed physical therapy exercises. These items were then evaluated by the expert review technique as described by Ikart. Afterwards, the synthesized survey was handed out to patients for the assessment of the quality of its items. Results: The results of the expert review technique identified some conceptual and grammatical problems. This led to the adjustment of some of the elements. The quality of the resulting questionnaire was deemed to be good, as patients were able to fully understand the concepts and answer accordingly. A statistical analysis was conducted to evaluate the responses. Conclusions: The items of this second questionnaire have proven to be reliable to assess the compliance of patients in an in-hospital setting. These items will be added to the cross-culturally adapted items of a previous questionnaire. Full article

Inertial measurement units (IMUs) are increasingly being used to assess knee function. The aim of the study was to record patients’ activity levels and to detect new parameters for knee function in the early postoperative phase after TKA. Twenty patients (n = 20) were prospectively enrolled. Two sensors were attached to the affected leg. The data were recorded from the first day after TKA until discharge. Algorithms were developed for detecting steps, range of motion, horizontal, sitting and standing postures, as well as physical therapy. The mean number of steps increased from day 1 to discharge from 117.4 (SD ± 110.5) to 858.7 (SD ± 320.1), respectively. Patients’ percentage of immobilization during daytime (6 a.m. to 8 p.m.) was 91.2% on day one and still 69.9% on the last day. Patients received daily continuous passive motion therapy (CPM) for a mean of 36.4 min (SD ± 8.2). The mean angular velocity at day 1 was 12.2 degrees per second (SD ± 4.4) and increased to 28.7 (SD ± 16.4) at discharge. This study shows that IMUs monitor patients’ activity postoperatively well, and a wide range of interindividual motion patterns was observed. These sensors may allow the adjustment of physical exercise programs according to the patient’s individual needs. Full article

Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia (SMD −2.03; 95% CI −2.88–−1.17). However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption (SMD −0.76; 95% CI −1.25–−0.26) and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group (SMD 0.83; 95% CI 0.47–1.20). The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain. Full article

Although numerous radiologic parameters of abnormal hip joint morphology are utilized in practice, studies on the relation of these parameters to acetabular fractures are limited. This study hypothesized that certain morphological features of hip joints are associated with acetabular posterior wall (PW) fracture patterns and aimed to identify morphological characteristics predictive of acetabular PW fracture. The records of 107 consecutive patients, who were diagnosed with acetabular fractures in a level I trauma center from August 2017 to April 2021, were initially reviewed. After excluding patients who lacked proper radiographic evaluation and had previous surgery or concomitant injury on the ipsilateral lower limb, a total of 99 patients were analyzed to investigate the morphological characteristics of the hip joint, measured in computed tomography, associated with acetabular posterior wall fracture. We included patient demographics, acetabular index (AI), sharp angle, acetabular depth-to-width ratio (AD/WR), center-edge angle (CEA), head–neck offset ratio (HNOR), acetabular head index (AHI), anterior acetabular sector angle (AASA), posterior acetabular sector angle (PASA), and acetabular version angle (AVA) in the univariate and multivariate analyses. The injury mechanism (p = 0.001) and AD/WR (p = 0.021) were predictors of PW fracture in the univariate analysis. In the multivariable analysis, injury mechanism (p = 0.011), AI (coefficient B = 0.320; Exp (B) = 1.377; p = 0.017), and AD/WR (coefficient B = 33.047; Exp (B) = 2.250 × 10¹⁴; p = 0.028) were significant predictors of PW fracture. This study highlights the importance of morphological factors, such as a larger AI and AD/WR, that may influence joint stress distribution, resulting in acetabular PW fracture. Understanding these pathomechanisms may protect the hip joint and prevent future injuries through the early identification and treatment of pathological conditions. Full article

It is essential to investigate patients post-surgery using functional surveys like the American Shoulder and Elbow Surgeons Shoulder (ASES) and the Constant–Murley shoulder (CMS) scores, as well as clinical tests, such as the Internal Rotation and Shift (IRO/Shift) and Jobe tests. In this study, 51 out of an initial 87 patients underwent an arthroscopic supraspinatus repair (22 single-row, 16 double-row, 13 debridement). Testing occurred pre-surgery, and 3 and 6 months post-surgery. Both surveys showed significant improvements over time among all 87 patients, but there were no differences between groups (lesion/no lesion) (p > 0.815) or time × group (p > 0.895). The IRO/Shift test showed a stronger ability to distinguish between both groups (positive vs. negative) with respect to the ASES and CMS scores over time, but the Jobe test did not (p > 0.100). Improvements in the CMS scores and the Jobe test were lower following repair compared to the ASES and IRO/Shift test. Most patients returned to adequate levels of functional abilities at 6 months post-surgery. The time required to return to activities of daily living and negative clinical tests was longer for the double-row repair patients compared to the single-row and debridement groups. In conclusion, both the functional surveys and the clinical tests demonstrated improvements following surgery. Full article

Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems. Full article

Background: Hip fractures in geriatric patients often have a poor outcome in terms of mortality, mobility as well as independence. Different surgical influence factors are known that improve the outcome. Methods: In this observational cohort study, 281 patients of a geriatric trauma unit were analyzed prospectively. Demographic factors, as well as data regarding the trauma mechanism and perioperative treatment, were recorded. The nutritional status was also analyzed. The follow-up was set to 120 days. Results: The key conclusion of this study is that a high ASA classification, the use of anticoagulatory medicine and malnutrition are significantly associated with higher mortality together with worse independence (p < 0.05). There is no significant difference in outcome concerning the time to surgery within the first 24 h. Conclusions: Malnutrition seems to be an important risk factor for an adverse outcome of geriatric patients and therefore warrants a focus in multidisciplinary treatment. The risk factor ASA cannot be improved during the pre-surgery phase, but requires intensified care by a multidisciplinary team specialized in orthogeriatrics. Full article

Background: Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs. Methods: A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging. Results: Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (−11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures. Conclusion: The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up. Full article

Background: Despite high rates of successful outcomes after open and arthroscopic distal clavicle excision (DCE) for symptomatic acromioclavicular joint (ACJ) degeneration, some patients present with persistent symptoms and disabilities after surgical intervention. This study aims to compare radiological, functional, and subjective outcomes of open revision surgery after failed arthroscopic DCE to primary successful arthroscopic DCE. Methods: In this retrospective case-control study, 10 patients who underwent open DCE revision were age- and gender-matched with 10 patients who did not require revision surgery after DCE. Radiographic evaluation included presence of acromioclavicular spurs and acromioclavicular joint distance. Functional and subjective outcomes were assessed using the CS, SSV, SST, VAS for pain, patient’s satisfaction, ASES and quick DASH score. Results: At the latest postoperative follow-up (case: 57.3 ± 19.2 months; control: 63.5 ± 16.3 months), spur formation was detected in twice as many cases in the revision group, while acromioclavicular distance showed no significant difference. However, a significant bony regrowth was noticed in the revision group between revision surgery and latest follow-up, with a decrease of the acromioclavicular distance from 9.2 ± 1.6 mm to 5.9 ± 4.6 mm (p = 0.026) and a development of new spur formations in 30% of cases. There were no significant differences in overall CS between the revision and control group (p = 0.174) at final follow-up, but the control group scored significantly higher in the CS subgroups pain (p = 0.012) and internal rotation (p = 0.016). Mean SSV was significantly lower in the revision (65.5 ± 22.3%) compared to the control group (85.9 ± 16.4%; p = 0.031). Conclusions: Bony regrowth at the distal clavicle presenting as postoperative AC-distance narrowing and new spur formation was observed more distinctly in the revision group. Despite a slight increase in postoperative outcomes after revision surgery, subjective satisfaction and recalcitrant pain remain a concern. Level of Evidence: Therapeutic Level III, retrospective case-control study Full article

The COVID-19 pandemic drastically changed many aspects of the traditional functioning of health systems all around the world. In Italy, as reported by the CIO, compared to the previous year, there was a significant reduction in 2020 in overall outpatient activities by up to 75%. These data support the need for telemedicine, which represents a current challenge and can no longer be postponed in the future. This study aims to elaborate on a possible model for remote shoulder examination based on traditional tests to improve the quality of telemedicine in orthopedic and rehabilitation. Between May 2020 and November 2020, ten orthopedic surgeons individually examined six patients with a known shoulder disorder, both in hospital and via webcam according to the previously shared protocol (B-STEP). According to the 10 observers, completing 100% of the ASES score and at least 87.5% of the Constant score is possible. Shoulder ROM and many specific tests are also reproducible via webcam, but with less sensitivity, according to the subjective opinion of observers. The B-STEP is a useful protocol for the standardization of the objective examination of the shoulder via webcam. Further studies are necessary to determine if the B-STEP protocol is useful for diagnosing pathology in unknown patients and evaluating its sensitivity and specificity for each pathology. Full article

We report our experience of preoperative plate contouring for periarticular fractures using three-dimensional printing (3DP) technology and describe its benefits. We enrolled 34 patients, including 11 with humerus midshaft fractures, 12 with tibia plateau fractures, 2 with pilon fractures, and 9 with acetabulum fractures. The entire process of plate contouring over the 3DP model was videotaped and retrospectively analyzed. The total time and number of trials for the intraoperative positioning of precontoured plates and any further intraoperative contouring events were prospectively recorded. The mismatch between the planned and postoperative plate positions was evaluated. The average plate contouring time was 9.2 min for humerus shaft, 13.8 min for tibia plateau fractures, 8.8 min for pilon fractures, and 11.6 min for acetabular fractures. Most precontoured plates (88%, 30/34) could sit on the planned position without mismatch. In addition, only one patient with humerus shaft fracture required additional intraoperative contouring. Preoperative patient specific periarticular plate contouring using a 3DP model is a simple and efficient method that may alleviate the surgical challenges involved in plate contouring and positioning. Full article

Due to the high heterogeneity in outcome measures after total hip arthroplasty (THA), the prospective observational study investigated the relationships between symmetry-based (SBMs), performance-based (PBMs), and functional outcome measures in THA patients to determine necessary or redundant categories of tests. The study material consisted of 24 patients with end-stage hip osteoarthritis scheduled for THA. The patients were examined one day before surgery and consecutively on the 4th day, 9th day, and 10th week postoperatively using the SBMs (weight-bearing chair-rising test, measurements of the maximal isometric torque of the quadriceps muscle); the PBMs (10-m walk, timed up-and-go, and stair-climbing tests); and the functional outcome measure (Harris Hip Score). The results obtained in a given category of tests at different time points were compared, and the correlations between the tests were determined. The reliability of the outcome measures was determined. The results of tests in the studied categories statistically significantly (p < 0.05) improved at the 10th week postoperatively compared to preoperative results. No strong correlations were revealed between the three studied types of outcome measures in THA patients. Therefore, none of them can be considered redundant. It also means that the relevance of symmetry for a core measurement set to describe the domain function in THA patients must be further clarified. Full article

Septic arthritis of the shoulder is an urgent medical emergency that often occurs in elderly patients and is associated with high morbidity and mortality. Retrospectively, 56 patients aged ≥60 years, treated for primary septic monoarthritis of the shoulder at a maximum care hospital between 1 July 2001, and 30 July 2022, were included in this study. The primary aim of the study was analyzing survival rates and different bacteria in these patients. For statistical analysis, Kaplan–Meier curves were used for survival probability and the log-rank test was used to compare a survival probability of 5 years. The mean patient age was 78.7 years and a mean follow-up time of 3011.8 days. The mean survival of the entire study population was 920.3 days or 2.5 years. Significantly impaired 5-year survival was found only with increasing age and higher American Society of Anesthesiologists (ASA) physical status (PS) classification scores. Eight different types of bacteria were detected in the synovial fluid cultures. A total of 42 of 48 overall pathogens was Gram-positive and 6 were Gram-negative bacteria. Staphylococcus aureus was identified as the most frequent variant. We conclude that the mean survival is significantly shortened within the first 5 years with increasing age and ASA PS classification. Full article

Purpose: Both dynamic intraligamentary stabilization (DIS) and reconstruction (RECO) are common treatment methods for anterior cruciate ligament (ACL) rupture. We report short term outcomes after DIS (Ligamys, Mathys, Bettlach, Switzerland) and RECO using semitendinosus tendon. We compared postoperative complications, deficits of range-of-motion (ROM), and revision rates between the two treatment options. Methods: A total of 690 patients (437 male, 253 female), after either DIS or RECO, were included. Of these, 147 patients (21%) received DIS and 543 (79%) underwent RECO. Follow-up examination focused on clinical examination, complications and revision rates. Anteroposterior instability and ROM deficits were analyzed in order to evaluate our policy of early intervention for all cases of ROM restrictions. Results: Relevant ROM restrictions occurred at a significantly higher rate after DIS than after RECO (4.8% vs. 1.3%; p = 0.008). Flexion was more restricted after DIS than RECO (110° vs. 124°, p < 0.001). Extension deficits also occurred more frequently after DIS compared to RECO (49.7% vs. 24.5%; p < 0.001). Total revision surgery rate was 9.1%, with patients after DIS being significantly more frequently affected (20.4% vs. 6.1%; p < 0.001). Conclusions: Our findings indicate a significantly higher risk for ROM restriction after DIS compared to RECO, resulting in a significantly higher revision rate. Full article

(1) Background: The aim of this study was to investigate and compare the effect of sensorimotor training on transversus abdominis activation. (2) Methods: Seventy-five patients with chronic low back pain were randomly assigned to one of three groups (whole body vibration training using Galileo^®, coordination training using Posturomed^®, or physiotherapy (control)). Transversus abdominis activation was measured by using sonography pre- and post-intervention. Second, changes in clinical function tests and their correlation with the sonographic measurements were determined. (3) Results: All three groups showed an improvement in activation of the transversus abdominis post-intervention, with the Galileo^® demonstrating the largest improvement. There were no relevant (r > 0.5) correlations between activation of the transversus abdominis muscle and any clinical tests. (4) Conclusions: The present study provides evidence that sensorimotor training on the Galileo^® significantly improves the activation of the transversus abdominis muscle. Full article

Introduction: The functional outcome after reverse shoulder arthroplasty (RSA) is closely linked to how much the humerus shifts because of the implants. While two-dimensional (2D) angle measurements have been used to capture this shift, it can be measured in three dimensions (3D) as the arm change position (ACP). In a previous study, the ACP was measured using 3D preoperative planning software with the passive virtual shoulder range of motion obtained after RSA. The main objective of this study was to evaluate the relationship between the ACP and the actual active shoulder range of motion measured after RSA. The hypothesis was that the ACP and the active clinical range of motion are related such that the ACP is a reliable parameter to guide the preoperative planning of an RSA. The secondary objective was to assess the relationship between 2D and 3D humeral displacement measurements. Materials and methods: This prospective observational study enrolled 12 patients who underwent RSA and had a minimum follow-up of 2 years. The active range of motion in shoulder flexion, abduction, and internal and external rotation was measured. At the same time, ACP measurements were taken from a reconstructed postoperative CT scan, in addition to the radiographic measurements of humeral lateralization and distalization angles on AP views in neutral rotation. Results: The mean humeral distalization induced by RSA was 33.3 mm (±3.8 mm). A non-statistically significant increase in shoulder flexion was observed for humeral distalization beyond 38 mm (R² = 0.29, p = 0.07). This “threshold” effect of humeral distalization was also observed for the gains in abduction, as well as internal and external rotations, which seemed better with less than 38 mm or even 35 mm distalization. No statistical correlation was found between the 3D ACP measurements and 2D angle measurements. Conclusion: Excessive humeral distalization seems to be detrimental to joint mobility, especially shoulder flexion. Humeral lateralization and humeral anteriorization measured using the ACP seem to promote better shoulder range of motion, with no threshold effect. These findings could be evidence of tension in the soft tissues around the shoulder joint, which should be taken into consideration during preoperative planning. Full article

Introduction: The purpose of this study was to analyze the real range of motion (RoM) measured in patients operated on for reverse shoulder arthroplasty (RSA) and compare it to the virtual RoM provided by the preoperative planning software. Hypothesis: There was a difference between virtual and real RoM, which can be explained by different factors, specifically the scapula-thoracic (ST) joint. Methods: Twenty patients with RSA were assessed at a minimum follow-up of 18 months. Passive RoM in forward elevation abduction, without and with manually locking the ST joint, and in external rotation with arm at side were recorded. The humerus, scapula, and implants were manually segmented on post-operative CTs. Post-operative bony structures were registered to preoperative bony elements. From this registration, a post-operative plan corresponding to the real post-operative implant positioning was generated and the corresponding virtual RoM analysis was recorded. On the post-operative anteroposterior X-rays and 2D-CT coronal planning view, the glenoid horizontal line angle (GH), the metaphyseal horizontal line angle (MH), and the gleno-metaphyseal angle (GMA) were measured to assess the extrinsic glenoid inclination, as well as the relative position of the humeral and glenoid components. Results: There were some significant differences between virtual and post-operative passive abduction and forward elevation, with (55° and 50°, p < 0.0001) or without ST joint participation (15° and 27°, p < 0.002). For external rotation with arm at side, there was no significant difference between planning (24° ± 26°) and post-operative clinical observation (19° ± 12°) (p = 0.38). For the angle measurements, the GMA was significantly higher (42.8° ± 15.2° vs. 29.1°± 18.2°, p < 0.0001), and the GH angle, significantly lower on the virtual planning (85.2° ± 8.8° vs. 99.5° ± 12.5°, p < 0.0001), while the MH was not different (p = 0.33). Conclusions: The virtual RoM given by the planning software used in this study differs from the real post-operative passive RoM, except for external rotation. This can be explained by the lack of ST joint and soft tissues simulation. However, in focusing on the virtual GH participation, the simulation looks informative. Some modifications between the glenoid and humerus starting positions before running the motion analysis could be provided for making it more realistic and predictive of the RSA functional results. Level of evidence: III. Full article

(1) Background: Patellar tendinopathy (PT) is an overuse condition of the knee extensor mechanism characterized by ventral knee pain at the lower pole of the patella and limited functionality. (2) Methods: In this retrospective study, a group of patients with PT (n = 41) was compared with a control group (n = 50) in terms of patient-related data and magnetic resonance imaging (MRI) characteristics. (3) Results: Patellar height was higher in the PT patient group and there was a significant difference in Caton–Deschamps index (CD) compared to the control group (p = 0.021). Patients with PT showed a lower patella–patellar tendon angle (PPTA) (p = 0.011). The patellar tendon thickness (PTT) in the proximal (PTTprox), middle (PTTmid) and distal (PTTdistal) part of the tendon was significantly thickened (p < 0.001). Increased signal intensity in MRI was detected in symptomatic tendons over 6 months compared to a duration of less than 6 months (p = 0.025). A significant relationship between the PTTprox and an increased signal intensity was observed (p < 0.001). (4) Conclusions: Patients with PT showed a significant difference in the patellar height and PPTA. With persistence of symptoms over 6 months, MRI seems suitable to detect the morphologic tendon changes and further identify patients suitable for surgical procedures. Full article

Background: Non-unions after intramedullary nailing of femoral shaft fractures are a significant problem. Treatment options such as augmenting with plates or exchange nailing have been proposed. The ideal treatment remains controversial. Methods: Augmentative plating using a 4.5 mm LCP or a 3.2 mm LCP leaving the nail in situ was tested biomechanically and compared to exchange intramedullary nailing in a Sawbone^TM model of a femoral shaft non-union. Results: The difference of fracture gap motion in axial testing was small. In rotational testing, the exchange nail allowed for the largest amount of motion. The 4.5 mm augmentative plate was the most stable construct in all loading conditions. Conclusions: Augmentative plating using a 4.5 mm LCP plate while leaving the nail in situ is biomechanically superior to exchange intramedullary nailing. A small fragment 3.2 mm LCP is undersized and does not reduce fracture motion sufficiently in a femoral shaft non-union. Full article

The aim of this study was to compare three sensorimotor training forms in patients with chronic low back pain to determine their effects on the reduction of pain-related impairment and changes in posturography. Over two weeks, during the multimodal pain therapy (MMPT) period, six sessions of sensorimotor physiotherapy or training in the Galileo^® or Posturomed^® (n = 25 per group) were performed. A significant reduction in pain-related impairment after the intervention phase was shown across all groups (time effect: p < 0.001; η_p² = 0.415). There was no change in postural stability (time effect: p = 0.666; η_p² = 0.003), but there was a significant improvement in the peripheral vestibular system (time effect: p = 0.014; η_p² = 0.081). An interaction effect was calculated for the forefoot-hindfoot ratio (p = 0.014; η_p² = 0.111). Only the Posturomed^® group showed an improvement in anterior-posterior weight distribution (heel load: 47% vs. 49%). These findings suggest that these forms of sensorimotor training in the context of MMPT are suitable for reducing pain-related impairment. Posturography demonstrated stimulation of a subsystem, but no improvement in postural stability. Full article

The C-Nail^® system is a novel intramedullary fixation method for displaced intra-articular calcaneal fractures. The aim of this study was to evaluate the biomechanical performance of the C-Nail^® system and compare it with conventional plate fixation for the treatment of displaced intra-articular calcaneal fractures using finite element analysis. The geometry of a Sanders type-IIB fracture was constructed using the computer-aided design software Ansys SpaceClaim. The C-Nail^® system (Medin, Nové Mesto n. Morave, Czech Republic) and the calcaneal locking plate (Auxein Inc., 35 Doral, Florida) and screws were designed according to the manufacturer specifications. Vertical loading of 350 N and 700 N were applied to the subtalar joint surfaces to simulate partial weight bearing and full weight bearing. Construct stiffness, total deformation, and von Mises stress were assessed. The maximum stress on the C-Nail^® system was lower compared with the plate (110 MPa vs. 360 MPa). At the bone level the stress was found to have higher values in the case of the plate compared to the C-Nail^® system. The study suggests that the C-Nail^® system can provide sufficient stability, making it a viable option for the treatment of displaced intra-articular calcaneal fractures. Full article

Background and Objectives: Anterior cruciate ligament (ACL) ruptures are common injuries, and ACL reconstruction (ACLR) is among the most common surgical procedures in sports surgery. Our research aims to compare the 6-month post-operative results of the modified all-inside (MAI) ACLR technique, single leg hop tests (SLHT), and Y balance tests applied in different directions on the operated and non-operated sides. Materials and Methods: A retrospective cohort of 22 male recreational athletes who underwent MAI ACLR techniques performed by the same surgeon were evaluated. The functional knee strengths of the participants on the operated and non-operated sides were evaluated with five different tests of SLHTs: single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) with hop for distance (MRH). Their dynamic balance was evaluated with the Y balance Test. Results: Compared to pre-operative levels, there was a significant improvement in the mean Lysholm, Tegner, and IKDC scores during the post-operative period (p < 0.05). There was a difference between SH, THD, CHD, MSTH, and MRH on the operated and non-operative sides (p < 0.05). There was no difference between Y balance scores on the operated and non-operative sides, and there were no differences between LSI scores resulting from SLHTs (p > 0.05). There were no significant relationships between YBT (composite scores) and SH, TH, CH, MSTH, and MRH distances in the healthy leg (p > 0.05), but a significant correlation with only CH in the ACL leg (p < 0.05). Conclusions: Our research shows that sixth-month post-operative SLHT findings were lower on the ACL side compared to the healthy side in patients tested with the MAI ACLR technique. However, when these scores are evaluated in terms of balance, it can be seen that both sides reveal similar findings. The similarity of LSIs in SLHTs applied in different directions, and balance scores of ACL and healthy sides revealed that the MAI technique is also an ACLR technique that can be used in athletes from a functional point of view. Full article

Background: Osteoarthritis of the proximal interphalangeal (PIP) joint of the finger often leads to global hand-function detriment. Different techniques for the arthrodesis of the proximal interphalangeal joint have been described that all lead to union in a reasonable percentage of patients and period of time. This biomechanical study aims to analyze and compare the primary stability of different techniques of arthrodesis to render postoperative immobilization unnecessary. Methods: Arthrodeses of 40° of composite cylinders were tested with different techniques in four-point bending for stability in extension as well as flexion. Results: In extension, the compression screw and the compression wires showed the highest stability—whereas in flexion, plate fusion was superior. Tension band, cerclage or compression screw fusion showed the best compromise in flexion/extension stability. Conclusions: Fusion techniques that apply compression to the fusion show superior stability. Cerclage, tension band and compression screws might be able to provide enough stability to withstand the forces exerted during unencumbered activities of daily living. Arthrodesis with plates should be limited to patients with special indications and require immobilization during consolidation. Full article

(1) Quadriceps tendon rupture (QTR) is a rare pathology, usually occurring in elderly patients with comorbidities, requiring surgical therapy. The aim of this study was to analyze rupture patterns and concomitant injuries using preoperative magnetic resonance imaging (MRI) and to evaluate patient-reported outcome measures. (2) In this retrospective cross-sectional study, 113 patients with QTR were screened and rupture patterns/concomitant injuries (n = 33) were analyzed via MRI. Clinical outcome was assessed in 45 patients using the International Knee Documentation (IKDC) and Lysholm score with a mean follow-up of 7.2 (±5.0) years. (3) The evaluation of preoperative MRIs showed multiple ruptures of subtendons in 67% with concomitant knee injuries in 45%. The most common associated pathology detected using MRI was pre-existing tendinosis (31.2%). Surgical refixation demonstrated good results with a mean post-operative IKDC score of 73.1 (±14.1) and mean Lysholm score of 84.2 (±16.1). Patient characteristics and individual radiologic rupture patterns did not significantly affect the clinical outcome of patients. (4) Acute QTRs are complex injuries with common involvement of multiple subtendons. MRI imaging can be useful for achieving an accurate diagnosis as pre-existing tendinosis as well as concomitant injuries are common, and might be useful for providing an individual surgical strategy and improving outcomes. Full article

Although the benefits of hand orthoses were shown in previous studies, they have not been able to establish themselves in clinical routines. With a focus on patient satisfaction, this study aimed to evaluate the latest generation of hand orthoses after palmar plate osteosynthesis for isolated distal radius fractures in comparison with circular plaster casts. 50 patients (16% dropout rate) were randomly assigned to an orthotic group (immobilization by orthosis, OG) or a control group (immobilization by a plaster cast, CG). Intra-articular fractures were present in 74% of the cases, and unstable AO C3 fractures in 26%. Questionnaires on patient satisfaction, documentation of the time required, clinical scores (DASH, SF-36), range of motion, grip measurements and radiographs were used for evaluation. The OG proved to be equivalent to the plaster treatment in terms of patient satisfaction, and stability of the reduction, as well as clinical scores DASH and SF-36. The OG was even superior in terms of personal hygiene (p = 0.011), handling (p = 0.008) and better adaptability (p = 0.013). Significantly less time was required to apply the orthosis (p < 0.001). In addition to the good results achieved so far, the study showed that the latest generation of orthoses has several advantages over plaster cast therapy, and could therefore become established in everyday clinical practice. Full article

Background: Malnutrition might lead to a worse outcome in hip fractures of older patients. The purpose of this study is to analyze different indicators of malnutrition that lead to worse outcomes. Methods: 252 patients of a geriatric trauma unit were analyzed prospectively. Different demographic, as well as data on the trauma and whether osteoporosis prophylaxis or anticoagulation was present, were recorded. The nutritional status with respect to laboratory parameters as well as nutritional risk score was also analyzed. Results: The main finding of this study is that a poor nutritional status is statistically significantly associated with higher mortality as well as worse independence (p < 0.05). A postoperatively prescribed osteoporosis prophylaxis is protective of mortality and independence (p < 0.05). Conclusions: Malnutrition of geriatric patients increases the risk for death, worse mobility, and independence after hip fractures. Osteoporosis prophylaxis prescribed during an inpatient stay enables patients to retain their independence. The nutritional status of geriatric patients with hip fractures should be obtained and provisions made. Full article

Background: Xenogeneic bone grafts, when compared to autologous grafts, are supposed to provide structural benefits without donor site morbidity. To date, there have been divergent results in the use of xenogeneic grafts in foot surgery, primarily in pediatric patient cohorts. The present study examines the incorporation and maintenance of the achieved correction using autologous and xenogeneic bone grafts in adult patients with a six-month follow-up period. Material/Methods: In this retrospective study, 31 adult patients (43 feet in total) treated in our clinic by a lateral calcaneus-lengthening osteotomy, according to Evans, between 01/2006 and 12/2020 were included. The patients were assigned to study groups according to the use of xenogeneic or autologous bone grafts. The osseous incorporation following the criteria of Worth et al., correction maintenance by measuring the talo-navicular coverage angle (TNCA), the talo-first metatarsal angle (TFMA), the calcaneal pitch angle (PCA) and necessary revisions six months after surgery were extracted from the medical files retrospectively. Furthermore, the medical files were screened for the relevant comorbidities, nicotine abuse, BMI, sex and age. Results: In total, 27 autogenous (iliac crest) and 16 xenogeneic bone grafts of bovine origin were used. The evaluation of the radiographs at follow-up demonstrated that there was a mean incorporation rate of 96.3% for the autologous grafts and 57% for the patients treated with xenogeneic grafts (p = 0.002). Compared to the autologous group, xenogeneic grafts did not increase the loss of hindfoot alignment in the postoperative course, regardless of being incorporated or not. ΔTNCA, ΔTFMA and ΔPCA displayed no significant differences in both groups (p = 0.45, p = 0.42 and p = 0.10). Conclusion: Despite a significantly lower incorporation rate, the use of xenogeneic grafts was not accompanied with a greater risk of hindfoot alignment loss in the first six months after surgery. Early revision after a postoperative course of six months should not be motivated solely by the radiographic picture of incomplete osseous integration. Full article

Background: The aim of this study was to determine whether traumatic dislocation of the patella is provoked by the presence of predisposing factors and examine the role of the mechanism of injury. Methods: Cases diagnosed with dislocation of the patella and covered by the workers’ compensation program were identified and classified as traumatic based on insurance regulations. We examined predisposing factors (e.g., frontal axis, torsional deviation, trochlear dysplasia, patella alta) in case groups based on age at dislocation and trauma mechanism. Retrospective cohort study, level of evidence III. Results: Our sample size comprised 104 cases, consisting of 54 children and 50 adults. The most common mechanism of injury in children and adults was rotational trauma. Only 20% of the children and 21% of the adults exhibited no relevant predisposing factors. Group specifically, falls accounted for the highest number of cases exhibiting none of the defined anatomical predisposing factors. Children are more frequently affected by predisposition-related dislocations than adults. Conclusion: The proportion of predispositions is high. A fall, direct impact, or rotational trauma can be viewed as an adequate mechanism of trauma. For successful treatment, it is paramount to analyze the exact mechanism of the trauma and address any underlying predispositions. Full article

Background: The correction of malposition according to vertebral fractures is difficult because the alignment at the time before the fracture is unclear. Therefore, we investigate whether the spinal alignment can be determined by the spino-pelvic parameters. Methods: Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), adjacent endplate angles (EPA), age, sex, body weight, body size, BMI, and age were used to predict mono- and bisegmental EPA (mEPA, bEPA) in the supine position using linear regression models. This study was approved by the Ethics Committee of the Medical Association of Saxony-Anhalt Germany on 20 August 2020, under number 46/20. Results: Using data from 287 patients, the prediction showed R² from 0.092 up to 0.972. The adjacent cranial and caudal EPA showed by far the most frequently significance in the prediction of all parameters used. Anthropometric and spino-pelvic parameters showed sparse impact, which was frequently in the lower lumbar regions. On average, a very good prediction was found. For two mEPA (L3/4 R² = 0.914, L4/5 R² = 0.953) and two bEPA (L3 R² = 0.899, L4 R² = 0.972), the R² was >0.8. However, the predicted EPA differed for individual patients, even in these very effective prediction models—roughly around ±10° as compared to the measured EPA. Conclusions: In general, the prediction showed good to perfect results. In the supine position, the spinopelvic and anthropometric parameters show sparse impact on the prediction of mEPA or bEPA. Full article

Background: This study aimed to investigate the effects of different shoulder orthoses on the neuromuscular activity of superficial and deep shoulder muscles during activities of daily living (ADL) and physiotherapeutic exercises. Methods: Ten participants with healthy shoulders (31 ± 3 years, 23.1 ± 3.8 kg/m²) were randomized to receive a “shoulder sling”, an “abduction pillow” and a “variably adjustable orthosis” on the dominant side. With each orthosis, they completed seven ADL with and four physiotherapeutic exercises without wearing the orthoses. An electromyographic system was used to record the neuromuscular activity of three superficial (trapezius, deltoid, pectoralis major) and two deep shoulder muscles (infraspinatus, supraspinatus) using surface and intramuscular fine-wire electrodes. Results: The neuromuscular activity differs between the orthoses during ADL (p ≤ 0.045), whereby the “variably adjustable orthosis” mostly showed the highest activation levels associated with the worst subjective wearing comfort rated on a visual analog scale. In addition, differences exist between the physiotherapeutic exercises (p ≤ 0.006) demonstrating the highest activations of the infra- and supraspinatus muscles for assistive elevation and wipe across a table, middle for pendulum and lowest for continuous passive motion exercises. Conclusions: The neuromuscular activity of superficial and deep shoulder muscles differs between the orthoses during ADL and also between the physiotherapeutic exercises. Full article

Introduction: The influence of the MPFL graft in cases of patella instability with dysplastic trochlea is a controversial topic. The effect of the MPFL reconstruction as single therapy is under investigation, especially with severely dysplastic trochlea (Dejour types C and D). The purpose of this study was to evaluate the impact of trochlear dysplasia on patellar kinematics in patients suffering from low flexion patellar instability under weight-bearing conditions after isolated MPFL reconstruction. Material and Methods: Thirteen patients were included in this study, among them were eight patients with mild dysplasia (Dejour type A and B) and five patients with severe dysplasia (Dejour type C and D). By performing a knee MRI with in situ loading, patella kinematics and the patellofemoral cartilage contact area could be measured under the activation of the quadriceps musculature in knee flexion angles of 0°, 15° and 30°. To mitigate MRI motion artefacts, prospective motion correction based on optical tracking was applied. Bone and cartilage segmentation were performed semi-automatically for further data analysis. Cartilage contact area (CCA) and patella tilt were the main outcome measures for this study. Pre- and post-surgery measures were compared for each group. Results: Data visualized a trending lower patella tilt after MPFL graft installation in both groups and flexion angles of the knee. There were no significant changes in patella tilt at 0° (unloaded pre-surgery: 22.6 ± 15.2; post-surgery: 17.7 ± 14.3; p = 0.110) and unloaded 15° flexion (pre-surgery: 18.9 ± 12.7; post-surgery: 12.2 ± 13.0; p = 0.052) of the knee in patients with mild dysplasia, whereas in patients with severe dysplasia of the trochlea the results happened not to be significant in the same angles with loading of 5 kg (0° flexion pre-surgery: 34.4 ± 12.1; post-surgery: 31.2 ± 16.1; p = 0.5; 15° flexion pre-surgery: 33.3 ± 6.1; post-surgery: 23.4 ± 8.6; p = 0.068). CCA increased in every flexion angle and group, but significant increase was seen only between 0°–15° (unloaded and loaded) in mild dysplasia of the trochlea, where significant increase in Dejour type C and D group was seen with unloaded full extension of the knee (0° flexion) and 30° flexion (unloaded and loaded). Conclusion: This study proves a significant effect of the MPFL graft to cartilage contact area, as well as an improvement of the patella tilt in patients with mild dysplasia of the trochlea. Thus, the MPFL can be used as a single treatment for patient with Dejour type A and B dysplasia. However, in patients with severe dysplasia the MPFL graft alone does not significantly increase CCA. Full article

Knee injuries are one of the most common injuries. Falls during the immobilization period can deteriorate the postoperative outcome. The risk factors causing falls after initial injury and the question of whether a rigid orthosis serves as a protective factor remain unclear. The primary aim of the study was to record the fall rate in the first six weeks after arthroscopic intervention. The secondary aim was to assess the influences of risk factors and protective factors on these fall ratios. Different scores were examined and compared in the groups ‘fall event’ and ‘no fall’. Data from 51 patients (39 males, 12 females) with a mean age of 31.2 years (19–57 years) were collected. A total of 20 patients suffered at least one fall event within the observation period. A total of 18 of 23 fall events happened within the first three weeks postoperatively. The Extra Short Musculoskeletal Function Assessment Questionnaire (XSMFA) showed a significant difference between the groups (p = 0.02). People with multiple injuries to the knee joint were more likely to suffer fall events. Conclusively, patients with limited knee functions appeared to fall more frequently within the first three weeks postoperatively. Therefore, appropriate measures should be taken to protect the postoperative outcome. Physical therapy and patient behavioural training should be practiced perioperatively in patients at risk. Full article

Purpose: Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture. Methods: The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients. Results: The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function. Conclusions: For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient’s age, the displacement of the femoral neck, and one’s expertise. Full article

Distal femur reaming-free total knee arthroplasty (TKA) was reported to possess lower risk of acute myocardial infarction (AMI) or venous thromboembolism (VTE) than conventional TKA in a retrospective population-based study. We tried to offer prospective biological evidence by comparing the levels of AMI and VTE serum surrogate markers among the patients undertaking navigation and conventional TKAs to support these observations. Thirty-four participants undertaking navigation TKA and 34 patients receiving conventional TKA were recruited between February 2013 and December 2015. Blood samples were drawn from all participants before TKA, and 24 and 72 h after TKA, to assess the concentration of soluble P-selectin, matrix metalloproteinase-9 (MMP-9), C-reactive protein (CRP), and interleukin-8 (IL-8) between the participants undergoing navigation and conventional TKAs. We showed that significantly lower serum levels of soluble P-selectin 24 h after, as well as CRP 24 and 72 h after TKA could be observed in the navigation cohort. The more prominent surge of serum soluble P-selectin and CRP were perceived 24 and 72 h after TKA among the participants undergoing conventional TKA. Based upon our prospective biological evidence, the merits of navigation TKA are strengthened by lower levels of AMI and VTE serum surrogate markers. Full article

Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes. Full article

(1) Background: Knee osteoarthritis (OA) is a serious orthopedic problem. In this context, the high tibial osteotomy (HTO) is an established surgical procedure to reduce the load and degeneration of the affected compartment. The aim of this investigation was to judge standing steadiness and asymmetry, pain intensity and quality of life among patients who underwent HTO surgery. (2) Methods: Twenty-five male patients with medial tibiofemoral OA finished this 2 year follow-up study. Standing balance was captured using force plates with four uniaxial sensors before, 6 weeks after, 1 year after, and 2 years after HTO surgery. The percentage weight (PW) under the foot at one side, the stability (ST) index and the weight distribution (WD) index were the main outcomes. Comparisons were conducted using repeated measures analyses of variance. (3) Results: Over time, the PW under the foot at the HTO side increased on average (p < 0.001). In terms of standing steadiness, the average ST remained similar over the time points (p = 0.71). The WD index was affected by time (p = 0.003). (4) Conclusions: In order to judge short-term effects, the PW is recommended, whereas long-term effects can be identified either through the PW or the WD index. Full article

The coexistence of overlapping impairments modulates the knee pattern in the swing phase of walking in children with cerebral palsy (CP). The impact and contribution of each impairment to the reduction of knee range-of-motion is unknown. The aim of the study was to establish the gradation of the impact of individual coexisting impairments on the knee flexion range-of-motion. Passive range-of-motion, selective motor control, strength, and spasticity from 132 patients (Male = 76, Female = 56, age:11 ± 4 years) with spastic CP were tested with clinical tools. Knee flexion range-of-motion at terminal stance, pre-swing, and initial swing phases were assessed by gait analysis. Hypertonia (β = −5.75) and weakness (β = 2.76) of knee extensors were associated with lower range of knee flexion (R² = 0.0801, F = 11.0963, p < 0.0001). The predictive factors (R² = 0.0744, F = 7.2135, p < 0.0001) were strength (β = 4.04) and spasticity (β = −2.74) of knee extensors and strength of hip flexors (β = −2.01); in swing those were knee extensors hypertonia (β = −2.55) and passive range of flexion (β = 0.16) (R² = 0.0398, F = 3.4010, p = 0.01). Hypertonia of knee extensors has the strongest impact on knee flexion range-of-motion; secondary is the strength of knee extensors. The knee extensors strength with knee extensors hypertonia and strength of hip flexors contributes in stance. Knee extensors hypertonia with passive knee flexion range-of-motion contributes in swing. Full article

Objective: This single-blind randomized controlled crossover pilot trial investigated whether hard or soft knee orthotics affect the back in action (BIA) test battery performance. Methods: Twenty-four healthy participants (13 males, 11 females) were randomly assigned into three equal groups differentiated through the order of device use. The data were collected in a laboratory setting. BIA test battery (balance tests, vertical jumps, and parkour hop tests) was run with a rigid orthotic device, a soft brace, or no aid in a crossover order. Analysis of Variance repeated measures and Friedman Test were used to calculate depended-group differences. Results: No significant or clinically relevant effect or differences was observed between running the BIA with a soft brace, rigid orthosis, or no aid (p = 0.53–0.97) for all included tests. No adverse events have been observed. Conclusion: Soft and rigid knee braces do not affect performance in healthy participants. Missing experience with the devices might explain a few influences on feedback mechanisms. There is no disadvantage to be expected regarding healthy participants running back to sports. Full article

(1) Background: Isolated posterior cruciate ligament (PCL) tears represent a severe type of injury. In hospitals, PCL reconstruction (PCL-R) is less frequently performed than other types of knee surgery. It is unclear whether there is consensus among surgeons on how to perform rehabilitation after PCL-R or if there are different, more individual approaches in daily routines. (2) Methods: Rehabilitation protocols and their main criteria (the progression of weight bearing and range of motion, the use of knee braces, rehabilitation training, and sports-specific training) were retrospectively analyzed after PCL-R. (3) Results: Only 33 of 120 (27.5%) analyzed institutes use rehabilitation protocols after PCL-R. The applied protocols showed vast differences between the individual rehabilitation criteria, especially with regard to the progression of weight bearing and the range of motion. The only standardized recommendations were the obligatory use of knee braces and the general restriction of weight bearing and range of motion immediately post-surgery. Therefore, because of the lack of a consensus about a standardized rehabilitation protocol after PCL-R, no recommendation can be made on one particular protocol. (4) Conclusion: There is no acknowledged standardized rehabilitation protocol after PCL-R. In clinical practice, recommendations are influenced by, i.a., surgeons’ opinions and experience. The lack of scientific evidence on a particular standardized rehabilitation protocol after PCL-R suggests that rehabilitation protocols need to be tailored to the individual patient. Full article

Numerous studies report the success and outcomes of the total knee arthroplasty (TKA); however, few papers present patients with knee osteoarthritis and ipsilateral hip fusion. One controversy when treating patients requiring a TKA with prior ipsilateral hip fusion is whether to first perform a total hip arthroplasty (THA) of the fused hip, followed by the ipsilateral TKA, or to proceed with the TKA without replacing the hip; studies suggest that the position of the fused hip is a key factor when making this therapeutical decision. In addition, performing a TKA in patients with an ipsilateral fused hip may require modifications to the surgical technique generated by the lack of joint mobility in the hip. We identified 12 studies encompassing 30 patients with hip fusion and ipsilateral TKA in current orthopedic literature, but only six offered insights on patient positioning on the operating table during surgery. This study aims to review the current literature on patients with knee osteoarthritis and prior ipsilateral hip fusion and to present some technical considerations when performing a TKA on a 75-year-old patient with hip ankylosis who underwent a total ipsilateral knee arthroplasty in our clinic. Full article

(1) Background: Allograft prosthetic composite (APC) represents one of the techniques used for reconstruction in large proximal humeral bone deficits. The present systematic review aimed at summarizing the state of the art of the technique and analyzing its outcomes. (2) Methods: The PRISMA guidelines were followed to perform this systematic review. A systematic electronic search was performed using PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. All the studies analyzing the rates of allograft prosthesis composite were pooled, and the data were extracted and analyzed. (3) Results: A total of 10 studies were eligible for inclusion in this systematic review for a total of 239 patients. The rate of patient satisfaction with surgery was reported in 7 studies with a mean of 86.4% ± 13.64. The mean constant score was 45.7 ± 3.51, the mean ASES score was 63.58 ± 8.37, and the mean SST was 4.6 ± 1.04. The mean revision rate observed was 10.32% ± 3.63 and the mean implant survival was 83.66% ± 14.98. (4) Conclusions: Based on the currently available data, allograft prosthesis composite represents a valuable option for the reconstruction of proximal humeral deficits. All studies analyzed showed the favorable impact of this surgical technique on clinical outcomes and patient satisfaction. Full article

Bosworth lesions are fracture-dislocations of the ankle and are characterized by entrapment of the proximal segment of the fibula behind the posterior tubercle of the distal tibia. Treatment is challenging, mainly due to failure of a closed reduction. The aim of this study was to review the literature concerning this type of injury. A total of 103 patients with Bosworth fractures were included in the study. The analyzed studies yielded a total of 103 cases, of which 68% (n = 70) were male and 32% (n = 33) were female. Bosworth fractures are mainly due to accidental trauma (58.2%), sports-related injuries (18.4%), and traffic accidents (18.4%). More than 76% of the patients presented a Danis–Weber B fracture, 8.7% a type C fracture, and only 0.97% presented a type A fracture. In 92.2% of the patients, the attempted closed reduction was unsuccessful. A definitive treatment with open reduction and internal fixation (ORIF) was used in 96 patients (93.2%). The most frequent complication was post-traumatic arthritis (10.7%). Bosworth fractures are challenging. The available literature lacks adequate information about this fracture, and an approved standardized algorithm for treating such fractures is not available. Full article

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations. Full article

Bilateral scaphoid fractures are rare lesions, warranting a review to synthesize current knowledge, identify gaps, and suggest research directions. Two authors, adhering to PRISMA guidelines, in January 2024 identified 16 case reports (1976–2023). Data extraction included demographics, injury mechanisms, associated injuries, fracture sites, treatments, and outcomes. Among 121 initial outcomes, 16 articles met the criteria, predominantly affecting young people (93.75% males, mean age 22 years). High-energy traumas (75%) often caused associated wrist injuries (68.75%). Most fractures required surgical intervention (68.75%), primarily headless compression screws. Bilateral scaphoid fractures, which are rare but associated with high-energy traumas, commonly involve wrist injuries. Surgical management is often necessary, yielding better outcomes with fewer complications. Further research is essential to understand the epidemiology, optimal management, and long-term results. Early diagnosis and appropriate treatment are crucial for preventing complications and ensuring favorable patient outcomes. Full article

Patellofemoral instability is a prevalent cause of pain and disability in young individuals engaged in athletic activities. Adolescents face a particularly notable risk of patellar dislocation, which can be attributed to rapid skeletal growth, changes in q-angle, ligamentous laxity, higher activity levels, and increased exposure to risk. Specific sports activities carry an elevated risk of patellar dislocation. Younger age and trochlear dysplasia present the highest risk factors for recurrent patellar dislocations. International guidelines recommend conservative therapy following a single patellar dislocation without osteochondral lesions but suggest surgical intervention in recurrent cases. In this study, we have compiled current scientific data on therapy recommendations, focusing on MPFL (medial patellofemoral ligament) reconstruction. We discuss patient selection, surgical indications, graft selection, location and choice of fixation, graft tensioning, and postoperative care. Full article

Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications. Full article

Purpose: Approximately 60% of patients undergoing arthroscopy of the knee present with chondral defects. If left untreated, osteochondral lesions can trigger an early onset of osteoarthritis. Many cartilage repair techniques are mainly differentiated in techniques aiming for bone marrow stimulation, or cell-based methods. Cartilage repair can also be categorized in one- and two-stage procedures. Some two-stage procedures come with a high cost for scaffolds, extensive cell-processing, strict regulatory requirements, and limited logistical availability. Minced cartilage, however, is a one-stage procedure delivering promising results in short term follow-up, as noted in recent investigations. However, there is no available literature summarizing or synthesizing clinical data. The purpose of this study was to analyze and synthesize data from the latest literature in a meta-analysis of outcomes after the minced cartilage procedure and to compare its effectiveness to standard repair techniques. Methods: We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score (mCMS) >60, cartilaginous knee-joint defects, and adult patients. Patient age < 18 years, biomechanical and animal studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a systematic review, we compared three studies and 52 patients with a total of 63 lesions. Results: Analysis of Knee Injury and Osteoarthritis Outcome Score (KOOS) sub scores at 12 and 24 months showed a significant score increase in every sub score. Highest mean difference was seen in KOOS sport, lowest in KOOS symptoms (12 month: KOOS sport (Mean difference: 35.35 [28.16, 42.53]; p < 0.0001), lowest in KOOS symptoms (Mean difference: 20.12 [15.43, 24.80]; p < 0.0001)). A comparison of International Knee Documentation Committee (IKDC ) scores visualized a significant score increase for both time points too ((12 month: pooled total mean: 73.00 ± 14.65; Mean difference: 34.33 [26.84, 41.82]; p < 0.00001) (24 month: pooled total mean: 77.64 ± 14.46; mean difference: 35.20 [39.49, 40.92]; p < 0.00001)). Conclusion: Due to no need for separate cell-processing, and thanks to being a one-step procedure, minced cartilage is a promising method for cartilage repair in small defect sizes (mean 2.77 cm², range 1.3–4.7 cm²). However, the most recent evidence is scarce, and takes only results two years post-surgery into account. Summarized, minced cartilage presents nearly equal short-term improvement of clinical scores (IKDC, KOOS) compared to standard cartilage repair techniques. Full article

To determine how the internal rotation and shift (IRO/shift) test compares to the gold standard of clinical tests (Jobe test) for diagnosing supraspinatus lesions and to confirm these clinical results with surgical findings, 100 symptomatic patients were clinically examined between October 2018 and November 2019. All 100 patients were evaluated using both the IRO/shift test and Jobe test. A total of 48 of these patients received surgical intervention. Based on these data, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for both the IRO/shift test and Jobe test were calculated. The IRO/shift test had a sensitivity of 96% (95% CI: 82–100%), specificity of 50% (95% CI: 27–73%), PPV of 73% (95% CI: 56–86%), NPV of 91% (95% CI: 59–100%), and an accuracy of 77% (95% CI: 63–88%). The Jobe test had a sensitivity of 89% (95% CI: 72–98%), specificity of 60% (95% CI: 36–81%), PPV of 76% (95% CI: 58–89%), NPV of 80% (95% CI: 52–96%), and an accuracy of 77% (95% CI: 54–81%). These results suggest that the IRO/shift test is comparable to the Jobe test, which is often viewed as the gold standard clinical examination for assessing supraspinatus lesions. This study was approved by the Ethics Commission of the Martin Luther University Halle-Wittenberg (reference number: 2018-05). Full article