Comparison of revision rates and epidemiological data of a single total knee arthroplasty system of different designs (cruciate retaining, posterior stabilized, mobile bearing, and fixed bearing): a meta-analysis and systematic review of clinical trials and national arthroplasty registries.

BACKGROUND: This study aimed to meta-analyze epidemiological data, revision rates, and incidences of different designs of a single Total Knee Arthroplasty System and compare these factors across different countries. METHODS: A systematic review was conducted on clinical studies and arthroplasty registries of ATTUNE TKA from 1999 to 2020. The main endpoints analyzed were revision rates and epidemiological data. RESULTS: The average age of patients was 67.8 years, with a gender distribution of 60% female and 40% male. The pooled average BMI was 29.4 kg/m2. Eight clinical studies showed a pooled revision rate per 100 observed CY of 0.5 (n = 1343 cases). Cumulative revision rates after 1, 3, and 5 years varied among registries, with the Swiss registry having the highest revision data (after 5 years: 6.3%) and the American registry having the lowest revision data (after 5 years: 1.7%). A comparison of the revision rates of mobile bearing and fixed bearing (41,200 cases) as well as cruciate retaining and posterior stabilized (n = 123,361 cases) showed no significant advantage in the first 5 years after implantation. CONCLUSION: In conclusion, pooled data from 41,200 cases of TKA with a single Total Knee Arthroplasty System in two arthroplasty registries revealed that there was no significant difference in revision rates between the mobile bearing and fixed bearing design within the first 5 years after implantation. In addition, a comparison of the revision rates in n = 123,361 cases showed no significant advantage for cruciate retaining or posterior stabilized in the first 5 years after implantation.

Occupational injuries in orthopedic and trauma surgeons in Austria.

BACKGROUND: The aim of this study was to investigate the frequency and type of injuries during the career of orthopedic and trauma surgeons in Austria. The hypothesis was that the percentage of occupational injuries among orthopedic and trauma surgeons aligns with the incidence reported in the United States, thus indicating the need for a workplace prevention program. METHODS: A web-based survey was created to collect all necessary data and was sent to all orthopedic and trauma surgeons in Austria via e-mail. Relevant parameters included the surgeons' age, work experience, severity of pain, type of injury, and current pain. Descriptive and explorative statistical analysis was performed. RESULTS: A web-based survey was sent to 1122 board-certified orthopedic surgeons and residents in Austria via e-mail. In total, the response rate was 135 (12%). Seventy-two surgeons (54%) had suffered from one or more occupational injuries during their career. We detected a significant raise of occupational injuries related to the work life duration in which operations were performed and the prevalence of injuries. Most injuries of surgeons were reported between 21 and 30 years of their professional life. According to the frequency at different locations, the distribution in descending order was 25% with injuries of the hand, 22% of finger(s), 12% of the foot, 10% of the spine, 2% of the neck, 3% of the head, and 2% of the abdomen. A causality of incapacity to work through injuries at the workplace was given as 4%. Four percent stated a sick leave of at least 3 weeks. In 7% of the facilities, there was no optimization of preventive measures following an occupational injury. We found no correlation of injuries and resident status. CONCLUSION: Orthopedic surgeons in Austria show a high incidence of occupational injuries in line with the findings of colleagues from the United States. The impact on the health system consists of absenteeism in the workplace of highly specialized health service providers as well as the incapacity to work of a high quality, highly trained workforce of at least 4%. With more preventive measures and more attention and care in the rehabilitation phase after such injuries, a positive effect could be achieved. We believe that residents should be specifically trained on how to avoid such injuries.

Smokers have increased risk of soft-tissue complications following primary elective TKA.

INTRODUCTION: Smoking has been associated with numerous adverse outcomes following surgical procedures. The purpose of this study was to investigate, whether smoking status at time of surgery influences the outcome of primary TKA. MATERIALS AND METHODS: Six hundred and eighty-one patients who underwent primary TKA between 2003 and 2006 were included in the study. Smoking status was defined as current, former, and never smoker. Complications leading to revisions were assessed until 17 years of follow-up. Functional outcome was evaluated using clinical scores: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Scale (VAS) for pain, Short Form-12 Physical and Mental Component Summaries (SF-12PCS/MCS), and Knee Society Function and Knee Score (KSFS and KSKS). RESULTS: At a mean follow-up of 95 months (± 47 months), 124 complications led to revision surgery. Soft-tissue complications (OR, 2.35 [95% CI 1.08-5.11]; p = 0.032), hematoma formation (OR, 5.37 [95% CI 1.01-28.49]; p = 0.048), and restricted movement (OR, 3.51 [95% CI 1.25-9.84]; p = 0.017) were more likely to occur in current smokers than never smokers. Current smokers were more likely to score higher at KSFS (p < 0.001) and SF-12PCS (p = 0.0197) compared to never smokers. For overall revision, differences were noted. CONCLUSION: Current smoking increases risk of soft-tissue complications and revision after primary TKA, especially due to hematoma and restricted movement. Smoking cessation programs could reduce the risk of revision surgery.

Higher use of fixed-bearing over mobile-bearing and posterior-stabilized over medial pivot designs in total knee arthroplasty (TKA): a systematic comparative analysis using worldwide arthroplasty registers from England and Wales, Australia, Norway, New Zealand, Germany and Switzerland.

INTRODUCTION: The aim of this study was to compare the use of mobile-bearing, fixed-bearing, posterior-stabilized (PS) and medial pivot design to describe epidemiological differences and subsequent outcomes. MATERIALS AND METHODS: A systematic literature search was performed using the NORE website to identify the relevant arthroplasty registers. Inclusion criteria were the following: (1) reports had to be publicly available, (2) reports had to be written in German or English language, (3) differentiation between mobile- and fixed-bearing, posterior-stabilized, and if possible, medial pivot designs had to be possible from the present reports, and (4) data had to be reported for at least three consecutive years and the latest report had to be from the year 2020 to retrieve recent data. RESULTS: Six registries (England and Wales, Australia, Norway, New Zealand, Germany, Switzerland) offered sufficient data according to the inclusion criteria. In all countries, the dominant type of bearing used for total knee arthroplasty (TKA) was fixed-bearing, with percentages ranging from 60.8% to 84.1% in 2018, 63.6% to 85.7% in 2019 and 66.2% to 87.4% in 2020. A large variation was observed concerning mobile-bearing design, which showed a range from 2.8% to 39.2% in 2018, 2.6% to 36.4% in 2019 and 2.9% to 33.8% in 2020. Some variation was found regarding the use of PS TKA, as its percentage frequency ranged from 9.7% to 29.2% in 2018, 9.8% to 29.4% in 2019 and 10.1% to 28.5% in 2020. Medial pivot design had a share of 9.1% in 2018, 8.6% in 2019 and 8.4% in 2020 in Australia, while it only accounted for 1.4% in 2018, 2.1% in 2019 and 2.5% in 2020 in Germany. CONCLUSION: The comparison of arthroplasty registers from England and Wales, Australia, Norway, New Zealand, Germany and Switzerland revealed large differences regarding the application of posterior-stabilized designs, but also common ground considering the overwhelming use of fixed-bearing inserts, which, when inserted correctly, eradicate the potential complication of bearing dislocation. Arthroplasty registers offer a real-world clinical perspective with the aim to improve quality and patient safety.

Musculoskeletal tuberculosis revisited: bone and joint tuberculosis in Austria.

BACKGROUND: To prevent further spread of the disease and secondary deformity, musculoskeletal tuberculosis (TB) remains a challenge in terms of early diagnosis and treatment. This study gives an overview on TB trends in Austria (pulmonary and extrapulmonary TB) (A) and analyses a retrospective series of musculoskeletal TB cases diagnosed and treated at an Austrian tertiary centre (B). METHODS: (A) We analysed data obtained from the Austrian national TB registry to provide information on TB patients´ demographics and manifestation sites between 1995 and 2019. (B) Furthermore, we performed an observational study of all patients with a confirmed diagnosis of musculoskeletal TB who were admitted to the Department of Orthopaedics and Trauma, Medical University of Graz (2005-2019). Demographic, diagnostic, clinical and follow-up data were retrieved from the medical records. RESULTS: (A) From 1995 to 2019, a significant linear reduction in overall Austrian tuberculosis incidence rates occurred (p < 0.001). In the period investigated, Austria recorded a total of 307 patients with musculoskeletal TB. (B) Our retrospective case-series included 17 individuals (9 males, 8 females; average follow-up 48.4 months; range 0-116). There was a biphasic age distribution with a peak in elderly native Austrians (median 69, range 63-92), and a second peak in younger patients with a migration background (median 29, range 18-39). Sites of manifestation were the spine (n = 10), peripheral joints (n = 5), and the soft tissues (n = 2). Diagnosis was based on histology (n = 13), PCR (n = 14), and culture (n = 12). Eleven patients underwent surgery (64.7%). Secondary deformities were frequent (n = 9), and more often observed in patients with spinal TB (n = 6). CONCLUSION: Musculoskeletal TB should be considered if untypical joint infections or nonspecific bone lesions occur in younger patients with a migration background or in patients with specific risk factors.

Patients successfully lose body weight after primary total knee arthroplasty but not more than a matched general population.

INTRODUCTION: High BMI is associated with increased risk for knee osteoarthritis, ultimately necessitating total knee arthroplasty (TKA). The aim of this retrospective study was to (1) analyse the amount of postoperative long-term weight loss as reflected by BMI change in TKA patients, (2) identify factors associated with increased change in BMI, and to (3) compare changes with BMI trends of a general population. MATERIALS AND METHODS: Overall, 298 TKA patients [198 females; mean age: 65.1 ± 7.9 years, median follow-up 8.8 (interquartile range: 5.9-10.8 years)] were included in the final evaluation and compared with an age group-matched control group from the general population regarding weight trends between 2006 and 2014. Main variable of interest in both cohorts was body mass index (BMI). Linear regression analyses were performed to assess changes in weight and BMI over time between TKA patients and the general population. Furthermore, mixed linear-effects models were constructed to analyse the potential change in BMI independent from age and gender. RESULTS: In TKA patients, a significant drop in BMI by 0.8 ± 3.2 points from postoperative to final follow-up was observed (p < 0.001), with reduction being significant independently from age (p = 0.382), gender (p = 0.310), or revision surgery (p = 0.195). In the general population, likewise a significant BMI-decrease by 0.7 ± 6.1 points was observed between 2006 and 2014, with younger people (p = 0.004) and females (p < 0.001) being more likely to reduce BMI. Yet, BMI-decrease between TKA patients and the general population over time was comparable (p = 0.734). Notably, patients with initially higher BMI were significantly more likely to lose weight postoperatively than normal-weight patients (p < 0.001). CONCLUSIONS: Our results point against the notion that TKA patients lose a considerable amount of weight in comparison to the general population as soon as improved joint function and pain relief have been achieved. Thus, individualized patient education programmes should be reinforced, promoting a healthy lifestyle.

Artificial intelligence-based computer-aided system for knee osteoarthritis assessment increases experienced orthopaedic surgeons' agreement rate and accuracy.

PURPOSE: The aims of this study were to (1) analyze the impact of an artificial intelligence (AI)-based computer system on the accuracy and agreement rate of board-certified orthopaedic surgeons (= senior readers) to detect X-ray features indicative of knee OA in comparison to unaided assessment and (2) compare the results to those of senior residents (= junior readers). METHODS: One hundred and twenty-four unilateral knee X-rays from the OAI study were analyzed regarding Kellgren-Lawrence grade, joint space narrowing (JSN), sclerosis and osteophyte OARSI grade by computerized methods. Images were rated for these parameters by three senior readers using two modalities: plain X-ray (unaided) and X-ray presented alongside reports from a computer-assisted detection system (aided). After exclusion of nine images with incomplete annotation, intraclass correlations between readers were calculated for both modalities among 115 images, and reader performance was compared to ground truth (OAI consensus). Accuracy, sensitivity and specificity were also calculated and the results were compared to those from a previous study on junior readers. RESULTS: With the aided modality, senior reader agreement rates for KL grade (2.0-fold), sclerosis (1.42-fold), JSN (1.37-fold) and osteophyte OARSI grades (3.33-fold) improved significantly. Reader specificity and accuracy increased significantly for all features when using the aided modality compared to the gold standard. On the other hand, sensitivity only increased for OA diagnosis, whereas it decreased (without statistical significance) for all other features. With aided analysis, senior readers reached similar agreement and accuracy rates as junior readers, with both surpassing AI performance. CONCLUSION: The introduction of AI-based computer-aided assessment systems can increase the agreement rate and overall accuracy for knee OA diagnosis among board-certified orthopaedic surgeons. Thus, use of this software may improve the standard of care for knee OA detection and diagnosis in the future. LEVEL OF EVIDENCE: Level II.

Combined femoral and popliteal nerve block is superior to local periarticular infiltration anaesthesia for postoperative pain control after total knee arthroplasty.

INTRODUCTION: After primary total knee arthroplasty (TKA), local periarticular infiltration anaesthesia (LIA) is a fast and safe method for postoperative pain control. Moreover, ultrasound-guided regional anaesthesia (USRA) with femoral and popliteal block is a standard procedure in perioperative care. Two analgesic regimens for TKA-LIA versus URSA with dexmedetomidine-were compared as an additive to ropivacaine. We hypothesised that the use of URSA provides a superior opioid sparing effect for TKA compared with LIA. METHODS: Fifty patients (planned 188 participants; safety analysis was performed after examining the first 50 participants) were randomised. These patients received LIA into the knee capsule during surgery with 60 ml of ropivacaine 0.5% and 1 ml of dexmedetomidine (100 µg ml-1) or two single-shot URSA blocks (femoral and popliteal block) before surgery with 15 ml of ropivacaine 0.5% and 0.5 ml of dexmedetomidine for each block. Postoperative opioid consumption in the first 48 h, pain assessment and complications were analysed. RESULTS: In the safety analysis, there was a significantly higher need for opioids in the LIA group, with a median oral morphine equivalent of 42.0 [interquartile range (IQR) 23.5-57.0] mg versus 27.0 [IQR 0.0-33.5] mg (P = 0.022). Due to this finding, the study was terminated for ethical considerations according to the protocol. CONCLUSION: This is the first study presenting data on LIA application in combination with dexmedetomidine. A superior opioid-sparing effect of URSA was observed when compared with LIA in TKA when dexmedetomidine is added to local anaesthetics. Also, a longer lasting opioid-sparing effect in the LIA group was observed when compared with the recently published literature; this difference could be attributed to the addition of dexmedetomidine. Therefore, multimodal analgesia regimens could be further improved when LIA or USRA techniques are combined with dexmedetomidine.

Successful Two-Stage Exchange Arthroplasty for Periprosthetic Infection Following Total Knee Arthroplasty: The Impact of Timing on Eradication of Infection.

Background: Periprosthetic joint infection (PJI) represents a serious complication following total knee arthroplasty. In the setting of chronic infections, the two-staged approach has traditionally been the preferred treatment method. The aim of this study was to determine the optimal period of rest between the first and second stage. Furthermore, we analyzed potentially outcome-relevant parameters, such as general and local conditions and the presence of difficult-to-treat or unidentified microorganisms, with regard to their impact on successful treatment of PJI. Patients and Methods: We performed a retrospective analysis of prospectively collected data for all patients treated for PJI at our institution. Seventy-seven patients who had undergone two-stage revision arthroplasty for PJI of the knee were included into the study. Antibiotic-loaded cement spacers were used for all patients. Results: After a median follow-up time of 24.5 months, infection had reoccurred in 14 (18.7%) patients. A prolonged spacer-retention period of more than 83 days was related to a significantly higher proportion of reinfections. Furthermore, significant compromising local conditions of the prosthetic tissue and surrounding skin, as well as repeated spacer-exchanges between first- and second-stage surgery, negatively influenced the outcome. Neither the patients' age nor gender exerted a significant influence on the outcome regarding reinfection rates for patients' age or gender. Conclusions: We observed the best outcome regarding infection control in patients who had undergone second-stage surgery within 12 weeks after first-stage surgery. Nearly 90% of these patients stayed free from infection until the final follow-up. An increased number of performed spacer-exchanges and a bad local extremity grade also had a negative impact on the outcome.

Application and Surgical Technique of ACL Reconstruction Using Worldwide Registry Datasets: What Can We Extract?

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. The purpose of this study was to compare surgical reconstruction of the ACL between different countries and regions in order to describe differences regarding epidemiological data, reconstruction frequency, and graft choice. A systematic literature search was performed using the ACL study group website in order to identify the relevant knee ligament registers. Four national registries were included, comprising those from Sweden, the UK, New Zealand, and Norway. A large variation was found concerning the total number of primary ACL reconstructions with a reported range from 4.1 to 51.3 per 100,000 inhabitants. The country-specific delay between injury and reconstruction varied between an average of 6.0 months and 17.6 months. The leading sports activities resulting in ACL injury included soccer, alpine skiing, handball, rugby, and netball. Moreover, a strong variability in graft choice for primary reconstruction was found. The comparison of ACL registers revealed large differences, indicating different clinical implications regarding conservative or surgical therapy and choice of the preferable graft. ACL registers offer a real-world clinical perspective with the aim to improve quality and patient safety by investigating factors associated with subsequent surgical outcomes.

The articular branch of the peroneal nerve to the proximal tibiofibular joint descends at a mean height of approximately 18 mm distal to the postero-lateral tip of the fibular head.

PURPOSE: The aim of the study was to evaluate the anatomical details of the articular branch of the peroneal nerve to the proximal tibiofibular joint and to project the height of its descent in relation to the fibular length. METHODS: Twenty-five lower extremities were included in the study. Following identification of the common peroneal nerve, its course was traced to its division into the deep and superficial peroneal nerve. The articular branch was identified. The postero-lateral tip of the fibular head was marked and the interval from this landmark to the diversion of the articular branch was measured. The length of the fibula, as the interval between the postero-lateral tip of the fibular head and the tip of the lateral malleolus, was evaluated. The quotient of descending point of the articular branch in relation to the individual fibular length was calculated. RESULTS: The articular branch descended either from the common peroneal nerve or the deep peroneal nerve. The descending point was located at a mean height of 18.1 mm distal to the postero-lateral tip of the fibular head. Concerning the relation to the fibular length, this was at a mean of 5.1%, starting from the same reference point. CONCLUSION: The articular branch of the common peroneal nerve was located at a mean height of 18.1 mm distal to the the postero-lateral tip of the fibular head, respectively, at a mean of 5.1% of the whole fibular length starting from the same reference point. These details represent a convenient orientation during surgical treatment of intraneural ganglia of the common peroneal nerve, which may result directly from knee trauma and indirectly from ankle sprain.

Successful reconstruction of the posterior cruciate ligament: assessment of posterior cruciate ligament footprints using an objective coordinate system.

INTRODUCTION: Anatomic cruciate ligament reconstruction is known to be correlated with better clinical results. The aim of the study was to provide a simple method to enable anatomic results in the setting of PCL reconstruction. We, therefore, assessed the tibial and femoral insertion site of the posterior cruciate ligament (PCL) by the use of an objective coordinate system in an anatomical study. We also sought to show reproducibility of these measurements using intra- and inter-observer coefficients. MATERIALS AND METHODS: We studied 64 knees, previously preserved according to Thiel's technique. After proper preparation of the articular surfaces of both the tibiae and femora, photographs were taken according to a standardized protocol. PCL footprints were measured by the use of a coordinate system twice by two examiners. We evaluated these measurements by use of the Cohen's kappa inter- and intra-observer coefficient for two observers. RESULTS: Tibial and femoral measurements of PCL footprints were generated with highly comparable inter- (k = 0.970) and intra-observer (k = 0.992) coefficients and may, therefore, be considered as highly reproducible. CONCLUSION: Our findings confirmed the reproducibility of defining PCL footprints using a coordinate system and may contribute to planning intraoperative graft-placement to ensure optimal conditions in the upcoming techniques for PCL reconstruction.

Patellar Tendon Length is Associated with Lower Extremity Length but Not Gender.

BACKGROUND: The aim of this study was to evaluate the patellar tendon length (PTL) with focus on gender differences and possible correlations with the total leg length (TLL) and the long bones of the lower extremity. MATERIALS AND METHODS: The sample involved 50 paired lower extremities from human adult cadavers. The TLL was measured between the medial malleolus and the apex of the greater trochanter. The femoral length (FL) was evaluated as the interval between the latter and the distal margin of the lateral epicondyle of the femur and the tibial length (TL) from the distal apex of the medial malleolus to the proximal border of the medial condyle of the tibia. The PTL was measured from the apex of the patella to its proximal insertion point at the tibial tuberosity. RESULTS: The PTL was at a mean length of 4.29 ± 0.49 cm (right side) and 4.20 ± 0.55 cm (left side) in females and 4.42 ± 0.53 cm (right) and 4.32 ± 0.55 cm (left) in males. There were no differences regarding gender (p = .412). The left PTL was significantly shorter in both sexes (p = .022). The PTL correlated positively with FL, TL, and TLL in both sexes and sides. CONCLUSION: PTL correlates significantly positively with size without gender differences.

Talocalcaneal Coalition Including Open Comminuted Calcaneal Fracture; A Case Report and Literature Review.

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

Survival Rate of Short-Stem Hip Prostheses: A Comparative Analysis of Clinical Studies and National Arthroplasty Registers.

BACKGROUND: The primary aim was to evaluate the outcome of short-stem hip prostheses in terms of overall revision rates. Data were taken from published literature and national arthroplasty registers. The second study aim was to evaluate a potentially superior outcome of dependent compared to independent clinical studies. METHODS: All clinical studies on short-stem hip prostheses between 2006 and 2016 were reviewed and evaluated with a special interest on revision rates. Revision rate was calculated as "revision per 100 component years." Short stems were divided into femoral neck retaining (NR), neck sparing (NS), and neck harming (NH) prostheses. Published literature was further classified into dependent and independent studies, and data were compared to the Australian National Arthroplasty Register. RESULTS: Fifty-two studies with 56 cohorts met the inclusion criteria and were therefore included in our study. All clinical studies showed a median revision rate of 4.8% after 10 years. NS and NH stems performed equally, whereas neck retaining prostheses were significantly inferior. Independent showed higher revision rates compared to dependent data without being statistically significant. The Australian register revealed a revision rate of 6.6% after one decade. CONCLUSION: Similar low revision rates for NS and NH short-stem prostheses were found in the included data. Dependent studies seem not to be biased with regard to the longevity of short-stem hip replacement. Longer follow-up periods in clinical studies and more detailed information in arthroplasty registers would be desirable for future studies.

The fifty highest cited papers in anterior cruciate ligament injury.

INTRODUCTION: The anterior cruciate ligament (ACL) is one of the most common injured knee ligaments and at the same time, one of the most frequent injuries seen in the sport orthopaedic practice. Due to the clinical relevance of ACL injuries, numerous papers focussing on this topic including biomechanical-, basic science-, clinical- or animal studies, were published. The purpose of this study was to determine the most frequently cited scientific articles which address this subject, establish a ranking of the 50 highest cited papers and analyse them according to their characteristics. METHODS: The 50 highest cited articles related to Anterior Cruciate Ligament Injury were searched in Thomson ISI Web of Science® by the use of defined search terms. All types of scientific papers with reference to our topic were ranked according to the absolute number of citations and analyzed for the following characteristics: journal title, year of publication, number of citations, citation density, geographic origin, article type and level of evidence. RESULTS: The 50 highest cited articles had up to 1624 citations. The top ten papers on this topic were cited 600 times at least. Most papers were published in the American Journal of Sports Medicine. The publication years spanned from 1941 to 2007, with the 1990s and 2000s accounting for half of the articles (n = 25). Seven countries contributed to the top 50 list, with the USA having by far the most contribution (n = 40). The majority of articles could be attributed to the category "Clinical Science & Outcome". Most of them represent a high level of evidence. DISCUSSION: Scientific articles in the field of ACL injury are highly cited. The majority of these articles are clinical studies that have a high level of evidence. Although most of the articles were published between 1990 and 2007, the highest cited articles in absolute and relative numbers were published in the early 1980s. These articles contain well established scoring- or classification systems. CONCLUSION: The identification of important papers will help current clinicians and scientists to get an overview on past and current trends in that special field of ACL injury and provides a basis for both further discussion as well as future research.

Langerhans-cell histiocytosis of the cervical spine in an adult patient: Case report and review of the literature.

Langerhans-cell histiocytosis (LCH) is a rare, benign bone tumor, usually occurring in children and younger adults under 20 years old. Only a few cases of solitary bone lesions of the adult spine are reported in literature, therapeutic guidelines or treatment regimens for lesions of the adult spine are not established yet to our knowledge.

Sports Activity after Low-contact-stress Total Knee Arthroplasty - A long term follow-up study.

The purpose of this study was to provide comprehensive long-term data about sports activity levels in patients following total knee arthroplasty (TKA) and to determine the impact of pre-operative function, pain and specific performed sports on the results. 236 patients who have undergone TKA for severe osteoarthritis of the knee were asked to provide specific information regarding exercised types of sports before surgery and after at least 10 years following TKA. Pre- and postoperative function and pain were evaluated by the use of Tegner-, WOMAC- and VAS Score. After a mean of 14.9 years, a significant improvement regarding pain and function was observed. Pre-operative Tegner- and WOMAC scores revealed significant positive correlations with the post-operative Tegner-Score. Accordingly, a high percentage of patients (70.9%) stayed actively involved in sports. Nevertheless, the number of performing patients has decreased according to the sports impact. 71.3% continued practising low-impact-, 43.7% intermediate-impact sports whereas only 16.4% kept performing high impact sports. We conclude that TKA is highly effective in long-time pain reduction as well as improvement of function. Additionally, we found considerable sports activities preserved in the investigated series. However, sports activities in particular, seem to decrease according to the impact of sports.

Two-stage revision of prosthetic hip joint infections using antibiotic-loaded cement spacers: When is the best time to perform the second stage?

AIM: Managing periprosthetic joint infections remains a challenging task, and adequate treatment strategies seem to be mandatory to avoid irreversible damage of the affected joint and/or systemic complications. Two-stage revision arthroplasty includes removing all implants and subsequent implantation of an antibiotic-loaded cement spacer, followed by revision arthroplasty as the second stage. Although this procedure is well described in the literature, results remain unpredictable due to various clinical findings and the absence of prospective randomised trials. We analysed (1) mortality and (2) reinfection rates in a series of patients who underwent two-stage revision surgery for periprosthetic hip joint infections with antibiotic-augmented joint spacers. We maintained a special focus on the spacer retention period and its influence on outcome in order to determine the best time for second-stage surgery. PATIENTS AND METHODS: A consecutive series of 76 patients with native and periprosthetic hip joint infections and who underwent two-stage revision surgery with antibiotic-loaded cement spacers were studied between 2005 and 2010. The second-stage operation was performed when it was assumed that infection was eradicated. The further operative procedure depended upon intra-operative findings (frozen section, local status). RESULTS: Mean implant-free period with the antibiotic-loaded spacer in situ was 12.6 weeks. Spacer re-implantation was necessary in 13 cases due to positive signs of acute infection in the frozen section and suspect intra-operative findings. Eight patients were not operated for a second time in the investigated time period due to poor general condition. In 40 patients, the spacer retention period was four to 11 weeks: 11 weeks for 23. We observed a significantly higher proportion of women free from reinfection in the four to 11-week group than in patients with the shorter or longer period. CONCLUSION: According to our findings, the optimal timing for second-stage surgery as a second-stage procedure is between four and 11 weeks. A significantly optimal reinfection rate was seen in patients undergoing revision arthroplasty within that time frame, and 90% of those patients remained infection free until final follow-up.

Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases.

BACKGROUND: Traumatic popliteal arterial injury carries the greatest risk of limb loss among all peripheral vascular injuries and is associated with high levels of morbidity and worse functional outcomes. The purpose of this study is to analyse the functional outcome among patients with popliteal artery injury (PAI) due to blunt and penetrating trauma and identify influencing factors. METHODS: We critically reviewed 64 cases of PAI due to blunt and penetrating trauma treated at our institution over a 20-year period. We evaluated the influence of parameters, such as patient demographics, injury mechanism, initial ISS and performed interventions, on limb amputation rates and functional outcomes. Functional outcome was examined within the 12-months follow-up using the Functional Independence Measure (FIM) score for feeding, expression and locomotion. FIM scores for each category ranged from 1 (full assistance required) to 4 (fully independent), with a maximum total FIM score of 12 representing full independence. RESULTS: The mechanism of injury was blunt in 55 % and penetrating in 45 % of the patients. The overall amputation rate in our series was 28 %. Out of these, 83.3 % of all performed amputations in our series were due to blunt trauma and 88.6 % of all blunt trauma patients were severely injured (ISS > 9) or polytraumatized (ISS > 15). Blunt mechanism of injury has also shown a negative effect on the functional outcome. Analysis of the 1-year clinical follow-up showed that 30 patients (65.3 %) returned to their normal activity level within 1 year after trauma. A total of 16 patients (34.7 %) were recorded to have limited activity levels, 76.5 % of them sustained a blunt trauma. Using the FIM score to quantify the level of disability, we detected significantly worse results in both FIM total (8.8 vs. 10.4) and FIM locomotion score (3.1 vs. 2.7) following blunt trauma. CONCLUSION: The main findings of the present study were that PAI due to blunt trauma is associated with a high percentage of severely injured or even polytraumatized patients. Amputation rates following blunt trauma were significantly higher compared to penetrating trauma. Functional independence measurement, assessed 12 months after injury, also showed significantly worse results in both FIM total and FIM locomotion score after blunt trauma. Other factors that seem to have a negative influence on the outcome in terms of amputation rates after PAI are patient's age, presence of associated injuries and prolonged lower extremity ischemia.