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Abstract Background Multi-drug-resistant bacteria (e.g. Carbapenem-resistant Acinetobacter baumannii, extended-spectrum betalactamase or carbapenemase-producing enterobacteriaceae) are emerging in early-onset infections. So far, there is no report describing the eradication of these bacteria in a osseous infection of an open proximal tibial fracture in combination with the hexapod technology to address both osseous consolidation and closed drop foot correction. Case presentation After sustaining a proximal tibial fracture (Gustilo 3B), a 41-year-old man was primarily treated with open reduction and internal fixation by a locking plate and split-thickness skin graft in the home country. At the time of admission to our hospital there was a significant anterolateral soft tissue defect covered with an already-necrotic split-thickness graft and suspicious secretion. CAT and MRI scans revealed no signs of osseous healing, intramedullary distinctive osteomyelitis, as well as a large abscess zone in the dorsal compartment. Multiple wound smears showed multi-drug-resistant bacteria: Acinetobacter baumannii (Carbapenem resistant) as well as Enterobacter cloacae complex (AmpC overexpression). After implant removal, excessive osseous and intramedullary debridements using the Reamer Irrigator Aspirator (RIA®) as well as initial negative pressure wound therapy were performed. Colistin hand-modelled chains and sticks were applied topically as well as an adjusted systemic antibiotic scheme was applied. After repetitive surgical interventions, the smears showed bacterial eradication and the patient underwent soft tissue reconstruction with a free vascularized latissimus dorsi muscle flap. External fixation was converted to a hexapod fixator (TSF®) to correct primary varus displacement, axial assignment and secure osseous healing. A second ring was mounted to address the fixed drop foot in a closed fashion without further intervention. At final follow-up, 12 months after trauma, the patient showed good functional recovery with osseous healing, intact soft tissue with satisfactory cosmetics and no signs of reinfection. Conclusions A multidisciplinary approach with orthopaedic surgeons for debridement, planning and establishing osseous and joint correction and consolidation, plastic surgeons for microvascular muscle flaps for soft tissue defect coverage as well as clinical microbiologists for the optimized anti-infective treatment is essential in these challenging rare cases. Level of evidence Level IV.

The purpose of the present study was to compare muscular strength of knee extensors and arm flexor muscles of cardiac patients (n = 638) and healthy controls (n = 961) in different age groups. Isometric torques were measured in a sitting position with the elbow, hip, and knee flexed to 900. For statistical analysis, age groups were pooled in decades from the age of 30 to 90 years. Additionally, the influence of physical lifestyle prior to disease on muscular strength was obtained in the patients. For statistical analysis three-way ANOVA (factors age, gender, and physical activity level) was used. Both in patients and in controls a significant age-dependent decline in maximal torque could be observed for arm flexors and knee extensors. Maximal leg extensor muscle showed statistically significant differences between healthy controls and cardiac patients as well as between subgroups of patients: Physically inactive patients showed lowest torques (male: 148 ± 18 Nm; female: 82 ± 25 Nm) while highest values were measured in control subjects (male: 167 ± 16 Nm; female: 93 ± 17 Nm). In contrast, arm flexor muscles did not show any significant influence of health status or sports history. This qualitative difference between weight-bearing leg muscles and the muscle group of the upper extremity suggest that lower skeletal muscle strength in heart patients is mainly a consequence of selective disuse of leg muscles rather than any pathological skeletal muscle metabolism. Since a certain level of skeletal muscle strength is a prerequisite to cope with everyday activities, strength training is recommended as an important part of cardiac rehabilitation.

Background: The role of local infiltration anesthesia (LIA) in knee surgery is significant. LIA can be more potent than a nerve block, but without the downsides. A wide range of agents are used for LIA, including some off-label medications such as dexmedetomidine and ropivacaine. Dexmedetomidine has recently received attention for decreasing demand for anesthetic agents and prolonged effect of anesthesia. The purpose of this study was to demonstrate safety of dexmedetomidine and ropivacaine as LIA., Methods: This is a retrospective analysis of 200 patients receiving 300 mg of ropivacaine, 100 µg of dexmedetomidine and 10 mL of saline solution as LIA. Both agents are off-label for this use. The LIA applied prior to skin closure as a pertiarticular block. Major knee surgery was defined as ligament reconstruction of at least one ligament, fracture of the femur and the tibia, knee replacement and osteotomy. We evaluated short-term major side-effects of these agents, and evaluated 30-day complications., Results: Included were 77 arthroplasties, 10 fracture fixations, 19 osteotomies, 55 primary and revision ACL, 10 isolated medial patellar femoral ligament reconstructions, 2 ACLs combined with a partial knee arthroplasty, 4 cartilage transplantations and 23 multiligament knee reconstructions. We observed one transitory discoloration after an ACL reconstruction that disappeared by the 48 h mark. We had no 30-day superficial or deep infections. Cardiac or allergic reactions were not observed., Conclusions: LIA in a combination of single high-dose ropivacaine and dexmedetomidine is safe in knee surgery. Further studies evaluating pain relief with this LIA combination are needed., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: A number of studies have demonstrated a significant reduction of surgical time for robotically assisted surgery (RAS) total knee arthroplasty (TKA) after the learning curve between 6 and 43 cases. It is unknown if the logistics of RAS produce a longer total theatre time since published literature only reflects the surgical time. It is also unknown how RAS surgical and total theatre times compare with computer assisted surgery (CAS) TKA., Methods: This is a prospective study of 524 consecutive patients undergoing a CAS or a RAS TKA using the same cementless implant. We recorded age, sex, body mass index (BMI), incision time of the first case, total surgical time, total theatre time, length of stay and 90-day complication and readmission rate., Results: During the study period, 205 CAS and 199 RAS TKA were performed. There was no difference at baseline in age (p = 0.546), sex (p = 0.920) or BMI (p = 0.791). Surgical time for CAS was 78.3 (± 22.2) min and for RAS was 80.1 (± 25.7) min, p = 0.451. Total theatre time for CAS was 117.4 (± 27.8) min and 119.3 (± 30.7) min for RAS, p = 0.515. There was no difference in length of stay (p = 0.674), 90-day complication (p = 0.530) or readmission rate (p = 0.930). There was a difference in skin-incision average time for the first case (p = 0.022)., Conclusions: Although theatre set-up for the first case is 5 min longer, RAS-TKA does not prolong the surgical time or total theatre time when compared with CAS-TKA. There was no reduction in case volume since the introduction of robotics., Level of Evidence: III., (© 2024. The Author(s).)

Background: Osteoporosis, age and frailty significantly impacts outcomes in fragility fractures of the pelvis, increasing morbidity and mortality. Identifying frailty aids in risk stratification and personalized care plans, enhancing recovery and reducing complications in older adults. Orthogeriatric co-management, an interdisciplinary approach combining orthopedics and geriatrics, optimizes care for older adults with fragility fractures. This model improves outcomes through integrated preoperative and postoperative care. This study examines the current literature for orthogeriatric co-management in pelvic ring or acetabular fractures, aiming to improve outcomes for older adults., Conclusion: Orthogeriatric co-management can be an effective tool to significantly enhances clinical care and reduces complications in older adults with pelvic ring and acetabular fractures. Studies demonstrate increased detection of urological complications and earlier patient mobilisation, alongside a notable decrease in revision surgery rates. The implementation of a specialized framework underscores the necessity for standardised orthogeriatric protocols, optimizing patient outcomes and satisfaction. Integrating geriatric expertise in surgical treatment addresses comorbidities more effectively and minimizes postoperative complications. The certification of such centers ensures adherence to quality standards, fostering continuous improvement in care. Standardised orthogeriatric management should extend to all older fracture patients., Competing Interests: Declarations Competing interests The authors declare that they have no competing interests. Consent of publication Not applicable. Ethics approval Not applicable., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: In recent years, coronal lower leg alignment has received significant attention. Two classifications recently described the variability in both femoral and tibial morphology, resulting in differing native lower limb alignment. The native trochlea and the variability in morphology has received less attention., Methods: This is a prospective cohort study of 200 patients undergoing robotically assisted TKA. Preoperative transverse CT scans were used to determine the posterior condylar axis (PCA), transepicondylar axis (TEA), lateral trochlear inclination (LTI), the sulcus angle (SA) and the anterior trochlear line (ATL). Outliers were defined as values > 1.5 IQR from median value. Trochlea dysplasia was defined as LTI < 12°. Gender differences were compared., Results: In total, 99 patients were female (49.4%). SA had a median of 137.0° (IQR 12°), ATL 4° (IQR 4), LTI 18° (IQR 7°). Median TEA-PCA was 5° external (IQR 3°). There were 5.0% outliers in SA, 3.0% of outliers in ATL, 3.5% outliers in LTI and 4.5% outliers in the TEA-PCA. Trochlear dysplasia was present in 11.5% of the measurements. There was no difference in any of the angles between the genders., Conclusion: The present study demonstrates no difference in trochlea morphology between the genders, rather a significant number of overall outliers in trochlear morphology. Larger cohorts but also, more investigations, are needed to better understand the trochlear morphology of patients undergoing total knee arthroplasty. The personalized alignment strategies and implants need to account for this variability in the population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: When planning and delivering total knee arthroplasty (TKA), there are multiple coronal alignment strategies such as functional alignment (FA), kinematic alignment (KA), mechanical and adjusted mechanical alignment (MA, aMA). Recent three-dimensional and robotic-assisted surgery (RAS) studies have demonstrated that KA potentially better restores the trochlear anatomy than MA. The purpose of this study was to compare the restoration of the native trochlear orientation in patients undergoing RAS TKA using four different alignment strategies. It was hypothesised that FA would result in the lowest number of outliers., Methods: This is a prospective study of 200 patients undergoing RAS-TKA with a single implant. All patients were analysed for MA and KA prebalancing, and 157 patients received aMA and 43 patients FA with intraoperative balancing. Preoperative transverse computed tomography scans were used to determine the posterior condylar axis (PCA), lateral trochlear inclination (LTI) angle, sulcus angle (SA) and anterior trochlear line (ATL) angle. Implant measurements were obtained using a photographic analysis. Intraoperative software data combined with implant data and preoperative measurements were used to calculate the differences. Outliers were defined as ≥3° of alteration. Trochlea dysplasia was defined as LTI < 12°., Results: Native transepicondylar PCA had a median of 2°, LTI 18°, SA 137°, ATL 4°. LTI outliers were observed in 47%-60% of cases, with KA < FA < aMA < MA. For ATL, the range of outliers was 40.5%-85%, KA < FA < aMA < MA. SA produced 81% of outliers. Of all median angle values, only LTI when using KA was not significantly altered compared to the native knee., Conclusion: There is a significant alteration of trochlear orientation after TKA, regardless of the alignment strategy used. KA produced the lowest, but a substantial, number of outliers. The uniform design of implants causes the surgeon to compromise on balance in flexion versus trochlear position. The clinical relevance of this compromise requires further clinical investigations., Level of Evidence: Level II, prospective cohort study., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Objectives: Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective., Methods: The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results., Results: Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively., Conclusion: Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement., Competing Interests: Declaration of competing interest Dr Joeris has nothing to disclose; Dr Kabiri reports other from Johnson and Johnson MedTech, during the conduct of the study; Dr Galvain reports other from Johnson and Johnson, during the conduct of the study; Ms Vanderkarr reports other from DePuy Synthes, Inc, during the conduct of the study; Dr Holy reports other from Johnson & Johnson, during the conduct of the study; other from Johnson & Johnson, outside the submitted work; and she is an employee of Johnson & Johnson; Dr Quintana Plaza has nothing to disclose; Dr Schneller has nothing to disclose; Dr Kammerlander reports other from DePuy Synthes, Inc, during the conduct of the study., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF)., Methods: We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH., Results: We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH., Conclusion: In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required., (© 2023. The Author(s).)

Robotic-assisted surgery (RAS) in total knee arthroplasty (TKA) is becoming popular due to better precision, when compared with other instrumentation. Although RAS has been validated in comparison with computer-assisted surgery (CAS), data from clinical settings comparing these two techniques are lacking. This is especially the case for sagittal alignment. Whereas pure mechanical alignment (MA) aims for 0 to 3 degrees of flexion of the femoral component and 3° of posterior slope for the tibial component, adjusted MA (aMA) mostly used with RAS allows for flexing of the femoral component for downsizing and increase of slope for an increase of the flexion gap. In the present study, we compared sagittal alignment after TKA using RAS with aMA and CAS targeting MA, which has been the standard in the center for more than 10 years. We analyzed a prospectively collected database of patients undergoing TKA in a single center. Femoral component flexion and tibial slope were compared for both techniques. In 140 patients, 68 CAS and 72 RAS, we found no difference in tibial slope ( p  = 0.661), 1° median femoral component flexion ( p  = 0.023), and no difference in outliers (femur, p  = 0.276, tibia, p  = 0.289). RAS slightly increases femoral component flexion, but has no influence on tibial slope, when compared with CAS in TKA. If MA is the target, RAS provides no benefit over CAS for achieving the targeted sagittal alignment. LEVEL OF EVIDENCE:  Level III retrospective study., Competing Interests: None declared., (Thieme. All rights reserved.)

The use of robotic-assisted surgery (RAS) in total knee arthroplasty (TKA) is becoming increasingly popular due to better precision, potentially superior outcomes and the ability to achieve alternative alignment strategies. The most commonly used alignment strategy with RAS is a modification of mechanical alignment (MA), labeled adjusted MA (aMA). This strategy allows slight joint line obliquity of the tibial component to achieve superior balancing. In the present study, we compared coronal alignment after TKA using RAS with aMA and computer-assisted surgery (CAS) with MA that has been the standard in the center for more than 10 years. We analyzed a prospectively collected database of patients undergoing TKA in a single center. Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were compared for both techniques. In 140 patients, 68 CASs and 72 RASs, we observed no difference in postoperative measurements (median 90 degrees for all, LDFA p  = 0.676, MPTA p  = 0.947) and no difference in outliers <2 degrees (LDFA p  = 0.540, MPTA p  = 0.250). The present study demonstrates no benefit in eliminating outliers or achieving neutral alignment of both the femoral and the tibial components in robotic-assisted versus computer-assisted TKA if MA is the target. To utilize the precision of RAS, it is recommended to aim for more personalized alignment strategies. The level of evidence is level III retrospective study., Competing Interests: None declared., (Thieme. All rights reserved.)

Background and Objectives: The treatment of elderly patients is an increasing challenge and the long-term sequelae often affect activities of daily living and quality of life in those patients. Handgrip strength (HGS) appears as a promising value to predict the outcome after trauma in elderly patients and to assess the overall muscle strength. Besides the possible role of psychological and hormonal factors, vitamin D may have a positive influence. Furthermore, some data suggest that Vitamin D is beneficial regarding muscle strength and possibly prevents further falls and injuries in orthogeriatric patients. The purpose of this study was to identify if Vitamin D is an influencing factor for HGSin elderly trauma patients., Materials and Methods: 94 elderly patients in a Level I Trauma Center aged 60 years or older were prospectively enrolled and HGS as well as serum 25-OH Vitamin D concentration (VDC) were measured. In addition, the standardized questionnaires Barthel Index (BI), Parker Mobility Score (PMS), Short Physical Performance Battery (SPPB), Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) and European Quality of Life 5 Dimensions 5 Levels Questionnaire (EQ-5D-5L), were used to record mental health status and demographic data., Results: HGS is mainly related to age and sex in elderly trauma patients. HGS was higher in men (mean male  = 27.31 kg (± 8.11), mean female  = 15.62 kg (± 5.63), p < 0.001 and decreased with age (β age  = - 0.58, p < 0.001). A significant negative correlation between HGS and VDC exists in the overall sample (β VDC  = - 0.27, p VDC  < 0.008), which still remains after adjusting for age (p VDC  < 0.004), but is not significant after adjustment for both main confounders, age and sex (p VDC  < 0.08). Furthermore, the HGS was lower in pateints who reported frequent falls, stumbling, dizziness or a late onset of menopause, and decreased if patients felt anxious or depressed during measurements (β anxiety+depression  = - 0.26, p anxiety+depression  < 0.01)., Conclusions: These results do not support the hypothesis that Vitamin D has a positive influence on muscle strength measured by HGS. Nevertheless, this study could confirm the usefulness of HGS as a tool to detect the risk for frequent falls or stumbling. Furthermore, HGS seems to be associated with dizziness and age at onset of menopause. A significant decrease of HGS could also be shown in patients with anxiety and depression. This underlines the importance of interdisciplinary treatment of elderly trauma patients and needs to be taken into account for further studies, as especially the psychological motivation seems to have a significant influence and is sometimes not considered enough in elderly musculo-skeletal patients., (© 2023. The Author(s).)

Background: Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality., Methods: Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints., Results: Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use., Conclusions: The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

Background: A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective., Methods: The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses., Results: The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%., Conclusions: Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available., Level of Evidence: Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H225 )., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Aim: Intramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures., Methods: Tibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment., Results: The TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT., Conclusion: The present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Physical activity is a relevant outcome parameter in orthopedic surgery, that can be objectively assessed. Until now, there is little information regarding objective gait parameters in the orthogeriatric population. This study focuses on the first 6 weeks of postoperative rehabilitation, and delivers objective data about gait speed and step length in typical orthogeriatric fracture patterns., Methods: Thirty-one orthogeriatric fracture patients [pertrochanteric femur fractures (PFF), femoral neck (FN), and proximal humerus fractures (PHF)] were consecutively enrolled in a maximum care hospital in a prospective study design. All patients wore an accelerometer placed at the waist during the postoperative stay (24 h/d) and at 6-week follow-up, to measure real gait speed and step length. In addition, self-assessment of mobility (Parker mobility score) and activities of daily living (Barthel index) were collected at baseline, during the inpatient stay, and at 6-week follow-up., Results: During postoperative hospitalization, significantly higher gait speed (m/s) was observed in the PHF group (0.52 ± 0.27) compared with the FN group (0.36 ± 0.28) and PFF group (0.19 ± 0.28) (p < 0.05). Six weeks postoperatively, gait speed improved significantly in all groups (PHF 0.90 ± 0.41; FN 0.72 ± 0.13; PFF 0.60 ± 0.23). Similarly, step length (m) differed between groups postoperatively [FN 0.16 ± 0.13; PFF 0.12 ± 0.15; PHF 0.31 ± 0.05 (p < 0.005)] and improved over time significantly (FN 0.47 ± 0.01; 0.39 ± 0.19; 0.50 ± 0.18). Self-assessment scores indicate that the majority of the patients had minor restrictions in mobility before the fracture. These values decreased immediately postoperatively and improved in the first 6 weeks, but did not reach the initial level., Conclusions: Gait speed, step length, and self-assessment in terms of mobility and activities of daily living improve significantly in the first 6 postoperative weeks in orthogeriatric fracture patients. As very low postoperative mobility during hospitalization was observed, this collective shows great potential in postoperative rehabilitation regardless of their fracture pattern. For this reason, specific aftercare concepts similar to the "fast track" concepts in primary arthroplasty are crucial for orthogeriatric patients in clinical practice., Level of Evidence: Prospective cohort study, 2., (© 2021. The Author(s).)

Purpose: Osteoporotic bone tissue appears to be an important risk factor for implant loosening, compromising the stability of surgical implants. However, it is unclear whether lumbar measured bone mineral density (BMD) is of any predictive value for stability of surgical implants at the pubic symphysis. This study examines the fixation strength of cortical screws in human cadaver specimens with different BMDs., Methods: The lumbar BMD of ten human specimens was measured using quantitative computed tomography (qCT). A cut-off BMD was set at 120 mg Ca-Ha/mL, dividing the specimens into two groups. One cortical screw was drilled into each superior pubic ramus. The screw was withdrawn in an axial direction with a steady speed and considered failed when a force decrease was detected. Required force (N) and pull-out distance (mm) were constantly tracked., Results: The median peak force of group 1 was 231.88 N and 228.08 N in group 2. While BMD values differed significantly (p < 0.01), a comparison of peak forces between both groups showed no significant difference (p = 0.481)., Conclusion: Higher lumbar BMD did not result in significantly higher pull-out forces at the symphysis. The high proportion of cortical bone near the symphyseal joint allows an increased contact of pubic screws and could explain sufficient fixation. This condition is not reflected by a compromised lumbar BMD in a qCT scan. Therefore, site-specific BMD measurement could improve individual fracture management., (© 2021. The Author(s).)

Introduction: Treatment of older adult hip fracture patients can be challenging and requires early postoperative mobilisation to prevent complications. Simple clinical tools to predict mobilisation/weight-bearing difficulties after hip fracture surgery are scarcely available and analysis of handgrip strength could be a feasible approach. In the present study, we hypothesised that patients with reduced handgrip strength show incapability to follow postoperative weight-bearing instructions., Materials and Methods: Eighty-four patients aged ≥ 65 years with a proximal femur fracture (trochanteric, n = 45 or femoral neck, n = 39), who were admitted to a certified orthogeriatric center, were consecutively enrolled in a prospective study design. Five days after surgery (intramedullary nailing or arthroplasty), a standardised assessment of handgrip strength and a gait analysis (via insole forcesensors) was performed., Results: Handgrip strength showed positive correlation with average peak force during gait on the affected limb (0.259), postoperative Parker Mobility Score (0.287) and Barthel Index (0.306). Only slight positive correlation was observed with gait speed (0.157). These results were congruent with multivariate regression analysis., Conclusion: Assessment of handgrip strength is a simple and reliable tool for early prediction of postoperative mobilisation complications like the inability to follow weight-bearing instructions in older hip fracture patients. Follow-up studies should evaluate if these findings also match with other fracture types and result in personalised adjustment of current aftercare patterns. In addition, efforts should be made to combine objectively collected data as handgrip strength or gait speed in a prediction model for long-term outcome of orthogeriatric patients., (© 2021. The Author(s).)

Total knee arthroplasty (TKA) improves the quality of life in those suffering from debilitating arthritis of the knee. However, little is known about the influence of TKA on restoring physical function. Prior studies have used artificial means, such as instrumented treadmills, to assess physical function after TKA. In this study an insole sensor device was used to quantify parameters of gait. The purpose of this study was to evaluate the ability of a wearable insole sensor device to measure immediate postoperative gait parameters at 2 weeks and 6 weeks following primary TKA and to determine if the device was suitable and sensitive enough to identify and measure potentially subtle changes in these measures at these early postoperative time periods. Twenty-nine patients with unilateral TKA, without contralateral knee pain, and aid-free walking before surgery were evaluated. An insole force sensor measured the postoperative parameters while walking a distance of 40 m on level ground at 2 and 6 weeks after TKA. The loading rate of the operated lower extremity was an average of 68.7% of the contralateral side at 2 weeks post-surgery and increased to 82.1% at 6 weeks post-surgery ( p  < 0.001). The mean gait speed increased from 0.75 to 1.02 m/s, ( p  < 0.001) and cadence increased from 82.9 to 99.9 steps/min ( p  < 0.001), while the numeric pain scale at rest decreased from 3.5/10 to 2.2/10, ( p  < 0.001) and the pain while walking from 3.9/10 to 2.4/10, ( p  < 0.001) from 2 to 6 weeks post-surgery. A significant improvement in gait parameters is detectable in the first 6 weeks after surgery with the use of a wearable insole device. As the gait speed and cadence increase and the VAS pain level decreases, the loading rate and average peak force begin to normalize. This device may allow for early gait analysis and have potential clinical utility in detecting early differences in patients' functional status following TKA., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Computed tomography (CT) is commonly used in trauma care, with increasing implementation during the emergency work-up of elderly patients with low-energy falls (LEF). The prevalence of incidental findings (IFs) resulting from CT imaging and requiring down-stream actions in this patient cohort is unknown. We have investigated the prevalence and urgency of IFs from emergency CT examinations in these patients., Methods: A total of 2871 patients with LEF and emergency CT examinations were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of IFs; the secondary endpoint was their urgency., Results: The median age was 82 years (64.2% were women). IFs were identified in 73.9% of patients, with an average of 1.6 IFs per patient. Of all IFs, 16.4% were classified as urgent or relevant, predominantly in the abdomen, chest and neck. Increasing age was associated with the prevalence of an IF (odds ratio: 1.053, 95% confidence interval: 1.042-1.064). Significantly more IFs were found in female patients (75.2% vs. 71.5%)., Conclusion: IFs resulting from CT examinations of the elderly are frequent, but in more than 8 out of 10, they are harmless or currently asymptomatic. For the benefit of an accurate diagnosis of traumatic lesions, concerns about IFs with respect to disease burden, further work-up and resource utilisation might be disregarded.

Background/aim: Open surgical reduction/fixation of thoracolumbar fractures results in significant soft-tissue trauma and related complications. Minimally-invasive technical developments could deliver similar radiological outcomes, while avoiding the related complications. We evaluated radiological and perioperative outcomes in thoracolumbar fractures by using a novel minimally-invasive device., Patients and Methods: Twenty-six patients with 29 thoracolumbar fractures using the NForce device were analyzed. Postoperative reduction and alignment were assessed by radiographic measurement of the local kyphosis angle (LKA) up until a follow-up period of 9 months., Results: Postoperative imaging revealed an average reduction of traumatic kyphosis of 8.25° (±7.72°) with an average postoperative LKA of 3.24° (±8.97°). The highest degree of reduction was 27.39°. The mean LKA had increased to 5.08° (±5.17°) at 3 months postoperative, 5.43° (±4.32°) at 6 months and 6.21° (±3.82°) at 9 months., Conclusion: The minimally invasive NForce system is effective in performing anatomic percutaneous reduction/fixation., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: Surgical treatment of jumper's fractures is a highly demanding situation for the surgeon due to its rareness and frequent association with severe concomitant injuries. There is no current consensus regarding a standard treatment approach, thus reducing quality of care. Our objectives were to describe, apply and assess a novel surgical technic., Methods: The presented research is an observational retrospective study of patients who underwent the described novel surgical intervention in a level 1 trauma center. We conducted analyses of the patient cohort using patient-related outcome measures at least 1 year after surgery, as well as investigating pain, quality of life and the clinical effectiveness of the procedure., Results: A total of 24 patients (17 male and 7 female) with an average age 47 ± 16.3 years were included. ISS scores ranged from 9 to 66 with a mean ISS of 40 ± 15. Clinical scores exist of 15 out of 24 patients (62.5%). The mean VAS score was 53.7 ± 12.9. The mean EQ-5D index was 0.68 ± 0.22. Significant negative correlation existed between the ISS value and the EQ-5D index (r =  - 0.704; p < 0.005) and EQ-5D VAS (r =  - 0.809; p < 0.001). Anatomical reduction was achieved in all patients (n = 24). Radiological follow-up was performed in 58%., Conclusion: We present one of the largest studies with operatively treated jumper's fractures of the sacrum. The technique is capable of reproducibly restoring the physiological anatomy of the patient and allows pain-adapted mobilization., (© 2021. The Author(s).)

Background: Posterior instrumentation using pedicle screws and rods is the most commonly used technique for the treatment of thoracolumbar fractures of the spine. The procedure aims to restore the neurologic and biomechanical functions of the spine and allows for early mobilization and rapid reintegration into society. It is unclear whether the magnitude of correction has an effect on postoperative outcomes., Objective: We aimed to determine whether the magnitude of sagittal angular correction during posterior instrumentation of the spine had an effect on postoperative quality of life, pain and function outcomes as measured using the EQ5D-3L and the Core Outcome Measures Index (COMI) instruments. We also aimed to quantify the correlation between EQ5D-3L and COMI scores., Methods: We analyzed the pre- and postoperative radiographs of 52 patients who underwent percutaneous pedicle screw placement for thoracolumbar fractures, as well as their self-reported EQ5D-3L and COMI quality of life, pain and functional outcome scores. Regression models were constructed to estimate the effect that the magnitude of Cobb angle correction had on postoperative outcomes. We also estimated the correlation between EQ5D-3L and COMI scores., Results: The median EQ5D-3L TTO score was 0.9 (range, -0.1 to 1). The median COMI score was 3.1 (range, 0 to 10). There was no significant effect of the magnitude of correction on EQ5d-3L TTO scores (p= 0.3379; R= 0.36) or on COMI scores (p= 0.3379; R= 0.15). Age and bone mineral density were not found to be significant predictors of outcome (p= 0.05). There was a strong correlation between the EQ5D-3L TTO and COMI scores (r=-0.62)., Conclusion: The magnitude of Cobb angle correction during pedicle screw instrumentation of thoracolumbar fractures did not influence quality of life, pain or function outcomes. There was good correlation between EQ5D-3L TTO scores and COMI scores.