Increasing grades of frontal deformities in knee osteoarthritis are not associated with ligamentous ankle instabilities.

PURPOSE: Varus or valgus deformities in knee osteoarthritis may have a crucial impact on ankle subtalar range of motion (ROM) and ligamentous stability. The purpose of this study was to assess whether the grade of ankle eversion and inversion rotation stability was influenced by frontal deformities of the knee joint. METHODS: Patients who were planned to undergo total knee arthroplasty (TKA) were prospectively included in this study. Patients were examined radiologically (mechanical tibiofemoral angle (mTFA), hindfoot alignment view angle (HAVA), anterior distal tibia angle (ADTA)) and clinically (ROM of the knee and ankle joint, foot function index, knee osteoarthritis outcome score). Ankle stability was assessed using an ankle arthrometer (AA) to test inversion/eversion (ie) rotation and anterior/posterior (ap) displacement stability of the ankle joint. Correlations were calculated using Pearson's coefficient, and differences between two independent groups of nonparametric data were calculated using a two-sided Wilcoxon signed rank test. RESULTS: Eighty-two (varus n = 52, valgus n = 30) patients were included. The preoperative mTFA significantly correlated with the HAVA (Pearson's correlation = - 0.72, p < 0.001). Laxity testing of the ankle demonstrated that in both varus and valgus knee osteoarthritis, higher grades of mTFA did not correlate with the inversion or eversion capacity of the ankle joint. The ADTA significantly correlated with the posterior displacement of the ankle joint (cor = 0.24, p = 0.049). CONCLUSIONS: This study could not confirm that higher degrees of frontal knee deformities in osteoarthritis were associated with increasing grades of ligamentous ankle instabilities or a reduced ROM of the subtalar joint. LEVEL OF EVIDENCE: II.

Implementation of online video consultations in a regional health network: a management feasibility analysis from an orthopedic perspective.

INTRODUCTION: Regional health care networks with interfaces between clinics, general practitioners and patients can act faster when utilizing digital measures. This manuscript describes the establishment of an online video consultation service in a clinic and its broad health care region to exemplify challenges and solutions for potential future approaches from a management perspective. METHOD: The underlying pilot project was planned and implemented for follow-up monitoring and consultative presentation of orthopedic and trauma patients within the Bundeswehr Medical Service from 2018 to 2020. With predominantly positive evaluation results regarding quality and acceptance among users, this research investigated organizational and processual aspects including total quality management, strategic control and change management approaches. RESULTS: The affected main and subprocesses of patient treatment could be streamlined by the project, as physician recommendations and arrangements could be accelerated and patient travel could be significantly reduced. A SWOT and portfolio analysis showed a high potential for improving existing patient treatment processes for health care enterprises via the use of digital technology. The involved staff should be strategically included at an early stage and continuously involved. By means of a PDCA cycle, the processes of the given project could be exemplarily illustrated with an outlook in the future. DISCUSSION: It has proven successful to consciously use management approaches to establish telemedical integrated care structures in a health region. Recommendations for the strategic introduction of an online video consultation for regional network strengthening and care development for a patient-oriented increase in efficiency could be compiled.

The use of online video consultations in the aftercare of orthopedic patients: a prospective case-control study.

BACKGROUND: Video consultations have proven to be an efficient source of support for patient-doctor interactions and have become increasingly used in orthopedics, especially during the COVID-19 pandemic. This study analyzed both patients' and doctors' acceptance of an orthopedic telemedical consultation (OTC) and compared the results of OTC examinations to the results of live consultation (LC) to identify discrepancies. METHODS: The study was carried out in an orthopedic department of a German hospital between 2019 and 2020. After written informed consent was obtained, patients voluntarily presented for follow-up by OTC and LC. The experience with and attitudes toward OTC among both patients and doctors was evaluated (using Likert scale-scored and open questions, 26 to 28 items). The results of the OTC and LC examinations were compared using a 12-item checklist. The data were analyzed by quantitative and qualitative statistics. RESULTS: A total of 53 patients were included, each of whom completed an OTC and an LC. The OTC was rated as pleasant, and the experience was rated as very satisfying (average rating on a 5-point Likert scale, with 1 indicating strong agreement: doctors: 1.2; patients: 1.3). Various technical and organizational challenges were identified. Compared to LC, OTC showed no significant differences in patient history or in inspection, palpation, or active range of motion results. Only for the functional or passive joint assessment did LC show significantly higher suitability (p < 0.05) than OTC. Recommendations for further procedures did not differ significantly between OTC and LC. CONCLUSIONS: Because of the high acceptance and the objective benefits of OTC and the similarity of clinical results with LC, OTC is recommendable for orthopedic follow-up examinations. To better assess joint functionality, meaningful digital alternatives for established examination methods should be further investigated.

Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function.

PURPOSE: The aim of this study was to demonstrate, whether the degree of limb alignment correction in varus knee osteoarthritis correlated with an increase in ankle symptoms and to define a cut-off value concerning the degree of correction above which to expect ankle problems. METHODS: Ninety-nine consecutive patients with preoperative intraarticular varus knee deformities who underwent total knee arthroplasty were retrospectively analyzed. Patients were examined clinically (Knee Society Score, Forgotten Joint Score, Foot Function Index, Range of Motion of the knee and ankle joint, pain scales) as well as radiologically. The mean follow-up time was 57 months. RESULTS: The degree of operative limb alignment correction strongly correlated with the Foot Function Index (R = 0.91, p < 0.05). Given this, higher degrees of knee malalignment corrections were associated with worse postoperative outcomes in the knee and ankle joint-despite postoperative improved joint line orientations. Subsequently, a cut-off value for arthritic varus deformities (14.5°) could be calculated, above which the prevalence of ankle symptoms increased manifold [OR = 15.6 (3.2-77.2 95% CI p < 0.05)]. Furthermore, ROM restrictions in the subtalar joint were associated with a worse outcome in the ankle joint. CONCLUSIONS: When correcting excessive intraarticular varus knee osteoarthritis, surgeons have to be aware of possible postoperative ankle symptoms and should consider ankle deformities or decreased subtalar ROM before operative procedures. LEVEL OF EVIDENCE: III.

Treatment Algorithm for Pilon Fracture - Clinical and Radiological Results.

PURPOSE OF THE STUDY The aim of the present study was to evaluate the postoperative outcome of patients with pilon tibial fractures with a minimum follow-up of 24 months, treated according to a staged treatment algorithm. MATERIAL AND METHODS In total, 27 patients (mean age 43.6 ± 13 years, range 18-69) with a pilon tibial fracture and a minimum follow-up of 24 months were included in the study. Medical recordings (discharge documents and surgical reports) and radiographic examinations were analyzed. All enrolled patients were invited for a clinical and radiological follow-up examination (ROM, AOFAS hindfoot score, Kellgren score). The mean follow-up time was 44.5 ± 16 months (range 24-82). RESULTS In 21 cases a two-stage operative strategy with initial closed reduction and external fixation was necessary prior to definitive osteosynthesis. Overall, the patients scored 82.1 ± 20 points (range 30-100) in AOFAS hindfoot score, which represents a good clinical outcome. Patients with B-type fractures scored significantly better than those with C-type fractures. Patients with closed pilon tibial fractures reached significantly higher values in the AOFAS hindfoot score than those with open ones. Age and gender did not affect the functional outcome. Total ankle range of motion was 41° ± 10° for B-type fractures (range 20°-55°) and 35° ± 17° (range 0°-60°) for C-type fractures respectively (p > 0.05). Only five patients reached higher scores (Grade III) in Kellgren classification system. DISCUSSION Within the last decades, the therapeutic algorithm of pilon fractures underwent a paradigm shift; a two-stage protocol has prevailed today. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. Moreover, the necessity for bone grafting, as an indirect measurement of bone comminution and bone defects, resulted in higher degrees of osteoarthritis in the final follow-up. Higher initial soft-tissue injury also had an impact on the functional outcome of the patients, as patients with closed fractures scored better in AOFAS at the final follow-up. In order to counteract these risk factors and to reduce complications that define the outcome of these severe injuries, clearly defined surgical principles and standardized treatment protocols are needed. CONCLUSIONS The present study confirms the fact that meticulous planning, respect of the soft-tissues and choice of the optimal timepoint for the definitive osteosynthesis and overall treatment according to standardized protocols can optimize the outcome of this severe injury. Key words:pilon, distal tibia fracture, outcome, algorithm.

Impaired fracture healing with high non-union rates remains irreversible after traumatic brain injury in leptin-deficient mice.

Patients with traumatic brain injury (TBI) and long-bone fractures can show increased callus formation. This effect has already been reproduced in wild-type (wt) mice. However, the mechanisms remain poorly understood. Leptin is significantly increased following TBI, while its role in bone healing remains unclear. The aim of this study was to evaluate fracture healing in leptin-deficient ob/ob mice and to measure any possible impact of TBI on callus formation. 138 female, 12 weeks old, ob/ob mice were divided into four groups: Control, fracture, TBI and combined trauma. Osteotomies were stabilized with an external fixator; TBI was induced with Controlled Cortical Impact Injury. Callus bridging was weekly evaluated with in vivo micro-CT. Biomechanical testing was performed ex vivo. Micro-CT showed high non-union rates after three and four weeks in the fracture and combined trauma group. No differences were observed in callus volume, density and biomechanical properties at any time point. This study shows that bony bridging is impaired in the present leptin-deficient trauma model. Furthermore, the phenomenon of increased callus formation after TBI could not be reproduced in ob/ob mice, as in wt mice. Our findings suggest that the increased callus formation after TBI may be dependent on leptin signaling.

The haematoma and its role in bone healing.

Fracture treatment is an old endeavour intended to promote bone healing and to also enable early loading and regain of function in the injured limb. However, in today's clinical routine the healing potential of the initial fracture haematoma is still not fully recognized. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) formed in Switzerland in 1956 formulated four AO principles of fracture treatment which are still valid today. Fracture treatment strategies have continued to evolve further, as for example the relatively new concept of minimally invasive plate osteosynthesis (MIPO). This MIPO treatment strategy harbours the benefit of an undisturbed original fracture haematoma that supports the healing process. The extent of the supportive effect of this haematoma for the bone healing process has not been considered in clinical practice so far. The rising importance of osteoimmunological aspects in bone healing supports the essential role of the initial haematoma as a source for inflammatory cells that release the cytokine pattern that directs cell recruitment towards the injured tissue. In reviewing the potential benefits of the fracture haematoma, the early development of angiogenic and osteogenic potentials within the haematoma are striking. Removing the haematoma during surgery could negatively influence the fracture healing process. In an ovine open tibial fracture model the haematoma was removed 4 or 7 days after injury and the bone that formed during the first two weeks of healing was significantly reduced in comparison with an undisturbed control. These findings indicate that whenever possible the original haematoma formed upon injury should be conserved during clinical fracture treatment to benefit from the inherent healing potential.

Treatment of Geriatric Proximal Humerus Fractures: Indications and Outcome.

Treatment algorithms of proximal humerus fractures are still controversially discussed. The enthusiasm towards operative treatment after the introduction of locking implants, has not been justified by the functional results in the elderly population. The majority of those fractures in the geriatric patients can be successfully treated conservatively. Thorough clinical and radiological examination for fracture analysis, dynamic stability control with the use of an image intensifier, and meticulous reduction, in addition with the appropriate orthesis for its retention and rehabilitation, are the keys for the successful treatment of the proximal humerus fracture in the elderly patient. The present review reports on the main treatment aspects of proximal humerus fractures in the geriatric population and proposes a treatment algorithm.

Treatment of Tibial Non-Unions - State of the Art and Future Implications.

healing disturbances occur in 5-10% of the cases. The anatomical region of the lower limb predisposes the tibia for bone healing disturbances. Reports about the incidence of non-unions of the tibial shaft are inhomogeneous. Different treatment strategies have been published which depend on the type of non-union as well as the history of the patient. These range from conservative approaches to complex procedures including segmental resection and bone transport. This review aimed to summarize the state of the art treatment of tibial non-unions and report about recent basic research results that may improve bone healing. Key words: tibial non-unions, treatment strategies, bone healing.

[Operative therapy of fractures of the distal femur. Predictive factors for a complicated course]. / Operative Therapie von distalen Femurfrakturen. Prognostische Faktoren für einen komplikationsbehafteten Verlauf.

BACKGROUND: Fractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high. OBJECTIVES: This study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment. MATERIALS AND METHODS: We retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed. RESULTS: Open soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia. CONCLUSIONS: The complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patient's general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.

Traumatic brain injury and bone healing: radiographic and biomechanical analyses of bone formation and stability in a combined murine trauma model.

INTRODUCTION: The combination of traumatic brain injury (TBI) and long-bone fractures has previously been reported to lead to exuberant callus formation. The aim of this experimental study was to radiographically and biomechanically study the effect of TBI on bone healing in a mouse model. MATERIALS AND METHODS: 138 female C57/Black6N mice were assigned to four groups (fracture (Fx) / TBI / combined trauma (Fx/TBI) / controls). Femoral osteotomy and TBI served as variables: osteotomies were stabilized with external fixators, TBI was induced with controlled cortical impact injury. During an observation period of four weeks, in vivo micro-CT scans of femora were performed on a weekly basis. Biomechanical testing of femora was performed ex vivo. RESULTS: The combined-trauma group showed increased bone volume, higher mineral density, and a higher rate of gap bridging compared to the fracture group. The combined-trauma group showed increased torsional strength at four weeks. DISCUSSION: TBI results in an increased formation of callus and mineral density compared to normal bone healing in mice. This fact combined with a tendency towards accelerated gap bridging leads to increased torsional strength. The present study underscores the empirical clinical evidence that TBI stimulates bone healing. Identification of underlying pathways could lead to new strategies for bone-stimulating approaches in fracture care.

Functional and radiological outcome of periprosthetic fractures of the ankle.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA). A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically. A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%. There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively. A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Complication rates and reduction potential of palmar versus dorsal locking plate osteosynthesis for the treatment of distal radius fractures.

BACKGROUND: The aim of this study was to evaluate the complication rates of volar versus dorsal locking plates and postoperative reduction potential after distal radius fractures. MATERIALS AND METHODS: For this study 285 distal radius fractures (280 patients/59.4 % female) treated with locked plating were retrospectively evaluated. The mean age of the patients was 54.6 years (SD 17.4) and the mean follow-up was 33.2 months (SD 17.2). The palmar approach was used in 225 cases and the dorsal approach in 60 cases (95 % type C fractures). RESULTS: Adequate reduction was achieved with both approaches, regardless of fracture severity. In the dorsal group, the complications and implant removal rates were significantly higher and the operative time was also longer. CONCLUSIONS: Based on these facts, we advocate the palmar locking plate for the vast majority of fractures. In cases of complex multifragmentary articular fractures where no compromise in reduction is acceptable, and with the biomechanical equality of palmar and dorsal plating remaining unproven, dorsal plating may still be considered. LEVEL OF EVIDENCE: Therapeutic level IV.

Surgical management and outcome of skeletal metastatic disease of the humerus.

PURPOSE OF THE STUDY Evaluation of outcome after surgical treatment of humerus metastases with a focus on tumour and patient derived factors, timing and strategy of intervention, surgical outcome and complications. MATERIAL AND METHODS Sixty-fie patients with a mean age of 64.3 years (range 25-89) with 66 metastases of the humerus were surgically treated in a 7-year time-period and retrospectively reviewed. RESULTS Renal cell carcinoma and breast cancer were the most abundant types of primary tumour. The mean time from diagnosis of primary tumour to fist metastasis was 14.5 months (range 0-173). The mean time from diagnosis of metastasis to surgery was 21.4 months (range 0-173). 38/28 intramedullary nails/locking plates were used for 58/8 manifest/impending pathological fractures. Mean cumulative survival was 16.3 months and implant failure rate was 6.1% with a mean time from initial surgery to revision of 22.2-20.6 months. CONCLUSIONS Our data indicate that treatment with intramedullary fiation or cement augmented plate osteosynthesis is successful for the vast majority of patients, but thorough clinical evaluation and precise decision making adapted to the patient's estimated life expectancy must be applied to avoid overtreatment or risk of implant failure. Key words: bone metastases, skeletal metastatic disease, humerus metastasis, pathologic fracture, impending fracture.

The treatment of the proximal humeral fracture with the use of the PHN Nailing System: the importance of reduction.

PURPOSE OF THE STUDY: Intramedullary nailing is a minimally invasive technique that respects humeral head. However, limited surgical approach does not permit an anatomical reduction. The significance of the reduction on the functional outcome has not been sufficiently investigated. The aim of the study was to examine the functional and radiological postoperative outcome in patients with proximal humeral fractures treated with intramedullary nailing and the significance of reduction. MATERIALS AND METHODS: The study population consisted of 43 patients with proximal humeral fractures that were treated with the Proximal Humerus Nail System (Targon, Aesculap). Mean follow-up period was 23.2 months (SD: 8.9). Shoulder function was assessed with the Constant-Murley Score. Reduction was examined radiographically anteroposterior and true lateral plane. Radiographs of 50 healthy shoulders served as controls. Malreduction was analyzed for 10°, 15° and 20° in both planes. RESULTS: The overall functional results were satisfying; mean CS of all patients at the last follow-up visit was 74.8 (SD: 19.3). Mean normalized CS for age and gender was 78.15 (SD 17.8). Fracture severity seemed to affect clinical outcome to a certain extent; 4-part fractures exhibited inferior results. Mean NSA was 126.5 (SD: 16.9) in anteroposterio and 137.4 (SD: 15.4) in true lateral view. The respective values in the control group were 134.1° (SD 7.1°) in anteroposterior and 133.7° (SD 12.8°) in true lateral view. A malreduction of >20° in the anteroposterior plane and >15° in both anteroposterior and true lateral planes resulted in significantly inferior clinical outcome. Thirteen complications were recorded, four of them being major. DISCUSSION The quality of reduction affected the postoperative outcome to a certain extent. Especially the anteroposterior reduction seemed to play a more important role in the postoperative function than reduction in the true lateral plane. However, this difference was statistically significant only after > 20° malreduction. The worst results in Constant Score were shown, as expected, in the group with malreduction in both planes; even a 15°malreduction resulted in statistically significant difference. The importance of anteroposterior reduction could be due to achievement of better ROM in the frontal plane, most probably because of better levers on the tuberosities. However an absolute anatomical reduction does not have to be achieved at all costs. The overall good results of the fractures in this study despite absence of anatomical reduction could partly result from the limited surgical approach. CONCLUSIONS: The majority of the patients treated with closed reduction and internal fixation with PHN show good postoperative functional results. However, fracture malreduction reduction cannot be always avoided with the use of PHN. Nevertheless, the evaluation of the Constant-Murley score shows an absolute anatomical reduction in not necessary for satisfying functional outcome. The reduction in anteroposterior plane seems to play a more important role in the postsurgical functional outcome. A malreduction that exceeds 15° in both planes or a malreduction of more than 20° in either plane should be avoided.

[Surgical management of thoracolumbar spinal sarcoma]. / Chirurgisches Management von Sarkomen der thorakolumbalen Wirbelsäule.

Primary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewing's sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.