Non-unions and wound infections do not differ following intramedullary nailing and plate osteosynthesis for distal third femur fractures: a meta-analysis.

Purpose: The fixation method of distal, extra-articular femur fractures is a controversially discussed. To ensure better stability itself, earlier mobilization and to prevent blood loss - all these are justifications for addressing the femur via reamed intramedullary nailing (RIMN). Anatomical reposition of multifragmentary fractures followed by increased risks of non-union are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of non-union and wound infection, as well as blood loss and time of surgery. Methods: According to the PRISMA guidelines we conducted this systematic review by searching the Cochrane, PubMed, Ovid, MedLine, and Embase databases. Inclusion criteria were the modified Coleman methodology score (mCMS) >60, age >18 years, and extra-articular fractures of the distal femur. Biomechanical and animal studies were excluded. By referring to title and abstract relevant articles were reviewed independently. In the consecutive meta-analysis, we compared 9 studies and 639 patients. Results: There is no statistically significant difference comparing superficial wound infections when RIMN was performed (OR = 0.50; 95% CI: 0.18 - 1.42; P = 0.19) as well as in deep wound infections (OR = 0.74; 95% CI: 0.19-2.81; P = 0.62). However, these results were not significant. We also calculated for potential differences in the rate of non-unions depending on the surgical treatment applied. Data of 556 patients revealed an overall number of 43 non-unions. There was no significant difference in rate of non-unions between both groups (OR = 0.97; 95% CI: 0.51-1.85; P = 0.92). Conclusion: No statistical difference was found in our study among RIMN and plate fixation in the treatment of distal femoral fractures with regard to the incidence of non-union and wound infections. Therefore, the indication for RIMN or plating should be made individually and based on the surgeon's experience.

Freehand Technique for Pedicle Screw Placement during Surgery for Adolescent Idiopathic Scoliosis Is Associated with Less Ionizing Radiation Compared to Intraoperative Navigation.

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.

Individual Influence of Trochlear Dysplasia on Patellofemoral Kinematics after Isolated MPFL Reconstruction.

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.

Minced Cartilage Is a One-Step Cartilage Repair Procedure for Small Defects in the Knee-A Systematic-Review and Meta-Analysis.

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.

[Reality of care of patella stabilizing operations : A status quo among active members of the German Society for Orthopedic and Trauma Surgery (DGOU)]. / Versorgungsrealität patellastabilisierender Operationen : Ein Status quo unter aktiven Mitgliedern der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

BACKGROUND: Patellofemoral instability is one of the most common pathologies of the knee joint. The planning and implementation of patella-stabilizing operations are very variable. With regard to the operative measures, the preoperative planning is of decisive importance, especially with regard to the complexity of underlying pathologies. OBJECTIVES: The aim of this study was to depict the current healthcare reality in relation to planning and implementation of patella stabilizing operations in Germany. Furthermore, it was to be ascertained whether automated analysis options would facilitate the planning and implementation of surgical procedures (in primary and revision cases). MATERIALS AND METHODS: An online survey with 16 questions was collected by email among all active members of the German Society of Orthopedic and Trauma Surgery. 7974 members were surveyed; 393 responses could then be analyzed. RESULTS: MPFL-reconstruction (89.8%) is the most frequently performed procedure, followed by tibial tubercle transfers (64.9%), osteotomies (51.2%), and trochleoplasty (19.9%). The choice of surgical approach is mainly based on a combination of clinical and radiological findings (90.3%). MRI imaging (81.2%), standard X­ray images (77.4%), and full leg images (76.6%) are mainly used for operative treatment decisions. 59.3% of the respondents would appreciate better preoperative planning and 59.0% would implement more radiologically detectable parameters in their individual preoperative planning if these were automatically available. CONCLUSIONS: The findings of this survey among members of the DGOU identify the MPFL-reconstruction as the central operative approach in the treatment of patellofemoral instabilities, whereas MRI imaging is the diagnostic tool of choice. Future establishment of automated software-based analysis methods could allow a large number of surgeons to expand the radiological parameters taken into account when planning patella-stabilizing operations.

Individual Concepts in Foot Surgery: A Comparison of Xenogeneic and Autologous Bone Grafts Used in Adults for Lateral Calcaneus-Lengthening Osteotomy According to Evans.

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.

Osteosynthesis or non-operative treatment of the fibula for distal lower-leg fractures with tibial nailing: a systematic review and meta-analysis.

Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation - all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29-0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76-2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21-2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually. Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003.

[Scrotal oedema: a urological chameleon]. / Das Skrotalödem ­ Ein Urologisches Chamäleon.

We report the case of a 28-year-old patient with acute scrotal swelling. A chemical laboratory test revealed no evidence of inflammation and ultrasound demonstrated good blood flow in both testicles. Testicular torsion seemed to be unlikely based on the patient's medical history and the physical examination. Therefore, we decided not to perform surgical treatment. Possible differential diagnoses were ruled out over time, and the suspicion of acute idiopathic scrotal oedema (AISE) was confirmed. After one day of inpatient antiphlogistic treatment, the patient was discharged. This case example demonstrates that AISE may also occur in non-paediatric patients and the best way to diagnose it is to rule out the presence of other possible conditions.

[How dangerous is American football in a German amateur league? An injury analysis according to playing position over a period of four seasons]. / Wie gefährlich ist American Football im deutschen Amateurbereich? Eine positionsbezogene Verletzungsanalyse über vier Spielzeiten.

BACKGROUND: American football is known for its high risk of injury, especially in the professional field. Although the number of players in the German football league (GFL) has risen in recent years, data concerning the injury rates of German amateur players in American football are scarce. OBJECTIVE: Analysis of the injury rates in league games and training sessions in amateur football according to playing positions and body region. MATERIAL AND METHODS: Injuries of 123 American football players in a club playing in the second GFL (first and second team) were prospectively recorded over a period of 4 seasons (2014-2018). A complete history of injuries was obtained from 72 players. The injuries were classified using the Orchard sports injury classification system 10.1 (OSICS 10.1). The injury rates were calculated per 1000 athlete exposures (AE) for training as well as for league games with respect to the playing position and for each body region. RESULTS: Overall 142 injuries were recorded. On average there were 35.5 injuries per season and 1.9 injuries per player. Of the injuries 54.7% occurred during training and 46.1% during games. The risk of injury was significantly increased during league games (15.6 ± 16.3) compared to training (3.1 ± 2.7, p < 0.0001). While wide receivers and cornerbacks had the highest overall injury rates, running backs had the highest injury risk during games (p = 0.046). Injuries to knees (27.3%) and shoulders (20.1%) were the most frequent. The shoulder was the body region injured most frequently during games (p = 0.002). Regarding the injury pattern, distorsions (30.9%) and contusions (22.5%) occurred more often compared to fractures (12.6%) and dislocations (16.1%). Concussion only contributed to 2.9% of the injuries. CONCLUSION: American football is a contact sport with high injury rates even in the German amateur field, especially during league games. Regarding body regions, shoulders and knees were predominantly affected while regarding the playing position, wide receivers and cornerbacks were particularly jeopardized. Therefore, a continuous close medical supervision during games and an intensive position-specific training seem to be necessary even in the amateur field in order to reduce the injury rate.